Citation Nr: 21041954 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 11-06 931 DATE: July 10, 2021 ORDER Entitlement to an initial rating greater than 40 percent for residuals of a head injury diagnosed as traumatic brain injury (TBI) is denied. Entitlement to an initial rating greater than 10 percent prior to May 23, 2019, for residuals of a head injury diagnosed as cephalgia (headaches) is denied. Entitlement to an initial rating greater than 10 percent for residuals of a head injury diagnosed as frontal skull paresthesia (frontal skull paresthesia) is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability is granted. REMANDED Entitlement to an initial compensable rating for residuals of a head injury diagnosed as status-post skull fracture with torn dura and laceration of the frontal lobe is remanded. FINDINGS OF FACT 1. The record evidence shows that the Veteran's residuals of a TBI are manifested by no worse than Level 2 impairment of cognitive function with subjective emotional impairment without separate psychiatric diagnosis, headaches, and frontal skull paresthesias. 2. The record evidence shows that, prior to May 23, 2019, the Veteran's headaches more nearly approximate headaches with characteristic prostrating attacks averaging one in two months over last several months. 3. The record evidence shows that the Veteran's frontal skull paresthesias are no worse than moderate. 4. The record evidence shows that the schedular requirements for TDIU have been met and his service-connected disabilities render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an initial rating greater than 40 percent for residuals of a TBI have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, §§ 4.1, 4.2, 4.3, 4.7, 4.15, 4.16, 4.124a, Diagnostic Code (DC) 8045. 2. The criteria for an initial rating greater than 10 percent prior to May 23, 2019, for headaches associated with TBI have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, §§ 4.1, 4.2, 4.3, 4.7, 4.15, 4.16, 4.124a, DC 8100. 3. The criteria for an initial rating greater than 10 percent for frontal skull paresthesia associated with TBI have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, §§ 4.1, 4.2, 4.3, 4.7, 4.15, 4.16, 4.124a, DC 8305, 8307, 8309 8312, 8045. 4. The criteria for a TDIU have been met. 38 U.S.C. §§ 1154(b), 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.15, 4.16(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from July 1978 to November 2009. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In June 2015, the Veteran testified at a Board hearing. In August 2015, the Veteran was notified that a written transcript of the proceeding could not be produced due to audio malfunctions. He was given another opportunity for a Board hearing and elected to have another hearing before the Board. In October 2016, the Veteran testified at a Board hearing and a transcript of this hearing is of record. In May 2021, the Veteran was notified that the Veterans Law Judge (VLJ) who conducted the October 2016 hearing is no longer employed by the Board. As such, the Veteran was given another opportunity for a hearing before another VLJ. There is no record of a response. The Veteran's hearing request is deemed satisfied and the Board will proceed to adjudicate this appeal. See 38 C.F.R. § 20.704. By way of background, in August 2017 the Board denied a compensable rating for skull fracture with torn dura and laceration of the frontal lobe, granted a 40 percent rating for residuals of a TBI, granted a 10 percent rating for headaches, granted a 10 percent rating for frontal skull paresthesia, and found that a claim for TDIU was raised as part and parcel of the increased rating claim pursuant to Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Board also remanded other issues including the TDIU claim. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court) by filing a Joint Motion for Partial Remand (JMPR). In April 2018, the Court granted the JMPR and vacated and remanded the Board's August 2017 decision on the issues of entitlement to an increased rating for service-connected fracture with torn dura and laceration of the frontal lobe, residuals of a TBI, headaches, and frontal skull paresthesia. Pursuant to the April 2018 JMPR, in November 2018, the Board remanded the issues for further development. In July 2020, the Board found that further remand is warranted as a supplemental statement of the case was not issued. During the appeal period, in an October 2020 rating decision, the RO increased the Veteran's rating from 10 percent to 50 percent effective May 23, 2019 for his service-connected headaches. As 50 percent is the highest rating for headaches, the Board will address whether the Veteran is entitled to an increased rating prior to May 23, 2019 for his service-connected headaches. The Board notes that, in March 2019, the RO sent VA Form 21-8940 (formal TDIU claim) to the Veteran. There is no record of a response from the Veteran to this correspondence. The Board observes that additional VA treatment records were received following the last adjudication by the RO in the October 2020 supplemental statement of the case. The Board has reviewed these records and observes that they are duplicative, cumulative, and/or not pertinent to the issues on appeal addressed in the decision below. Thus, the Board finds that a remand for RO review of these records in the first instance is not warranted. Increased Rating The record reflects the Veteran's residuals of a TBI include difficulties with memory and concentration, headaches, and cranial nerve pain. DC 8045 provides for the evaluation of TBI residuals. See 38 C.F.R. § 4.124a, DC 8045. The Veteran's headaches are rated under DC 8100, covering migraine headaches. The Veteran's frontal skull paresthesia is rated analogously under DC 8305, covering neuritis. 1. Entitlement to an initial rating greater than 40 percent for residuals of a TBI is denied. 2. Entitlement to an initial rating greater than 10 percent prior to May 23, 2019, for headaches is denied. 3. Entitlement to an initial rating greater than 10 percent for residuals of a head injury diagnosed as frontal skull paresthesia is denied. Based on the evidence of record, and after resolving any reasonable doubt in favor of the Veteran, the Board finds that the symptomatology attributable to the service-connected residuals of a TBI are consistent with a 40 percent rating. The Board next finds that the symptomatology attributable to the service-connected headaches is consistent with a 10 percent rating prior to May 23, 2019. The Board finally finds that the symptomatology attributable to the service-connected frontal skull paresthesia is consistent with a 10 percent rating. As the issues on appeal are intertwined the Board will address each disability concurrently. By way of background, in May 1988 the Veteran underwent a left frontal craniotomy with elevation of depressed skull fracture (orbital roof) and debridement of brain laceration and suturing of dura and placement of dural graft. During the surgery, four bur holes were arranged around the depressed segment which was approximately the size of the bur hole involving the more lateral aspect of the orbital rim. There were two large pieces of the bone of the orbital roof that were removed. One could not be fixed back in its position. The other attached to the orbital rim and it was possible to save this piece for reconstruction of the orbital roof. The segment of orbital roof bone was then positioned and popped into position. The bone chips that had been collected at the time of the initial placement of the bur holes were than repacked into the bur holes and along the craniectomy defect as well as in the region where the orbital rim had been destroyed. A small piece of the orbital floor bone was then fashioned to fit into the part of the orbital rim defect. Turning to the relevant medical evidence, in the November 2009 VA general examination, the Veteran reported that he had bifrontal headaches after the accident. Currently, his headaches were achy and throbbing about one time per month. The headaches usually last two hours with a pain level of three to four out of ten that responded well to Tylenol and Motrin. He denied that his headaches interfere with his job or activities of daily living. He also denied having dizziness, vertigo, weakness or paralysis, sleep disturbance, mobility symptoms, balancing problems, or speech difficulty. There was no pain except for headaches that are mild and are occurring less frequently. He reported of having chronic numbness and tingling in the left forehead supraorbital region, infraorbital region, and left malar region. There are no flare ups but some mild hyperesthesia that seems to be a little more sensitive to sharp. He also endorsed having some memory impairment and some difficulty in concentration and decreased attention span. On examination, he had normal motor activity and visual spatial activity. His cranial nerves two through twelve were intact. He did have a slight increased hypersensitivity to sharp over his left forehead and left malar area, and long the left supra and infraorbital ridge. His memory was good, and his attention, concentration, and executive function appeared to be well intact. He was noted to have a skull depression left frontal area, 1 cm x 2 cm with a dept of 0.2 cm. He was also noted to have a 0.5 cm depression along the medial aspect of the infraorbital ridge from bone harvesting for ORIF of depressed skull fracture. He also was noted to have a depression of 3.8 cm x 0.5 cm with a 0.2 depth that extends 3 cm from the left lateral eye corner, from the eyebrow going superiorly on the forehead. The depressed skull defect did show some disfigurement. In the May 2010 notice of disagreement, the Veteran stated that he has splitting headaches that are increased by heat and by the pressure produced from aerobic and anaerobic types of activity. The area from his left cheek bone to the top part of the damaged area would feel numb and he would have a sensation of having a foreign material. He further stated that he gets neurological pinch sensations in the damaged area, that can be simultaneously felt in various other area of his body. The Veteran claims that these conditions seem to be getting worse as he gets older. See May 2010 NOD. In a July 2010 correspondence, the Veteran stated that he has issues with his cognitive ability. Specifically, he claimed that he has a habit of nodding in agreement to things that he does not understand. He stated that his cephalgia is more than mild and is quite intense at times. The paresthesia is more than mild and is accompanied by neurological pinch sensations that are felt simultaneously in different areas of his body. In the September 2010 VA TBI examination, the Veteran reported that his cognitive impairment worsened. He has bifrontal headaches once a week or more (more frequent in the past) at a pain level of seven to eight that lasts few hours. He denied having mobility symptoms, balancing problems, and speech difficulties. The Veteran endorsed some memory impairment. He reported some difficulty in concentration and decreased attention span. He claimed that multitasking was not possible. The examiner diagnosed the Veteran with moderate traumatic brain injury status post skull fracture with torn dura and laceration of frontal lobe with residual frontal skull paresthesia and cephalgia. In the September 2010 VA mental examination, the Veteran stated that he does not read anymore because he does not remember "stuff." On examination, he had unremarkable psychomotor activity, unremarkable speech, intact attention, intact orientation, unremarkable thought process and thought content, intact judgment, and intact insight. He exhibited routinely appropriate social interaction and had one or more neurobehavioral effects that do not interfere with workplace interaction or social interaction. He was able to communicate and comprehend by spoken and written language. No mental diagnosis was rendered. The examiner concluded that he cannot address the Veteran's cognitive impairment without resorting to mere speculation as he is unable to obtain an accurate presentation of any difficulties the Veteran may be experiencing based on the results of the assessment. As such, no diagnosis could be provided at the time of the examination. In a November 2011 VA treatment record, the Veteran denied having chronic headache and blurred vision. He exhibited normal speech, and logical and linear thought process. He had intact concentration, memory, and judgment. In a February 2012 VA treatment record, the Veteran had average speech. He exhibited logical and goal directed thought process with no evidence of psychosis. He had adequate attention, concentration, and memory. His judgment and insight were fair. In a March 2012 neuropsychological evaluation, the Veteran complained of poor memory, concentration, focus, and task completion. He sometimes forgets conversations and will forget what he is reading while he is reading it. He managed his own finances and drives and denied having any significant difficulty doing either. The Veteran underwent multiple procedures and tests. On examination, his thought processes were logical, coherent, and goal directed. He was appropriately groomed and was pleasant and socially appropriate. He required only occasional repetition and/or clarification of questions and task instructions. He was fully cooperative, and it is believed that this assessment is a valid indication of his present level of cognitive functioning. His premorbid intellectual functioning was estimated to be in the average to above average range. He performed within normal limits on a forward digit repetition task, indicating adequate basic auditory attention. His performance was below expected levels on backward digit span. He performed in the average range on a task of mental arithmetic calculations. He performed in the mildly impaired range on a visual delayed recognition span task. He performed within expected levels on a visual task of sustained attention and psychomotor speed. His performance was in the low average range on an oral information processing speed task. The Veteran's abstract reasoning was in the average range with adequate ability to describe object and concept similarities. His performance was in the mildly impaired range on formal evaluation of judgment. On learning and memory, he was oriented to person, place, time and situation. With a recognition format, he correctly endorsed nine of the originally presented words and made nine false positive errors, showing poor discriminability. The neuropsychologist determined that overall results revealed relatively intact cognitive functioning with a few areas of mild difficulty, such as mild difficulty with working memory, though other areas of attention and information processing were within normal limits. There was no evidence of significant executive dysfunction, other than mild difficulty with judgment. Language and related functions were within normal limits, except for mild difficulty with semantic word generation. Visuospatial skills were within normal limits. There was no evidence of significant memory dysfunction. The Veteran was diagnosed with cognitive disorder not otherwise specified. The neuropsychologist determined that given the Veteran's history of a TBI and his 2009 computerized tomography (CT) scan of the left frontal encephalomalacia, it is possible that his TBI contributed to his mild cognitive problems as his presentation is not inconsistent with the findings. In a January 2014 and July 2014 VA treatment records, the Veteran denied having headaches, or cerebellar deficit. He had no sensory or motor loss. In March, April, and September 2015 VA treatment records, the Veteran denied having headaches and dizziness. He had no sensory or motor loss. In a February 2016 VA treatment record, his emotional assessment was within normal limits. In a June 2015 correspondence, the Veteran stated that his headaches are a constant throb which are made worse by increased heat and level of exertion. The site of the damage is normally the focal point of the headache pain. In a September 2016 correspondence, the Veteran stated that his headaches are a constant throb and are made much worse by increased body heat and level of exertion. He reported that the medication (Tramadol) prescribed for his back and shoulder pain along with the strongest Tylenol available, taken throughout the day are helpful in taking some of the edge off. That, along with dim lighting and a controlled temperature environment, are also helpful. The absence of any of the above results in exploding headaches. In the October 2016 hearing, the Veteran attested that he has exploding headaches with inability to do very much of anything without head pressure buildup. The headaches are chronic, but they get so much worse. He endorsed having memory loss and confusion all the time and that he felt dazed a lot of time. In a March and July 2018 VA treatment records, the Veteran endorsed having headache "routinely" and memory loss. In a May 2019 VA treatment record, the Veteran stated that he will have a couple of beers once or twice per month with his son and any more than that can increase his headache. In the May 2019 VA scar and/or disfigurement examination, the Veteran denied having skin breakouts on the scars on the face status post craniotomy. He also denied having painful and unstable scars of the head, face, or neck with frequent loss of covering of skin over the scar. He had the following scars: 28 centimeter (cm) x 0.2 cm hairline healed scar extending from the right temple to the left temple; 3 cm x 0.2 cm hypopigmented scar from the left lateral eyebrow; 3 cm x 2 cm depression without scarring of the left frontal area depth of 1.5 cm; 0.5 cm x 0.5 cm depression with scarring, infraorbital ridge of the left eye; and 2.5 cm x 0.2 cm depression without scarring from corner of the left eye to the left eyebrow. The approximate total area of head, face, and neck with hypo- or hyperpigmented area is 0.5 cm2. There is no gross distortion of asymmetry of facial features or visible or palpable tissue loss. He had decreased sensation on the left side of the face in distribution of cranial nerve V (trigeminal) as a symptom associated with his scar. In the May 2019 VA mental disorder examination, the examiner noted that this examination is for neuropsychological testing purposes only. The examiner noted that there is no cognitive dysfunction. On examination, his speech was spontaneous, normal, and easily understood. Results of brief neuropsychological tests indicate normal cognitive status, normal executive functioning and normal memory, attention and concentration based on objective testing measures from this examination. Results of this brief testing battery do not support a DSM-5 (or DSM-IV) diagnosis of any cognitive or memory disorder. In the May 2019 VA central nervous system examination, the examiner noted that the Veteran does not have muscle weakness in the upper and/or lower extremities. He also does not have bowel functional impairment. He exhibited normal gait and speech. On a cranial nerve test, he had decreased sensation of the frontal and left side of the face. The examiner determined that the Veteran has painful and/or unstable scars with a total area equal to or greater than 39 square cm located on the head, face, or neck. On current evaluation, he exhibited relatively intact neuropsychological functioning with very mild difficulty on only a few of the many tasks he performed. He did endorse a significant number of symptoms of depression. There is also the possibility that his history of head injury is contributing to his mild cognitive problems, given that head CT scan in 2009 showed left frontal encephalomalacia and his presentation is not inconsistent with this. In the May 2019 VA TBI examination, the Veteran complained of problems with short term memory, attention, and concentration. He stated he easily becomes overwhelmed by events that come to him or unable to focus or concentrate with work at hand as he would get easily distracted. On examination, the Veteran complained of mild memory loss. He exhibited normal judgment. His social interaction was routinely appropriate. He was always oriented to person, time, place, and situation. His motor activity was normal. His visual spatial orientation was normal. There were three or more subjective symptoms that mildly interfere with work (mild to moderate headaches, easily overwhelmed with situations, and insomnia). There was no evidence of neurobehavioral effects. The Veteran has the inability to communicate either by spoken language, written language, or both, more than occasionally but less than half of the time, or to comprehend spoken language, written language, or both, more than occasionally but less than half of the time. He can generally communicate complex ideas. He exhibited normal consciousness. In the May 2019 VA miscellaneous examination, the Veteran stated that he drinks alcohol socially about one to two times per month. He will have a couple of beers with his son but any more than that can increase his headaches. On examination, he exhibited intact memory, attention, concentration, and executive function. The examiner determined that there was insufficient evidence to warrant or confirm a current diagnosis of cognitive disorder due to service-connected brain disease. The neuropsychological testing completed by Dr. J. states that "results of brief neuropsychological tests indicate normal cognitive status, normal executive functioning and normal memory, attention and concentration based on objective testing measures from this examination. Results of this brief testing battery do not support a DSM-5 (or DSM-IV) diagnosis of any cognitive or memory disorder." In a May 2019 VA headaches examination, the Veteran reported that he has throbbing headaches with elevated blood pressure otherwise complaints of stabbing pain on the left side of the head injury constant with a 5/10 that increase to 8/10 especially with alcohol intake. He has prostrating attacks of migraine headache once every month. In the October 2020 VA bones examination, the Veteran reported that his headaches and memory loss became progressively worse. He claimed that he received little reprieve from headaches about two to three hours per day when Tylenol and Tramadol would kick in together. He endorsed light and noise sensitivity but denied nausea and vomiting. He stated that he gets three to four hours of sleep at night due to headache pain. His described his pain as a steady, severe ache that becomes sharp. He claimed his confusion and short-term memory loss also became worse. He lives with his son and reports that he relies on his son to help him with bills, dates, etc. He gets easily distracted from tasks and often cannot remember what task or why he was participating in the task post distraction. In the October 2020 VA cranial nerve condition examination, the Veteran reported that his headaches have 'grown worse since 2000.' He reported little reprieve from headache pain about two to three hours a day when Tylenol and Tramadol would kick in together. He endorsed light and noise sensitivity and denied nausea or vomiting. On examination, he had decreased sensation to the cranial nerve V on the left upper face and forehead. In the October 2020 VA bones examination, the Veteran endorsed having continuous headache on a continuous basis. He affirmed that Tylenol and Tramadol alleviates his symptoms. There was no weakness, stiffness, swelling, heat, redness, drainage, or fever. He denied having periods of flare ups of his bone disability. He had evidence of deformity in the left upper skull, distal left eye. The examiner confirmed that the Veteran did sustain a loss of bone or part of a bone in the left upper skull, distal left eye. Residuals of TBI The Veteran claimed that he has impaired memory and concentration. Specifically, in the September 2010 VA mental examination, he stated that he does not read anymore because he does remember or retain the information. Despite these assertions, the records show that he exhibited, at worst, objective evidence on testing of mild impairment of memory, attention, concentration or executive functions resulting in mild functional impairment consistent with a 40 percent rating. As noted above, in the November 2009 VA general examination, his memory was noted to be good and his attention, concentration, and executive function appeared to be well intact. In the September 2010 VA mental examination, he had unremarkable psychomotor activity, unremarkable speech, intact attention, intact orientation, unremarkable thought process and thought content, intact judgment, and intact insight. In a November 2011 VA treatment record, he exhibited normal speech, and logical and linear thought process. He had intact concentration, memory, and judgment. In a February 2012 VA treatment record, he had average speech. He exhibited logical and goal directed thought process. He had adequate attention, concentration, and memory. His judgment and insight were fair. In a March 2012 neuropsychological evaluation, the Veteran's thought processes were logical, coherent and goal directed. He required only occasional repetition and/or clarification of questions and task instructions. He performed in the mildly impaired range on a visual delayed recognition span task. He performed within expected levels on a visual task of sustained attention and psychomotor speed. His performance was in the low average range on an oral information processing speed task. The examiner determined that overall, the results revealed relatively intact cognitive functioning with a few areas of mild difficulty, such as mild difficulty with working memory, though other areas of attention and information processing were within normal limits. There was no evidence of significant executive dysfunction, other than mild difficulty with judgment. In the May 2019 VA examination for mental disorder, his speech was spontaneous, normal, and easily understood. Results of brief neuropsychological tests indicated normal cognitive status, normal executive functioning and normal memory, attention and concentration based on objective testing measures from this examination. Based on the foregoing, the Board finds that the Veteran's facet of memory, attention, concentration, executive functions more nearly approximates a Level 2 of impairment. Under DC 8045, a Level 2 impairment accounts for objective evidence on testing of mild impairment of memory, attention, concentration or executive functions resulting in mild functional impairment. As for the Veteran's judgment, the Board finds that the Veteran's judgment, at the worst, was noted to be fair and mildly impaired which is consistent with no higher than a Level 2 that recognizes mildly impaired judgment. The Veteran's social interaction is within normal limits (cooperative and friendly) during the appeal period, and as such a Level 0 is assigned as his social interaction is routinely appropriate. Likewise, the Veteran's orientation and motor activity is at a Level 0 as he is always oriented to person, time, place, and situation and his motor activity is normal. Regarding the Veteran's visual spatial orientation, in a March 2012 neuropsychological evaluation, he had a mildly impaired range on a visual delayed recognition span task and required occasional repetition and/or clarification of questions and task instructions, the Board finds that his spatial orientation is consistent with Level 1 showing mildly impaired visual spatial orientation. As for the Veteran's subjective symptoms, the Board finds that the Veteran's complaint is consistent with Level 1 as he has three or more subjective symptoms that mildly interferes with work and social interaction. Specifically, he has headaches, insomnia, and is easily overwhelmed with situations. Concerning neurobehavior effects, the Board finds that the Veteran has no neurobehavioral effects such as irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability. As such, the Board assigns a Level 0. Regarding communication, the Board finds that the Veteran's communication skills more nearly approximates a Level 2 impairment. The records show that he consistently had unremarkable and normal speech. Because he endorsed having difficulties in reading and needing repetition and/or clarification, the Board finds that his communication level is consistent with a finding of inability to communicate either by spoken language, written language, or both, more than occasionally but less than half of the time but can generally communicate complex ideas. He is not entitled to a Level 3 impairment as he has not shown that he cannot communicate either by verbal or written language at least half of the time but not all of the time. As for consciousness, as the Veteran is conscious during the entire appeal period, a Level 0 is assigned because he was not in persistent altered state of consciousness such as vegetative state, minimally responsive state, or coma. Based on the forgoing, the Board finds that the highest level assigned to the Veteran is Level 2, consistent with a 40 percent rating for the entire appeal period. He is not entitled to the next higher rating of 70 percent as he did not show moderate impairment of memory, attention, concentration or executive functions, moderately severely impaired judgement, inappropriate social interaction most or all of the time, disorientation to two or more of the four aspects of orientation, motor activity moderately decreased due to apraxia, moderately severely impaired visual spatial orientation, inability to communicate either by spoken language, written language, or both, at least half of the time but notal of the time, or neurobehavioral effects that interfere with or preclude workplace interaction or social interaction at any time during the appeal period. He otherwise has not identified or submitted any evidence demonstrating his entitlement to an increased rating for his service-connected residuals of a TBI. In summary, the Board finds that the criteria for a disability rating greater than 40 percent for residuals of a TBI have not been met. Headaches Considering the evidence of record in the light most favorable to the Veteran, the Board finds that the service-connected headaches are consistent with a 10 percent rating prior to May 23, 2019. The Board acknowledges that in the May 2010 notice of disagreement, July 2010 correspondence, September 2010 VA TBI examination, and October 2016 hearing, the Veteran stated that his headaches are more than mild and in fact was at a pain level of seven or eight at least once a week. Prior to May 23, 2019, the records show that he only endorsed prostrating headaches to the VA but did not complain or sought treatment for his headaches from his treating physicians. For instance, in the November 2009 VA examination, he reported that he has mild throbbing headache about one time per month that would last about two hours. He admitted that his headaches do not interfere with his job or activities of daily living. In a November 2011, January 2014, July 2014, March 2015, April 2015, and September 2015 VA treatment records, he consistently denied having headaches. The Board finds the Veteran's statement regarding the severity of his headaches not credible as it is entirety inconsistent with the treatment records. The Board finds it reasonable to conclude that, if the Veteran had prostrating headache so much so that he is deemed helpless and exhausted at least once a month, he would have sought treatment or at least complained of having prostrating headaches instead of affirmatively denying that he has headaches repeatedly. As such, the Board finds that the Veteran's symptomatology is consistent with a 10 percent rating prior to May 23, 2019. He otherwise has not identified or submitted any evidence demonstrating his entitlement to a disability rating greater than 10 percent prior to May 23, 2019, for his service-connected headaches. In summary, the Board finds that the criteria for a disability rating greater than 10 percent prior to May 23, 2019, for headaches have not been met. Frontal skull paresthesia The rating schedule does not specifically provide for ratings for frontal skull paresthesias; however, as the October 2020 examiner stated that the Veteran has decreased sensation on the left side of the face in distribution of cranial nerve V (trigeminal), the Board will rate the service-connected frontal skull paresthesias by analogy to DC 8305. The Board notes that, because there are no organic changes to the nerve roots shown by the evidence, the maximum rating which may be assigned for the Veteran's "neuritis" will be that for moderate paralysis under each applicable code. Moderate neuritis for any of the codes 8305, 8307, 8309, 8310, 8311, and 8312 warrant a 10 percent rating, which is both the minimum and maximum possible compensable rating for neuritis under any of these applicable codes. 38 C.F.R. § 4.124a. The Veteran has sensory manifestations of the left side of his forehead. Because the only compensable rating for such symptoms under any applicable code, to include DC 8305, is 10 percent, the Board finds that the criteria for a disability rating of 10 percent under DC 8305 for the Veteran's frontal skull paresthesias associated with TBI have been met for the entire appeal period. 4. Entitlement to a TDIU is granted. At the outset, the Board notes that service connection is in effect for cephalgia rated at 10 percent effective December 1, 2009 and 50 percent effective May 23, 2019, residuals of TBI rated at 40 percent effective December 1, 2009, disfigurement of a status post skull fracture injury rated at 30 percent effective December 1, 2009, acromioclavicular joint arthritis of the left shoulder rated at 10 percent effective December 1, 2009, degenerative disc disease of the lumbar spine rated at 10 percent effective December 1, 2009, bilateral tinnitus rated at 10 percent effective December 1, 2009, frontal skull paresthesia rated at 10 percent effective December 1, 2009, and for status post skull fracture with torn dura and laceration of the frontal lobe, vitreal degeneration with floaters of the left eye, hearing loss of the left ear, hypertension, genitofemoral nerve entrapment, benign prostatic hypertrophy, erectile dysfunction and bilateral inguinal scar status post hernia repair, each at a noncompensable rating effective December 1, 2009. The Veteran's combined disability rating is 80 percent effective December 1, 2009, and 90 percent effective May 23, 2019. Accordingly, for the entire appeal period the Veteran meets the schedular criteria for a TDIU. See 38 C.F.R. § 4.16(a). A review of the records shows that the Veteran's highest level of education is three years of college in aviation aeronautics. He stated that after serving 31 years in the US Coast Guard, he retired in 2009 and has not worked since his retirement from service. In March 2011, he stated that while he is able to perform the basic functions (bathing, cooking, driving a car, using electronic equipment), his day is littered with chronic forgetfulness and absentmindedness. At the Board hearing, he testified that he is unable to work due to the residuals from his TBI. In his November 2017 notice of disagreement, he stated that his confusion and memory loss alone would make him a liability in any sort of work environment because that would lead to a series of incomplete tasks and possibly even accidents. Regarding the Veteran's residuals of a TBI, the May 2019 examiner opined that this disability would impact his ability to work. For example, he complained of constant headache rated at 5/10 that increases to 8/10 intermittently affecting his daily activities. He also reported some problems with short term memory and being overwhelmed by events that come his way. He endorsed being easily distracted and unable to focus or concentrate. The October 2020 examiner opined that headaches and memory loss status post TBI would greatly impact his ability to focus on the task at hand. In contrast, the June 2019 examiner opined that as the March 2012 neuropsychological assessment only diagnosed the Veteran with depressive disorder NOS and not TBI, the Veteran's disability is less likely than not to render him unable to secure and maintain substantially gainful employment. The examiner also opined that frontal lobe and residuals of a TBI and frontal skull paresthesia are less likely to prohibit him from gainful employment. The Board affords little probative value to the June 2019 examiner's medical opinion as it is factually incorrect. The March 2012 neuropsychological evaluation diagnosed the Veteran with cognitive disorder not otherwise specified. The March 2012 neuropsychologist even noted that the Veteran's cognitive disorder is possibly from his TBI as a 2009 CT scan showed left frontal encephalomalacia which would explain his presentation. As for his scar, the May 2019 examiner opined that the Veteran's scar or disfigurement of the head, face, or neck does not impact his ability to work. The June 2019 examiner opined that the scars are less than likely to prohibit him from obtaining gainful employment. Regarding the Veteran's paresthesia, the May 2019 examiner determined that the Veteran's paresthesia would impact his ability to work. The July 2019 examiner opined that paresthesia residuals are less than likely prohibit him from gainful employment. The October 2020 examiner opined that the frontal skull paresthesia does not limit his functional ability. That being said, the examiner noted that headaches and memory loss status would greatly impact the Veteran's ability to focus on the task at hand. Concerning the service-connected left shoulder disability, a June 2019 examiner opined that it is less than likely to prohibit the Veteran from obtaining gainful employment. The examiner explained that the left shoulder disability may result in increased pain which will produce decreased range of motion and as such the Veteran may not be able to lift loads above head. Sedentary work is not affected. As for the service-connected low back disability, a June 2019 examiner opined that this disability is less than likely to prohibit the Veteran from gainful employment. No rationale was given. Regarding the service-connected eye disability, the examiner opined that there is no scenario in which the Veteran would be unable to work due to floaters. The Board has considered the functional limitations caused by the Veteran's service-connected disabilities and the medical opinions of record. The Board finds that, due to the Veteran's left shoulder disability and low back disability, he is prohibited from lifting and carrying more than 10 pounds frequently. He would be limited in his use of the left arm such as reaching. Due to the residuals of a TBI, he is limited to performing simple and repetitive tasks. The Board recognizes that he would have difficulties in performing clerical jobs as he has headaches, memory loss, and difficulties with concentration. The Board also considered whether he can perform simple and repetitive jobs such as sorting and packing. Due to his residuals of TBI, left shoulder disability, and low back disability, the Board finds that the Veteran would not be a reliable employee and would be off task for more than five percent of the time. As such, the Board finds that the Veteran is not capable of performing the physical and mental acts required for employment and thus grants the claim of entitlement to a TDIU. REASONS FOR REMAND Entitlement to an initial compensable rating for residuals of a head injury diagnosed as status-post skull fracture with torn dura and laceration of the frontal lobe is remanded. The Veteran's loss of part of the skull, both inner and outer tables, is rated under DC 5296. In the October 2020 VA bones examination, the examiner noted that the Veteran has evidence of deformity in the left upper skull and distal left eye. The examiner also confirmed that the Veteran sustained a loss of bone or part of a bone in the left upper skull and distal left eye and noted that there was a depression. The examiner did not indicate the size of the bone loss. The Board has considered the May 1988 surgery report and the October 2020 VA bones examination but finds that there is insufficient evidence to determine whether there was loss of part of skull of both the inner and outer tables and whether the size of the loss was that of a size of a 25-cent piece (0.716 in2) or bigger. As such, the Board finds that a remand is warranted. The matter is REMANDED for the following action: 1. Schedule the Veteran for an appropriate examination to determine the size of the bone loss (skull fracture) due to his service-connected residuals of a head injury. The clinician is asked to determine whether the Veteran's loss of part of the skull includes both the inner and outer tables. If so, then the clinician is asked to state whether the bone loss covers an area smaller than the size of a 25 cent piece or 0.716 in2 (4.619 cm2), intermediate size, or an area that is larger than the size of a 50-cent piece or 1.140 in2 (7.355 cm2). 2. Thereafter, readjudicate the appeal. MICHAEL T. OSBORNE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Noh, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.