Citation Nr: 22019540 Decision Date: 04/01/22 Archive Date: 04/01/22 DOCKET NO. 19-21 932 DATE: April 1, 2022 ORDER The petition to reopen the claim for service connection for left knee strain is denied. The petition to reopen the claim for service connection for broken left orbital bone is denied. The petition to reopen the claim for service connection for broken right orbital bone is denied. Entitlement to an earlier effective date for the grant of service connection of left lower extremity radiculopathy is denied. The reduction of the disability rating for left ankle sprain from 10 percent to 0 percent, effective January 19, 2018, was not proper; a 10 percent rating is restored. The reduction of the disability rating for traumatic headaches from 30 percent to 0 percent, effective January 19, 2018, was not proper; a 30 percent rating is restored. Entitlement to a rating in excess of 30 percent for traumatic headaches is denied. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) with traumatic brain injury (TBI) from December 11, 2017, is denied. Entitlement to an effective date prior to December 11, 2017, for the grant of a 70 percent rating for PTSD with TBI is denied. REMANDED Service connection for brain syncope (also claimed as fainting) is remanded. Service connection for high blood pressure is remanded. Entitlement to a rating in excess of 10 percent for left ankle sprain is remanded. Entitlement to a rating in excess of 10 percent for temporomandibular joint (TMJ) disorder is remanded. Entitlement to a rating in excess of 10 percent for lumbosacral strain is remanded. Entitlement to a rating in excess of 10 percent for left hip strain is remanded. Entitlement to a rating in excess of 20 percent for left shoulder (minor) strain is remanded. Entitlement a rating in excess of 10 percent for left lower extremity radiculopathy is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Service connection for left knee strain was denied in an unappealed October 2015 rating decision. 2. Service connection for broken right and left orbital bone were denied in an unappealed September 2016 rating decision. 3. The evidence received since the October 2015 and September 2016 rating decisions is cumulative and redundant and neither relates to an unestablished fact necessary to substantiate the claims nor raises a reasonable possibility of substantiating the claims. 4. December 11, 2017, is the earliest effective date assignable for service connection for left lower extremity radiculopathy. 5. At the time of the reduction, the 10 percent rating for a left ankle disability and 30 percent rating for traumatic headaches had been in effect for less than five years. 6. Resolving all doubt in the Veteran's favor, the severity of his left ankle and traumatic headache symptoms do not reflect an overall improvement in his ability to function under the ordinary conditions of life and work. 7. The Veteran's traumatic headaches do not manifest with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 8. It was not factually ascertainable that the Veteran's PTSD with TBI had worsened until January 19, 2018. 9. From December 11, 2017, the severity, frequency, and duration of the Veteran's symptoms do not more closely approximate total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria to reopen the claim for service connection for left knee strain have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 2. The criteria to reopen the claim for service connection for broken left orbital bone have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria to reopen the claim for service connection for broken right orbital bone have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 4. Entitlement to an earlier effective date for the grant of service connection of left lower extremity radiculopathy is denied. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 5. The criteria for an effective date prior to December 11, 2017, for the award of a 70 percent rating for PTSD with TBI have not been met. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. 6. The criteria for a restoration of a 10 percent disability rating for left ankle sprain have been met. 38 U.S.C. §§ 1155, 5107, 5112; 38 C.F.R. §§ 3.102, 3.105(e), 3.344, 4.71a, Diagnostic Code 5271. 7. The criteria for a restoration of a 30 percent disability rating for traumatic headaches have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105 (e), 4.104, Diagnostic Code 8100. 8. The criteria for a rating in excess of 30 percent for traumatic headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8100. 9. The criteria for a rating in excess of 70 percent for PTSD with TBI from December 11, 2017, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code 8045-9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 2012 to June 2015. This matter comes before the Board of Veterans' Appeals (Board) from a March 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board acknowledges the January 2019 notice of disagreement includes a disagreement with the effective dates assigned in the March 2018 rating decision regarding increased ratings for lumbosacral strain, TMJ disorder, left shoulder strain, and left hip strain. However, the rating decision denied increased ratings and there were no effective dates assigned with which to dispute. Similarly, while the January 2019 notice of disagreement includes a disagreement with the effective date of the Veteran's left ankle disability, the Board herein restores the Veteran's 10 percent disability rating such that there is no effective date to dispute. Therefore, these issues are not before the Board. Additional evidence was submitted after the appeal was certified to the Board. As in this case, section 501 of the Camp Lejeune Act of 2012 provides an automatic waiver of evidence submitted by a veteran or his or her representative with or after a substantive appeal received on or after February 2, 2013. Therefore, the Board may properly consider this evidence. Additionally, the Veteran's representative agreed to waive AOJ consideration. Therefore, the Board may review the evidence in the first instance. See 38 C.F.R. § 20.1304 (c). New and Material Evidence 1. The petition to reopen the claim for service connection for left knee strain is denied. 2. The petition to reopen the claim for service connection for broken left orbital bone is denied. 3. The petition to reopen the claim for service connection for broken right orbital bone is denied. The Veteran seeks to reopen a claim for service connection for left knee strain and broken left and right orbital bones. The Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156 (a). Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. An October 2015 rating decision denied service connection for left knee strain because the evidence failed to demonstrate an in-service injury, event, or disease. The Veteran was notified of the decision in an October 2015 correspondence. The Veteran did not initiate an appeal of this decision. Although VA medical records were associated with the claims file within one year of the decision, the records were not material to the claim of service connection for left knee strain. As new and material evidence was not received within a year of notice of the October 2015 rating decision, the decision finalized. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156 (b), 20.302, 20.1103; see also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011). Service connection for broken left orbital bone was denied in November 2015 and September 2016 rating decisions because the medical evidence of record failed to show that the disability was clinically diagnosed. Service connection for broken right orbital bone was denied in a September 2016 rating decision because the evidence did not show a currently diagnosed disability nor evidence of an in-service event, disease, or injury. The Veteran was notified of the decisions and his appellate rights in November 2015 and September 2016. He did not file a notice of disagreement, and no new and material evidence was received within one year of notification of the decisions. Therefore, the November 2015 and September 2016 rating decisions became final. In December 2017, the Veteran sought to reopen a claim for service connection for broken left and right orbital bone disability and left knee disability. Evidence received since the October 2015 and September 2016 rating decisions includes VA treatment records. The VA treatment records continue to reflect a history of in-service left orbital bone fracture and a current left knee disability. After a review of the evidentiary record, the Board finds new and material evidence has not been received to reopen the claims for service connection for left knee strain and broken left and right orbital bone. While some of the evidence is new, it is not material because it does not establish an in-service left knee injury, a current orbital bone disability, or a causal relationship between a current left knee or orbital bone disability and his service. Neither medical records nor the lay statement of record suggests a current left or right orbital bone disability. Additionally, the medical records do not contain any opinion linking a current left knee or orbital bone disability to his service. The treatment records are essentially redundant and cumulative of the prior evidence of record. Neither the Veteran nor the record has presented any new evidence that would create a reasonable possibility of substantiating the claim or that would trigger the need for a VA examination or medical opinion pursuant to Shade. The threshold for reopening a claim is low, but it is a threshold nonetheless. See Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). As the Veteran has not fulfilled the threshold burden of submitting new and material evidence, the petition to reopen the final disallowed claim of service connection for left knee strain and broken left and right orbital bone is denied. Effective Dates 4. Entitlement to an earlier effective date for the grant of service connection of left lower extremity radiculopathy is denied. The Veteran seeks an effective date prior to December 11, 2017, for service connection of left lower extremity radiculopathy. A March 2018 rating decision granted service connection for left lower extremity radiculopathy with a 10 percent rating effective December 11, 2017. Generally, except as otherwise provided, the effective date of an award of compensation based on an original claim will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. The date of entitlement for an award of service connection will be the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service. Otherwise, the effective date will be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400 (b)(2)(i). For VA compensation purposes, a "claim" is defined as "a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." 38 C.F.R. § 3.1 (p). An informal claim is "[a]ny communication or action indicating an intent to apply for one or more benefits." It must "identify the benefit sought." 38 C.F.R. § 3.155 (a). Thus, the essential elements for any claim, whether formal or informal, are "(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing." Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). When determining the effective date of an award of compensation benefits, the Board is required to review all communications in the file that could be interpreted as a formal or informal claim for benefits. See Lalonde v. West, 12 Vet. App. 377, 380-81 (1999). A November 2015 rating decision denied service connection for radiculopathy. The Veteran was notified of the decision and his appellate rights in a November 2015 correspondence. New and material evidence was not received within one year of notification of the decision, and the Veteran did not file a notice of disagreement with the decision. Therefore, the November 2015 rating decision finalized. Thereafter, a careful review of the record does not show an unadjudicated claim for service connection for lower extremity radiculopathy. While a November 17, 2017, VA treatment record notes immediate lumbar pain radiating to left leg, the January 2018 VA back examination is the first evidence of record that demonstrates a diagnosis of left lower extremity radiculopathy. The Veteran's increased rating claim for his service-connected back disability was received on December 11, 2017. The present appeal stems from that claim. A claim for increased rating for a back disability necessarily includes consideration of any associated objective neurologic abnormalities. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). Therefore, a claim for radiculopathy affecting a lower extremity was part of the underlying claim for an increased rating for his service-connected back disability. Therefore, the currently assigned effective date of December 11, 2017, is the earliest effective date assignable for service connection. The legal authority governing effective dates is clear and specific, and the Board is bound by such authority. Here, based on the evidence of record and the applicable VA regulations, the earliest date allowable for the award of service connection for left lower extremity radiculopathy is the current effective date of December 11, 2017, the date on which the Veteran's claim for increased rating for his back disability was received. See 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. As the evidence weighs persuasively against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 5. Entitlement to an effective date prior to December 11, 2017, for the award of a 70 percent rating for PTSD with TBI is denied. The Veteran seeks an effective date prior to December 11, 2017, for the award of a 70 percent rating for PTSD with TBI. Generally, the effective date of an award based on a claim for increase shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110 (a); see 38 C.F.R. § 3.400. An effective date for increased disability compensation shall be the earliest date as of which it is factually ascertainable that an increase in disability occurred, if application is received within one year from such date. 38 U.S.C. § 5110 (b)(2); 38 C.F.R. § 3.400 (o)(2). "[A]n increase in a veteran's service-connected disability must have occurred during the one-year period prior to the date of the veteran's claim in order to receive the benefit of an earlier effective date." Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010) (discussing 38 U.S.C. § 5110 (b)(2) and 38 C.F.R. § 3.400 (o)(2)). If the increase in disability is shown to have occurred after the date of claim, the effective date is the date of increase. See 38 U.S.C. § 5110 (b)(2); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. § 3.400 (o)(1); VAOPGCPREC 12-98 (1998). In determining when an increase is "factually ascertainable," all of the evidence must be looked to, including testimonial evidence and expert medical opinions, and an effective date must be assigned based on that evidence. See McGrath v. Gober, 14 Vet. App. 28, 35-36 (2000); VAOPGCPREC 12-98. Thus, "it is the information in a medical opinion, and not the date the medical opinion [that] was provided that is relevant when assigning an effective date." Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010); see also Young v. McDonald, 766 F.3d 1348 (Fed. Cir. 2014). Turning to the evidentiary record, the Veteran originally filed a claim for service connection for PTSD in June 2015. An October 2015 rating decision granted service connection. The Veteran did not file a notice of disagreement with the October 2015 rating decision; however, he filed an increased rating claim in May 2016. New and material evidence was associated with the record within one year of the October 2015 rating decision such that it did not finalize. A September 2016 rating decision increased the Veteran's disability rating to 50 percent effective May 6, 2016. The Veteran was notified of the decision and his appellate rights in September 2016. He did not file a notice of disagreement nor was new and material evidence received within one year of notification of the decision. Therefore, the September 2016 rating decision finalized. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104 (a), 3.160(d), 3.156(b), 20.302, 20.1103. Furthermore, a careful review of the record shows that there is no evidence of an unadjudicated claim for an increased rating for PTSD prior to December 2017. As the Veteran's claim for increased ratings was received on December 11, 2017, the proper effective date is December 11, 2017, or within the one-year look back period if it is factually ascertainable that an increase in disability occurred. The record does not include relevant evidence between December 2016 and June 2017. A June 2017 VA treatment record indicates the Veteran reported some improvement since increasing medication. He denied suicidal and homicidal ideation. The treating physician indicated he was on time for his appointment and alert and oriented in all spheres. He was further described as displaying logical and coherent thought processes, fluent speech with rate and volume within normal limits, no psychotic processes, no psychomotor agitation, normal consciousness, appropriate affect, and intact judgment and insight. A January 2018 VA examination indicates the Veteran's mental health diagnosis has worsened. The examiner characterized the Veteran's level of impairment as occupational and social impairment with deficiencies in most area, such as work, school, family relations, judgment, thinking, and/or mood. The examiner noted symptoms of anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent event; flattened affect; impaired abstract thinking; difficulty in adapting to stressful circumstances, including work or a worklike setting; and inability to establish and maintain effective relationships. The examiner noted the Veteran reported no longer enjoying a variety of activities and being less social, emotionally numb, and easily angered. The Veteran denied suicidal ideation. A May 2018 VA TBI examination reflects a compliant of intermittent mild memory loss, which he described as difficulty with short-term memory, mixing up dates, or trouble recalling thinks like what he did last week. The examiner noted normal judgment and routinely appropriate social interaction. The Veteran was oriented to person, time, place, and situation. He had normal motor activity, consciousness, and visual spatial orientation. The examiner noted three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships. He also had one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them. He was able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language. A June 2018 VA examination characterized the Veteran's impairment as occupational and social impairment with reduced reliability and productivity. The examiner noted symptoms of depressed mood; anxiety; chronic sleep impairment; difficulty in adapting to stressful circumstances, including work or a worklike setting; and inability to establish and maintain effective relationship. A September 2018 VA treatment record indicates the Veteran was alert and orient with grooming and hygiene within normal limits. He was described as displaying mildly anxious and depressed mood, full-range affect, normal speech, and no perceptual or thought abnormalities. The treating physician described the Veteran as possessing linear, logical, and goal directed thought processes with grossly intact insight and judgment. The Veteran continued to deny suicidal and homicidal ideation. A February 2019 VA treatment record indicates the Veteran was well-groomed and displayed fair mood affected by pain, cooperative behavior, normal speech, no evidence of thought disorder, and no delusions or paranoia. He denied suicidal or homicidal intent or plan. A March 2021 VA treatment record indicates the Veteran was oriented with normal speech and displayed clear and linear thoughts, euthymic mood, and no perceptual disturbances. He continued to deny suicidal ideation. A May 2021 VA treatment record notes variable sleep with some PTSD night terrors. After a careful review of the evidentiary record, the Board finds it was not factually ascertainable that the Veteran's PTSD had increased until January 19, 2018, which is after the Veteran's application for an increased rating. Thus, the Veteran is already in receipt of the earliest effective date possible, December 11, 2017. The Board reiterates that the legal authority governing effective dates is clear and specific. Based on the evidence of record and the applicable VA regulations, the earliest date allowable for the award of a 70 percent rating for PTSD with TBI is the current effective date of December 11, 2017, the date on which the Veteran's claim for increased rating for PTSD with TBI was received. See 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. As the evidence weighs persuasively against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Reductions When a reduction in an evaluation of a service-connected disability is considered warranted and the lower evaluation would result in a reduction or discontinuance of compensation payments being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons. In addition, the RO must notify the Veteran that he has 60 days to present additional evidence showing that compensation should be continued at the present level. 38 C.F.R. § 3.105 (e). In this case, the Veteran was not notified of the proposed reduction of his disability ratings in accordance with 38 C.F.R. § 3.105 (e). However, as the rating action that implemented the rating reductions did not change the Veteran's overall disability rating, a reduction of compensation payments did not occur, and the procedural safeguards of 38 C.F.R. § 3.105 (e) do not apply. See VAOPGCPREC 71-91 (Nov. 7, 1991); Stelzel v. Mansfield, 508 F.3d 1345, 1347- 49 (Fed.Cir.2007). Reducing a rating also brings concurrent substantive requirements that must be followed. When a disability rating has been in effect less than five years, as in this case, a rating reduction is warranted where reexamination of the disability discloses improvement of that disability. 38 C.F.R. § 3.344 (c). In making this determination, however, VA is required to comply with several regulations applicable to all rating-reduction cases, regardless of the rating level or the length of time that the rating has been in effect. 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.13; see Brown v. Brown, 5 Vet. App. 413, 420 (1993). The regulations impose a clear requirement that rating reductions be based upon review of the entire history of the veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Such review requires VA to ascertain whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based upon thorough examinations. Thus, in any rating reduction case it not only must be determined whether an improvement in disability occurred but whether it actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. Brown, 5 Vet. App. at 420-21; Faust v. West, 13 Vet. App. 342, 350 (2000); see also 38 C.F.R. §§ 4.2, 4.10. Moreover, though a rating reduction must have been supported by the evidence on file at the time of the reduction, pertinent post-reduction evidence favorable to restoring the rating also must be considered. Dofflemeyer v. Derwinski, 2 Vet. App. 227 (1992). 6. The reduction of the disability rating for left ankle sprain from 10 percent to 0 percent, effective January 19, 2018, was not proper; a 10 percent rating is restored. The Veteran seeks to restore a 10 percent rating for left ankle sprain effective January 19, 2018. An October 2015 rating decision granted service connection for left ankle sprain and assigned a 10 percent rating effective June 13, 2015. In December 2017, the Veteran sought an increased rating. A March 2018 rating decision decreased the Veteran's left ankle sprain evaluation to 0 percent effective January 19, 2018. The 10 percent rating for left ankle sprain was reduced effective January 19, 2018; therefore, the rating was in effect for less than five years. Thus, 38 C.F.R. § 3.344 (c) is applicable, and the added protections of § 3.344(a), (b) are not applicable. A reexamination disclosing improvement in this disability will warrant a reduction in the rating. 38 C.F.R. § 3.344 (c). Nonetheless, for the following reasons, the Board finds that the reduction of the rating for left ankle sprain was improper. The Veteran's left ankle disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5271, for limitation of motion of the ankle. Under Diagnostic Code 5271, a 10 percent rating is warranted for moderate limited motion of the ankle and a 20 percent rating is warranted for marked limited motion of the ankle. Id. According to MERRIAM WEBSTER, "moderate" means "tending toward the mean or average amount or dimension". See www.merriam-webster.com/dictionary/moderate. "Marked" means "having a distinctive or emphasized character". See www.merriam-webster.com/dictionary/marked. The 10 percent rating was granted based on moderate limitation of motion of the ankle based on dorsiflexion less than 15 degrees. An August 2015 VA examination reflects dorsiflexion to 10 degrees and plantar flexion to 45 degrees with pain on dorsiflexion. The examiner indicated that while pain significantly limits functional ability with repeated use over a period of time and/or during a flare-up, there is no change in range of motion because the pain affects lateral movement only. The January 2018 VA examination used to support the reduction of the Veteran's disability rating reflects dorsiflexion to 20 degrees and plantar flexion to 45 degrees. The examiner was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limit functional ability with flare-ups. The Veteran reported flare-ups with prolonged walking and standing and increased stabbing pain in left ankle. The Board finds that the evidence weighs in favor of a restoration of the 10 percent rating because it is not shown that the severity of the Veteran's left ankle symptoms reflects actual improvement in his ability to function under the ordinary conditions of life and work. Significantly, the pertinent post-reduction evidence, in the form of the Veteran's competent and credible lay testimony, shows his disability has not improved overall. While the January 2018 examination report notes that his ranges of motion are normal, the examination does not adequately consider additional limitation due to pain with repeated use over a period of time or during a flare-up that may reduce the Veteran's range of motion. Accordingly, the 10 percent rating for the Veteran's left ankle disability is restored effective January 19, 2018. 7. The reduction of the disability rating for traumatic headaches from 30 percent to 0 percent, effective January 19, 2018, was improper; a 30 percent rating is restored. The Veteran seeks to restore a 30 percent rating for traumatic headaches effective January 19, 2018. A November 2015 rating decision granted service connection for traumatic headaches and assigned a 30 percent rating effective June 13, 2015. In December 2017, the Veteran sought an increased rating. A March 2018 rating decision decreased the Veteran's traumatic headaches evaluation to 0 percent effective January 19, 2018. The 30 percent rating for traumatic headaches was reduced effective January 19, 2018; therefore, the rating was in effect for less than five years. As noted above, the rating action that implemented the rating reductions did not change the Veteran's overall disability rating, a reduction of compensation payments did not occur, and the procedural safeguards of 38 C.F.R. § 3.105 (e) do not apply. See VAOPGCPREC 71-91 (Nov. 7, 1991); Stelzel, 508 F.3d at 1347- 49. Nonetheless, for the following reasons, the Board finds that the reduction of the rating was improper. Headaches are rated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100, for migraine. A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months. The phrase "characteristic prostrating attacks" is used in the criteria corresponding to 10 percent and 30 percent ratings under Diagnostic Code 8100 to describe the nature and severity of migraines, but it is not defined in the regulation. Pursuant to Dorland's Illustrated Medical Dictionary 1531 (32d ed. 2012), prostration is defined as "extreme exhaustion or powerlessness." Thus, the phrase "characteristic prostrating attacks" is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness. The 30 percent rating was granted based on characteristic prostrating attacks occurring on an average of once a month over the last several months. An August 2015 VA examination indicates the Veteran's headache pain includes pulsating or throbbing head pain, pain localized to one side of the head, and pain that worsens with physical activity. He also experiences non-headache symptoms such as nausea, sensitivity to sound, and dizziness. His head pain lasts for more than 2 days on the left side of the head. The examiner indicated the Veteran has characteristic prostrating attacks of migraine/ non-migraine headache pain with less frequent attacks. The examiner also indicated the Veteran has very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. An October 2015 VA examination similarly reflects that the Veteran's headache pain includes constant head pain, pulsating or throbbing head pain, pain localized to one side of the head, and pain that worsens with physical activity. The examiner indicated the Veteran experiences non-headache symptoms associated with headaches, including nausea, sensitivity to light and sound, changes in vision, and sensory changes. He experiences this head pain for less than 1 day on the left side of the head. The examiner indicated the Veteran has characteristic prostrating attacks once every month and has very prostrating and prolonged attacks of pain productive of severe economic inadaptability. The examiner indicated the Veteran's headache disability impacts his ability to work because he does not feel safe driving due to associated black outs. The January 2018 VA examination used to support the reduction of the Veteran's disability rating indicates the Veteran reported constant headaches and headaches that last a couple of seconds to a couple of minutes. The examiner indicated the Veteran experiences constant head pain, pulsating or throbbing head pain, and pain localized to one side of head. The examiner also indicated the Veteran experiences non-headache symptoms such as nausea and lightheadedness. The examiner indicated the typical head pain last for less than one day on the left side of head. The examiner also indicated the Veteran does not have characteristic prostrating attacks of headache pain. A February 2018 VA treatment record notes headaches without aura or scotomata that are usually left parietal with photophobia and phonophobia. A May 2018 VA TBI examination indicates the Veteran reported having migraines which cause him to have nausea and lightheadedness/dizziness. He also reported feeling tingling in the back of his head and sometimes missing work/class due to headaches. The examination also indicated that the daily headaches are mild to moderate. An October 2018 VA examination indicates the Veteran experiences constant head pain, pulsating or throbbing head pain, pain located to one side of the head, and sensitivity to light and sound. The examiner also found the Veteran does not have characteristic prostrating attacks of headache pain. The January and October 2018 VA examiner also found the Veteran's headache disability does not impact his ability to work. The evidence weighs in favor of restoration of the 30 percent rating because it is not shown that the severity of the Veteran's traumatic headaches reflects actual improvement in his ability to function under the ordinary conditions of life and work. Significantly, the pertinent post-reduction evidence, in the form of the Veteran's competent and credible lay testimony, shows his disability has not improved overall. The January and October 2018 VA examination reports indicate the Veteran's headaches manifested in non-prostrating attacks that do not impact his ability to work. In contrast, the Veteran's lay reports reflect that his symptoms have not improved throughout the appeal period. Indeed, during a May 2018 TBI examination, the Veteran reported his headaches cause him to have intermittent absences from work. Moreover, the Board observes that those two examination reports appear to show that headache symptoms and frequency that are consistent with the 2015 examination reports upon which the 30 percent rating was based. Moreover, the 2018 examination reports did not address the Veteran's report of missing work due to his headaches when finding that he no longer has prostrating attacks. Accordingly, the 30 percent rating for the Veteran's traumatic headache disability is restored effective January 19, 2018. Increased Ratings 8. Entitlement to a rating in excess of 30 percent for traumatic headaches is denied. The Veteran seeks a rating in excess of 30 percent for traumatic headaches. The period on appeal begins December 11, 2016, one year prior to receipt of the Veteran's increased rating claim. Headaches are rated pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8100, for migraine. Under Diagnostic Code 8100, a 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 50 percent rating is the highest schedular rating under Diagnostic Code 8100. The rating criteria of Diagnostic Code 8100 are considered successive, meaning that a claimant cannot fulfill the criteria of the higher rating without fulfilling those of the next lower rating. Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018). This renders 38 C.F.R. §§ 4.7 and 4.21 inapplicable. Johnson, 30 Vet. App. at 252. The rating criteria do not define "severe economic inadaptability;" however, nothing in the applicable diagnostic code requires the claimant to be completely unable to work in order to qualify for a 50 percent rating. See Pierce v. Principi, 18 Vet. App. 440 (2004). The probative evidence weighs against entitlement to a rating in excess of 30 percent. From December 11, 2016, the evidence of record reflects migraine headaches that are usually left parietal without aura or scotomata but are positive for photophobia and phonophobia. However, the record does not demonstrate that the Veteran's traumatic headaches manifest with frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Thus, a 50 percent rating under Diagnostic Code 8100 is not warranted. The Veteran is competent to report his readily observable symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The record reflects the Veteran has reported his headaches cause him to have intermittent absences from work. Similarly, in October 2021, a private certified vocational evaluator and rehabilitation counselor found the Veteran's traumatic headaches impact his ability to work because they make it difficult for him to focus on his job and sometimes progress to seizures. VA treatment records dated in August 2017, February 2018, September 2018, and November 2018 reveal left parietal migraine headaches with no aura. The Veteran reported photophobia and phonophobia. During his January 2018 VA examination, the Veteran reported constant headaches that last a couple of seconds to a couple of minutes. The Veteran indicated the head pain lasts less than one day on the left side of the head. A May 2018 VA TBI examination indicates the Veteran's daily mild to moderate headaches mildly interfere with work, in conjunction with other TBI symptoms. His October 2018 VA examination also indicates the head pain lasts less than one day on the left side of the head. While the Veteran's migraines have manifested very frequently, even daily, they have not been productive of severe economic inadaptability. The Veteran reports the duration of his headaches are only a couple of seconds to a couple of minutes and the evidence reflects the Veteran reported missing work or only 'sometimes' or 'intermittently.' The Board finds intermittent absences from work is not most consistent with prolonged attacks capable of being producing severe economic inadaptability. None of the examining VA clinicians have suggested, after evaluating the Veteran and reviewing the record, that the Veteran's traumatic headaches are productive of severe economic inadaptability. Therefore, the Board finds that his headaches are more nearly approximate to his currently assigned 30 percent rating. In sum, the Board concludes the Veteran's headaches did not occur with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability Accordingly, a rating in excess of 30 percent for traumatic headaches under Diagnostic Code 8100 is not warranted. 9. Entitlement to a rating in excess of 70 percent from December 11, 2017, for PTSD with TBI is denied. The Veteran seeks a rating in excess of 70 percent from December 11, 2017. An October 2015 rating decision granted service connection for PTSD. In December 2017, the Veteran sought an increased rating for PTSD. A March 2018 rating decision granted a 70 percent rating effective December 11, 2017. A June 2018 rating decision recharacterized the issue as PTSD with TBI and continued the 70 percent rating. The appeal period begins December 11, 2016, one year prior to receipt of the Veteran's increased rating claim. The Veteran's PTSD with TBI is rated pursuant to 38 C.F.R. § 4.130, Diagnostic Codes 8045-9411. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that TBI (Diagnostic Code 8045) is rated under the criteria for psychiatric disorders (Diagnostic Code 9411). Diagnostic Code 9411 is rated under the General Rating Formula for Mental Disorders (General Formula). Under the General Formula, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). Additionally, under the General Formula, a 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. After a review of the evidentiary record, the Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 100 percent. The Veteran's symptoms more closely approximated the symptoms associated with a 70 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. The VA treatment records, VA examinations, and the Veteran's lay statements discussed above show that the Veteran's PTSD with TBI was manifested by depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent event; flattened affect; impaired abstract thinking; difficulty in adapting to stressful circumstances, including work or a worklike setting; and inability to establish and maintain effective relationships. Therefore, his PTSD was manifested by symptoms associated with a 70 percent rating, including depression, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships. His PTSD was also manifested by symptoms associated with a 100 percent rating, including memory loss. The Board finds the severity, frequency, and duration of the Veteran's symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. The Board also finds the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 70 percent rating. The Veteran experienced occupational and social impairment ranging from reduced reliability and productivity to deficiencies in most areas. Mental status examinations in VA treatment records and the January 2018 and June 2018 VA examinations indicate that the Veteran was alert and oriented with grooming and hygiene within normal limits. He generally displayed cooperative behavior, normal speech, no evidence of thought disorder, and no delusions or paranoia. While the Veteran did report symptoms contemplated by a 100 percent ratingnamely memory lossthe evidence overall does not demonstrate the level of impairment associated with a 100 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 70 percent rating. Further, he was not totally socially impaired. While the January 2018 VA examiner noted the Veteran reported decreased interest in activities and being social, records show the Veteran generally reported a girlfriend throughout the appeal period and a good relationship with his father. Finally, a higher or separate rating is not available under Diagnostic Code 8045. The evidence generally indicates the Veteran's PTSD and TBI symptoms overlap such that they cannot be distinguished. See June 2018 VA PTSD examination. However, contemplating the Veteran's symptoms under Diagnostic Code 8045 would not warrant a rating in excess of 70 percent because the record does not show that a severity level of total is warranted for any of the facets tested under the TBI table at any time during the appeal period. In short, the evidence of record persuasively weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 100 percent rating. The criteria for a 100 percent or higher rating are not met and the appeal must be denied. REASONS FOR REMAND 10. Entitlement to a rating in excess of 10 percent for lumbosacral strain is remanded. 11. Entitlement to a rating in excess of 10 percent for TMJ disorder is remanded. 12. Entitlement to a rating in excess of 10 percent for left ankle sprain is remanded. 13. Entitlement to a rating in excess of 10 percent for left hip strain is remanded. 14. Entitlement to a rating in excess of 20 percent for left shoulder (minor) strain is remanded. The January 2018 VA examinations for the left ankle disability, left hip strain, left shoulder strain, lumbosacral strainand TMJ disorder do not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). The examiners were unable to provide assessments of any additional range of motion loss due to pain on use or during flare-ups, without resort to speculation. However, the examiners did not indicate that the speculation was due to lack of knowledge within the medical community. Accordingly, new examinations should be obtained. 15. Entitlement a rating in excess of 10 percent for left lower extremity radiculopathy is remanded. The evidence obtained from the remand for the lumbosacral strain will likely yield evidence for the left lower extremity radiculopathy. Thus, the Board will defer adjudication of this issue at this time. 16. Service connection for brain syncope (also claimed as fainting) is remanded. The Veteran seeks service connection for brain syncope and/or fainting. Unfortunately, addition clarification regarding the nature and etiology of the Veteran's claimed disability is necessary, to include whether he has a current disability resulting in seizures or seizure-like symptoms, and whether such disability is secondary to his service-connected PTSD with TBI and/or his traumatic headaches. Service treatment records show that in October 2013 the Veteran passed out after completing a physical training run, resulting in a left-sided head injury. An October 2014 record shows he had headaches preceded by severe left facial pain and suspected vasovagal syncope induced by pain; transient alteration of awareness and presentation atypical of seizure disorder was also noted. In November 2014 transient alteration of awareness and presentation atypical of seizure disorder was noted. The treating physician noted his symptoms likely represented panic attacks or spectrum somatoform disorder. In January 2015, the Veteran was referred to neurology regarding a syncope episode precipitated by severe headache. The record reflects a provisional diagnosis of fainting. A February 2015 record notes fainting (syncope) and multiple episodes of alteration of consciousness that appeared to be more related to anxiety or panic attack than any neurologic syndrome; however, the clinician indicated vestibular migraines or basilar migraines may have caused some of his complaints (but are not responsible for all of his prodromal symptoms.) An April 2015 health questionnaire for dental treatment notes brain syncope as an unusual medical problem. After service, an August 2015 VA seizure disorders examination report indicated the Veteran does not have a seizure disorder; however, the examiner noted July 2015 electroencephalography (EEG) results were supportive of a diagnosis of nonepileptic seizures (NES). A September 2015 VA treatment record indicates the Veteran's spells have been shown to be non-epileptic and a differential diagnosis of psychogenic nonepileptic seizures (PNES) versus complicated migraines was provided. A February 2020 VA treatment record indicates the Veteran was told he does not have seizures and seizure symptoms were stress related. In October 2021, a private certified vocational evaluator and rehabilitation counselor reviewed the Veteran's claims file and indicated his headaches sometimes progress to tonic-clonic seizures. Accordingly, on remand, an opinion on the nature and etiology of the Veteran's claimed brain syncope disorder should be obtained, to include whether the disability is caused or aggravated by his service-connected PTSD with TBI and/or his traumatic headaches. 17. Service connection for high blood pressure is remanded. The Veteran contends his high blood pressure onset during active service. The Veteran's service treatment record note 'isolated blood pressure was elevated' as a problem. His post-service treatment records reflect a diagnosis of hypertension and treatment of blood pressure with Chlorthalidone. See February 2020 VA treatment record; see also July 2021 VA treatment record. A May 2019 VA treatment record indicates the Veteran's hypertension may be due to pain. A December 2019 VA treatment record suggests his hypertension may be related to his service-connected sleep apnea. The Board cannot make a fully informed decision on the issue of hypertension because no VA examiner has opined whether such condition is related to service or to his service-connected disabilities. As the low threshold of McLendon has been met, VA has a duty to assist the Veteran in substantiating his claim by providing an examination. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 18. Entitlement to a TDIU is remanded. In October 2021, a private certified vocational evaluator and rehabilitation counselor reviewed the Veteran's claims file and found him 'totally occupationally disabled from all competitive employment due to his service-connected PTSD with TBI, left shoulder (minor) strain, lumbosacral strain, left hip strain, tinnitus, TMJ disorder, left lower extremity radiculopathy, left ankle strain, and traumatic headaches.' Thus, entitlement to a TDIU has been reasonably raised by the evidence of record. Rice v. Shinseki, 22 Vet. App. 447, 455 (2009). This issue is remanded so the RO can provide the Veteran with a VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability). VA treatment records dated in November 2017 indicate that the Veteran may have filed a claim for worker's compensation related to a back injury sustained from an on-the-job accident. On remand, he should be requested to provide any and all relevant evidence regarding that worker's compensation claim. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left ankle, left hip, left shoulder strain, lumbosacral strain, and TMJ disabilities. The examiner(s) should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran's disabilities under the rating criteria. The examiner must also test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups or due to pain on use over time. The examiner must express any such functional impairment in terms of ranges of motion. The examiner is also asked to describe the additional functional impairment that occurs during flare-ups or with repeated use over time and state whether such functional loss results in additional loss of range of motion. If so, this should be provided in degrees of motion. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups or with repeated use over time based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed brain syncope disability. The examiner is asked to clarify whether the Veteran has a brain syncope disability resulting in his symptoms or whether his symptoms are a part of his service-connected PTSD with TBI and/or traumatic headaches. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: a) Is the disability at least as likely as not related to service or did it onset in service? b) Is the disability at least as likely as not proximately due to the Veteran's service-connected traumatic headaches and/or PTSD with TBI? c) Is the disability at least as likely as not aggravated by the Veteran's service-connected traumatic headaches and/or PTSD with traumatic brain injury? Provide a rationale to support the opinion(s). In doing so, consider the Veteran's description of his in-service and post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 3. Schedule the Veteran for an examination for his claimed hypertension. The examiner is asked to provide a response to the following: a) Is it at least as likely as not that the Veteran's hypertension began during active service or is otherwise related to service, including any elevated blood pressure readings therein? b) Is the Veteran's hypertension at least as likely as not proximately due to a service-connected disability, including his sleep apnea syndrome and/or a disability resulting in pain? c) Is the Veteran's hypertension at least as likely as not aggravated by a service-connected disability (including as a result of pain) and specifically his sleep apnea syndrome? Provide a rationale to support the opinions. Consider the Veteran's description of his symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 4. Ask the Veteran to complete and return VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability). 5. Ask the Veteran to either submit and/or provide written authorization to obtain his workers' compensation records. After receiving any needed authorization, obtain pertinent records associated with that claim. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.Aoughsten, 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.