Citation Nr: A25035369 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 240206-415857 DATE: April 16, 2025 ORDER Entitlement to an effective date earlier than March 9, 2018, for service connection for other specified bipolar disorder with cannabis use disorder (hereinafter, "psychiatric disability") is denied. Entitlement to an effective date earlier than March 28, 2019, for service connection for surgical scars s/p cholecystectomy (hereinafter, "surgical scars") is denied. Entitlement to an initial 100 percent rating for the service-connected psychiatric disability is granted. Entitlement to an initial, compensable rating for service-connected surgical scars is denied. Entitlement to an initial rating of 30 percent, but no higher, for service-connected gallbladder removal with irritable bowel syndrome (IBS) for the entire period on appeal is granted. Entitlement to a 10 percent rating based upon multiple, noncompensable service-connected disabilities is moot and is dismissed. Entitlement to an effective date earlier than May 18, 2022, for the grant of a total disability rating based on individual unemployability (TDIU) is moot and is dismissed. REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to an effective date earlier than May 18, 2022, for the grant of entitlement to basic eligibility for Dependents' Educational Assistance (DEA) benefits is remanded. FINDINGS OF FACT 1. On March 9, 2018, VA received notice of the Veteran's intent to file a claim for compensation and the Veteran's formal claim for service connection for his psychiatric disorder was received within a year of such notice. 2. The record contains no formal claim, informal claim, or other written intent to file a claim for entitlement for service connection for a psychiatric disability prior to March 9, 2018. 3. On March 28, 2019, VA received notice of the Veteran's intent to file a claim for compensation and the Veteran's formal claim for service connection for his gallbladder condition was received within a year of such notice. 4. The record contains no formal claim, informal claim, or other written intent to file a claim for entitlement for service connection for a gallbladder condition prior to March 28, 2019. 5. Resolving reasonable doubt in favor of the Veteran, for the entire period on appeal, the occupational and social impairment resulting from his psychiatric disability has more closely approximated total impairment 6. The Veteran's surgical scars do not involve the head, face, or neck; are not associated with underlying soft tissue damage; do not affect an area exceeding at least 39 square centimeters; are not painful or unstable; and do not result in other functional impairment. 7. Throughout the initial rating period on appeal, the Veteran's gallbladder removal with IBS has manifested in more or less constant abdominal distress, with daily abdominal pain, bloating, distention, and an average of 3 to 4 loose bowel movements a day. 8. The Veteran has been in receipt of a compensable rating for at least one service-connected disability since the effective date of his compensation award. 9. For the entire period on appeal, the Veteran has been in receipt of a 100 percent rating for his psychiatric disability and does not have another service-connected disability that alone, without consideration of impairment related to his psychiatric disability, causes the Veteran to be unable to obtain and maintain gainful employment. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to March 9, 2018, for the grant of service connection for the Veteran's psychiatric disability are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400. 2. The criteria for an effective date prior to March 28, 2019, for the grant of service connection for surgical scars are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400. 3. The criteria for an initial 100 percent rating for the Veteran's psychiatric disability are met for the entire period on appeal. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9432. 4. The criteria for an initial compensable rating for surgical scars have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.10, 4.118, Diagnostic Code 7802. 5. The criteria for an initial rating of 30 percent, but no higher, for gallbladder removal with IBS have been met for the entire period on appeal. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.114, Diagnostic Codes 7318, 7319. 6. The criteria for a 10 percent disability rating based upon multiple, noncompensable service-connected disabilities is moot. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.324. 7. The criteria for entitlement to a TDIU prior to May 18, 2022, is moot. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2009 to July 2010, from August 2010 to January 2011, and from August 2012 to September 2012. This case comes before the Board of Veterans' Appeals on appeal of March 2023 and July 2023 Higher-Level Review (HLR) rating decisions. The procedural history in this case is long and complex, Initially, the Veteran was granted entitlement to service connection for his gallbladder removal at zero percent, effective March 28, 2019, in a May 2020 rating decision. In May 2021, the Veteran filed a VA Form 20-0996, Decision Review Request, HLR in which he requested review of the initial rating assigned for his gallbladder removal in the May 2020 rating decision. In a July 2021 HLR rating decision, the zero percent rating for the gallbladder removal was continued. In an April 2022 rating decision, the Veteran was granted entitlement to service connection for IBS, which was combined with his already service-connected gallbladder removal, and assigned a 30 percent rating effective December 27, 2021. In a July 2022, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, in which he requested review of the rating assigned for his gallbladder removal and IBS. In an August 2022 rating decision, the Veteran was granted entitlement to a TDIU and DEA benefits, effective May 18, 2022; he was granted entitlement to service connection for a gallbladder removal residual surgical scar, effective July 1, 2022, at zero percent; and the 30 percent rating for his gallbladder removal with IBS was continued. In March 2023, the Veteran submitted a VA Form 20-0996, Decision Review Request: HLR, in which he requested review of the rating assigned for his gallbladder removal and IBS, the effective date assigned for his TDIU, the effective date assigned for DEA benefits, and both the effective date assigned for the grant of service connection and the initial rating assigned for his gallbladder removal residual surgical scar. The March 2023 HLR rating decision on appeal was issued in response to that request. In that decision, the Veteran was granted entitlement to an effective date of March 28, 2019, for the grant of service connection for his gallbladder removal residual surgical scar; he was denied earlier effective dates for the grants of both the TDIU and DEA benefits; the 30 percent rating for his gallbladder removal and IBS was continued; the zero percent rating for his gallbladder removal residual surgical scar was continued; and the Veteran was denied entitlement to a 10 percent rating for multiple, noncompensable disabilities. Based on the above, the Board finds that the Veteran has continuously pursued the effective date and initial rating assigned for his gallbladder removal and IBS, the effective date and initial rating assigned for his gallbladder removal residual surgical scar, and the effective dates assigned for his entitlement to a TDIU and DEA benefits. In the meantime, the Veteran was originally denied entitlement to service connection for various psychiatric disabilities, to include PTSD in a July 2019 rating decision. In a February 2020 rating decision, the Veteran was denied entitlement to service connection for adjustment disorder. Later in February 2020, the Veteran filed a VA Form 20-0995, Decision Review Request: Supplemental Claim, in which he requested review of the July 2019 denial of entitlement to service connection for PTSD. In a March 2020 rating decision, the denial of entitlement to service connection for PTSD was continued. In January 2021, the Veteran submitted a VA Form 20-0996, Decision Review Request: HLR, in which he requested review of the denials of entitlement to service connection for adjustment disorder in the February 2020 rating decision and the denial of entitlement to service connection for PTSD in the March 2020 rating decision. In an April 2021 HLR rating decision, the denials of entitlement to service connection for adjustment disorder and PTSD were continued. In February 2022, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, in which he requested review of the April 2021 HLR rating decision denials of entitlement to service connection for adjustment disorder and PTSD. In a March 2022 rating decision, the prior denials of entitlement to service connection for PTSD and adjustment disorder were continued. In a June 2022 rating decision, the Veteran was granted entitlement to service connection for other specified bipolar disorder with cannabis use disorder, effective May 18, 2022, rated 70 percent; and the prior denial of entitlement to service connection for PTSD was continued. In a February 2023 VA Form 20-0995, Decision Review Request: Supplemental Claim, the Veteran requested review of the effective date assigned for service connection for his psychiatric disability, and the continued denial of entitlement to service connection for PTSD in the June 2022 rating decision. In a June 2023 rating decision, the Veteran was denied entitlement to an earlier effective date for the grant of service connection for his psychiatric disability, and the prior denial of entitlement to service connection for PTSD was continued. In June 2023, the Veteran submitted a VA Form 20-0996, Decision Review Request: HLR, in which he requested review of the denials made in the June 2023 rating decision. The July 2023 HLR rating decision on appeal was issued in response to that request. In the July 2023 HLR rating decision, the Veteran was granted entitlement to an effective date of March 9, 2018, for the grant of service connection for his psychiatric disability; the 70 percent rating assigned for his psychiatric disability was continued; and the prior denial of entitlement to service connection for PTSD was continued. Based on the above, the Board finds that the Veteran has continuously pursued the effective date and initial rating assigned for his psychiatric disability, and the claim of entitlement to service connection for PTSD. In the February 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the respective August 2022 and June 2023 agency of original jurisdiction (AOJ) decisions with regard to the issues addressed in each, which were subsequently subject to HLR. 38 C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the decisions, which were subsequently subject to HLR, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. However, because the Board is remanding the claim of entitlement to service connection for PTSD, any evidence the Board could not consider will be considered by the AOJ in the adjudication of that claim. 38 C.F.R. § 3.103(c)(2)(ii). Earlier Effective Date In general, the effective date of an award based on an original claim, or a claim reopened after final adjudication of compensation shall be fixed in accordance with the facts found but shall not be earlier than the date of the receipt of the application. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. Generally, the effective date of an award of disability compensation based on an original claim shall 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 effective date of an award of disability compensation based on a claim to reopen after a final disallowance shall be the date of receipt of the new claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (q)(ii)(r). The provisions of 38 C.F.R. § 3.400(b)(2) allow for assignment of an effective date the day following separation from active service if a claim is received within one year after separation from service. Earlier Effective Date - Psychiatric Disability The Veteran contends that his service-connected psychiatric disability warrants an effective date earlier than March 9, 2018. Initially, the Board notes that neither the Veteran nor his attorney have made any specific arguments pertaining to the earlier effective date claim. A review of the record indicates that VA first received the Veteran's intent to file a claim on March 9, 2018. The Veteran submitted his VA Form 21-526EZ on November 15, 2018, asserting a claim for, in pertinent part, entitlement to service connection for PTSD, adjustment disorder, mood disorder, panic attacks, anxiety disorder, and nightmares. As detailed above, the Veteran was eventually granted entitlement to service connection for bipolar disorder with cannabis use disorder, effective May 18, 2022. That effective date was reviewed, and the Veteran was ultimately assigned an effective date of March 9, 2018, for the grant of service connection for his psychiatric disorder. In this case, the date of the claim is March 9, 2018, as this is the date VA first received notice of the Veteran's intent to file a claim for his psychiatric disability, and VA received the Veteran's formal claim within one (1) year of receipt of such notice of intent. The Board has reviewed the claims file and finds no formal, informal, or other written intent to file a claim for service connection for a psychiatric disability prior to that date. Regarding the date entitlement arose, the Board notes that to the extent that the Veteran may have had symptoms and sought medical treatment for the claimed disability prior to March 9, 2018, the mere existence of medical records generally cannot be construed as an informal claim; rather, there must be some intent by the claimant to apply for a benefit. See Brannon v. West, 12 Vet. App. 32, 35 (1998); Criswell v. Nicholson, 20 Vet. App. 501, 504 (2006). Considering that the effective date for service connection is the later date of claim or date entitlement arose, there is simply no basis to award the Veteran an effective date any earlier than the March 9, 2018. The Board thus concludes that an effective date earlier than March 9, 2018, for the grant of service connection for the Veteran's psychiatric disability is not warranted. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). The Board has considered the benefit-of-the-doubt rule but finds that it is not applicable as the evidence weighs persuasively against the claim and is not in approximate balance. 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). Earlier Effective Date - Surgical Scars The Veteran contends that an effective date earlier than March 28, 2019, for service connection for his surgical scars post gallbladder removal. Initially, the Board notes that neither the Veteran nor his attorney have made any specific arguments pertaining to the earlier effective date claim. A review of the record indicates that VA first received the Veteran's intent to file on March 28, 2019. The Veteran submitted his VA Form 21-526EZ on February 4, 2020, asserting a claim for a "gallbladder condition." As detailed above, the Veteran was ultimately granted entitlement to service connection for his gallbladder removal residual surgical scar, effective July 1, 2022. That effective date was reviewed, and the Veteran was ultimately assigned an effective date of March 28, 2019, for the grant of service connection for his gallbladder removal residual surgical scar. In this case, the date of the claim is March 28, 2019, as this is the date VA first received notice of the Veteran's intent to file a claim related to his gallbladder disability, and VA received the Veteran's formal claim within one (1) year of receipt of such notice of intent. The Board has reviewed the claims file and finds no formal, informal, other written intent to file a claim for service connection for surgical scars and/or a gallbladder disability prior to that date. With regard to the date entitlement arose, the Board notes that to the extent that the Veteran may have had symptoms and sought medical treatment for the claimed disability prior to March 28, 2019, the mere existence of medical records generally cannot be construed as an informal claim; rather, there must be some intent by the claimant to apply for a benefit. See Brannon, 12 Vet. App. at 35; Criswell, 20 Vet. App. at 504. To the extent that the Veteran filed a claim of entitlement to service connection for chronic abdominal pain in November 2018, that was denied in a July 2019 rating decision, the Board notes that this does not constitute a claim of entitlement to service connection for gallbladder removal surgery. In this regard, the gallbladder removal was a distinct procedure as opposed to the vague claim of entitlement to service connection for chronic abdominal pain. Further, to the extent that a person could infer it as a claim for service connection for gallbladder removal, the Board notes that the claim was denied in July 2019. Following that decision, the Veteran did not file a supplemental claim, a HLR request, or a Board appeal within the required time frame to request review of the July 2019 rating decision. Rather, the Veteran filed a "new" claim on a VA Form 21-526EZ that was received by VA in February 2020. Additionally, at his April 2020 VA examination for his gallbladder removal, the Veteran denied experiencing any current symptoms related to that disability, to include chronic abdominal pain. Accordingly, the Board finds that the November 2018 claim of entitlement to service connection for chronic abdominal pain is not considered a claim of entitlement to service connection for gallbladder removal so as to warrant the assignment of an effective date earlier than March 28, 2019, for the grant of service connection for a residual surgical scar. Considering that the effective date for service connection is the later date of claim or date entitlement arose, there is simply no basis to award the Veteran an effective date any earlier than the March 28, 2019. The Board thus concludes that an effective date earlier than March 28, 2019, for the grant of service connection for the Veteran's surgical scars is not warranted. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). The Board has considered the benefit-of-the-doubt rule but finds that it is not applicable as the evidence weighs persuasively against the claim and is not in approximate balance. 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776. Increased Rating Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Increased Rating - Psychiatric Disability The Veteran contends that his psychiatric disability is worse than that contemplated by its initial 70 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9432. VA and private treatment records indicate that the Veteran experienced periods of depression, anxiety, and chronic trouble sleeping. The Veteran intermittently reported having "no complaints" to having "anxious mood, irritability, and recurring dreams and intrusive thoughts of his military service." See July 2022 VA Treatment Records; but see March 2023 VA Treatment Records. The records indicate that the Veteran was not working and stayed at home with his children. That being said, the Veteran had significant problems staying awake or being engaged enough to get his children off to school or take care of them throughout the day. See March 2023 VA Treatment Records. In April 2023, the Veteran's wife contacted his care team to indicate that he had been "withdrawn, dysphoric, and lethargic" over the last month. However, the Veteran suddenly had a "burst of energy to the point that he got in his head that he was going to build a barn all by himself." His wife also indicated that the Veteran had been reclusive and extremely anxious to go out in public. She revealed that he often vomited from anxiety. The Veteran was afforded a VA examination in June 2019. During the examination, the Veteran reported being a stay-at-home dad to his two children and a full-time student. The Veteran further reported that he had not been formally employed since his separation from the military and that he could not handle leaving the house or going to work "because of the crowds." The Veteran indicated that though he stayed at home with his young children, he was rarely engaged with them and spent most of his time during the day playing videogames. The Veteran estimated that he spent an average of 8 hours a day playing videogames. He also indicated that aside from one friend from high school, his other friends were known solely online. The examiner indicated that the Veteran had persistent, distorted cognitions about the cause or consequences of events that the Veteran experienced during the military, exhibited signs of hypervigilance, and had symptoms of anxiety. Upon a mental status examination, the Veteran presented as casually dressed, with normal speech, affect, and attention. His mood was appropriate and cooperative and there was no evidence of thought dysfunction. Based on the Veteran's statements and a review of the record, the examiner indicated that the Veteran's psychiatric disability resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The Veteran's wife submitted a statement dated December 2019. In the statement, she reported that upon separating from the military, the Veteran became obsessed with the idea of extreme isolation. He exclusively sought to purchase a home in a rural location and indicated he would only settle on a location "with no neighbors for 3 miles." The Veteran's wife stated that once they moved into their home, the Veteran rarely left the house and would need a tremendous amount of encouragement to even go to the grocery store. She also indicated that the Veteran's "emotional regulation was compromised," and that the Veteran often had outbursts of anger and irritability. Though the Veteran wanted to attend social functions with his children, when he would attempt such outings, he exhibited uncontrollable shaking, feeling faint, and profuse sweating. See also February 2022 VA Treatment Records (indicating that the Veteran reported having intrusive thoughts about being bombed while at a child's birthday party). The Veteran's wife further reported that after such periods, the Veteran would isolate from the rest of the family in his bedroom for several days. She further indicated that the Veteran had a history of making vague, passively suicidal remarks about "no longer wanting to be here." The Veteran submitted a private disability benefits questionnaire dated December 2019. The examiner indicated that the Veteran had significant family and financial difficulties. They further indicated that the Veteran's symptoms included anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, difficulty in understanding complex commands, disturbances in motivation or mood. Based on the Veteran's treatment and a review of the record, the examiner indicated that the Veteran's psychiatric disability resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. In a statement dated June 2021, the Veteran's high school friend likewise indicated that the Veteran rarely left his home and stopped attending social functions with friends. The Veteran also told his friend that he did not believe he would be able to ever work because he was too afraid to go out in public. The Veteran's friend reported observing the Veteran looking anxious and constantly searching for an exit in the rare times that the Veteran left his home. The Veteran was afforded another VA examination in May 2022. During the examination, the Veteran reported that he had not been able to secure or maintain a job in the 10 years since his separation from the military. He further reported that though he stayed at home with his children, he did not engage with them at all and instead chose to isolate and play videogames during the day. When describing his daughter, he referred to her as "it." He indicated that he avoided his children because he "did not want to ruin their lives" and further stated that his children were afraid of him because of his emotional outbursts. Upon mental status examination, the Veteran presented as "odd" with a flat affect. The examiner indicated that the Veteran had great difficulty describing symptoms and lacked insight into his symptoms and behaviors. The examiner further indicated that the Veteran's symptomatology included depressed mood, anxiety, suspiciousness, near-continuous depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, flattened affect, impaired judgment disturbances of motivation and mood, difficulty adapting to stressful circumstances, including work or a work like setting, inability to establish and maintain effective relationships, and neglect of personal appearance and hygiene. The examiner opined the Veteran's symptomatology only resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran underwent a private examination in July 2022. During the examination, the Veteran went through his entire mental health history and previous treatment notes. Upon mental status examination, the Veteran was indicated to have a "constricted" affect and dysphoric mood. Though the Veteran was responsive and cooperative, he had to pause intermittently to "compose himself." The examiner indicated that the Veteran had a history of passive suicidal ideology that was intermittent in nature but occurred during particularly bad "depressive episodes." The examiner further indicated that the Veteran's symptomatology included traumatic nightmares, flashbacks, intense or prolonged distress and marked physiologic reactivity after exposure to traumatic reminders, avoidance, negative emotional state, diminished interests, alienation, constricted affect, irritable behavior, hypervigilance, exaggerated startle response, problems with concentration, sleep disturbance, excessive anxiety and worry, fatigue or loss of energy, depressed mood, change in appetite and/or weight, feelings of worthlessness or guilt, near-continuous depression affecting the ability to function independently, appropriately and effectively, disturbances of motivation and mood, impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks, an inability to establish or maintain effective relationships, difficulty in adapting to stressful circumstances including work or a worklike setting, and neglect of personal appearance and hygiene. Thus, the examiner indicated it was "at least as likely as not" that the Veteran's psychiatric disability "caused him total occupational and social impairment" for the entire period on appeal. Another VA examination was afforded to the Veteran in May 2023. During the examination, the Veteran reported a social history substantially similar to his past history but indicated that he only had one friend now that he saw a couple times a year. Upon mental status examination, the Veteran appeared calm, cooperative, and attentive. The examiner indicated that the Veteran's symptomatology included anxiety and impaired judgment. Based on the examination, the examiner opined the Veteran's psychiatric disability manifested in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. Resolving reasonable doubt in the Veteran's favor, the Board finds that he is entitled to an initial higher 100 percent rating throughout the appeal period. In this regard, the Veteran is considered to have total occupational and social impairment due to such symptoms as intermittent passive suicidal thoughts, extreme isolationism, grossly inappropriate behavior in failing to attend and care for his young children while being the stay-at-home parent, and intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene. Further, beyond the Veteran's social impairment, there is evidence that his psychiatric disability impaired his ability to secure and maintain employment. 38 C.F.R. § 4.126. Therefore, the Board finds that when the Veteran's disability picture is considered as a whole, it is apparent that the Veteran's symptoms more closely approximated those contemplated by a 100 percent rating and as such, a higher rating is warranted for his psychiatric disability. 38 C.F.R. § 4.130, Diagnostic Code 9432. The Board acknowledges that that the VA examiners opined that the Veteran's psychiatric disability manifested in occupational and social impairment more nearly approximating a 30 or 70 percent rating. However, the symptomatology endorsed during the psychiatric examinations indicated approximation of occupational and social impairment to a higher degree than that assigned. Moreover, the VA and private treatment records associated with the case file demonstrate that the Veteran's mood, affect, and ability to adequately portray his symptomatology varied heavily day-to-day, and the Veteran's wife was heavily involved and offered insight in his regular psychiatric care and was not able to provide such during his VA examinations. As the VA treatment records and the Veteran's and his wife's lay statements provide a more consistent picture, they are more probative of the Veteran's total disability level. Consequently, the Board finds that the symptoms and events reported more nearly approximate a 100 percent rating. The Board further acknowledges that the results of the medical and lay evidence of record do not indicate that the Veteran experienced all symptoms associated with a 100 percent rating, such as persistent delusions or hallucinations, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. However, the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather are intended serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002); see Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017) (requiring VA to "engage in a holistic analysis" of the claimant's symptoms to determine the proper disability rating). Accordingly, a finding that there is total social and occupational impairment is sufficient to warrant a 100 percent rating for the entire period on appeal. Accordingly, the Board finds that the evidence for and against the claim of entitlement to a 100 percent rating for the Veteran's psychiatric disability for the entire period on appeal is in approximate balance. Therefore, the benefit of the doubt must be resolved in favor of the Veteran, and entitlement to such rating is warranted. 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776. Increased Rating - Surgical Scars The Veteran contends that he is entitled to an initial compensable rating for his surgical scars post gallbladder removal. However, the Board notes that the Veteran has not provided any detail regarding why the scar should be assigned a higher rating, to include a report of any symptoms he experiences as a result of the scar. On VA examination in January 2022 regarding the Veteran's IBS, the examiner observed three scars on the Veteran's abdomen - one in the upper middle abdomen measuring 2.0 cm. x 0.2 cm., one in the mid right abdomen measuring 0.2 cm. x 1.0 cm., and one in the lower right abdomen measuring 0.2 cm. x 1.0 cm. No other scars were noted upon examination. The examiner indicated that the scars were not painful, were not unstable, did not have a total area equal to or greater than 39 sq. cm. and that there were no scars on the Veteran's face or neck. No other pertinent physical findings were noted regarding the scars. The Veteran underwent VA examinations for his IBS and gallbladder condition in July 2022. Again, the examiners observed three scars on the Veteran's abdomen - one in the upper middle abdomen measuring 2.0 cm. x 0.2 cm., one in the mid right abdomen measuring 0.2 cm. x 1.0 cm., and one in the lower right abdomen measuring 0.2 cm. x 1.0 cm. No other scars were noted upon examination. The examiners indicated that the scars were not painful, were not unstable, did not have a total area equal to or greater than 39 sq. cm. and that there were no scars on the Veteran's face or neck. No other pertinent physical findings were noted regarding the scars. There is no other medical evidence in the record pertaining to the current level of severity of the Veteran's surgical scars. Based on the foregoing, the Board finds that an initial compensable rating is not warranted for the Veteran's surgical scars. In this regard, the Veteran's scars are not of the head, face, or neck; have not been shown to have associated underlying soft tissue damage; do not affect an area of at least 39 sq. cm.; are not unstable or painful. The record is also silent of any assertion from the Veteran that his scars cause other functional impairment not contemplated by the diagnostic codes pertaining to scars. As such, the Board finds that an initial compensable rating for the Veteran's surgical scars is not warranted. 38 C.F.R. § 4.118; Diagnostic Codes 7800, 7801, 7802, 7804, 7805. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Consideration has been given to assigning staged ratings. However, at no time during the period in question has the disability warranted a higher schedular rating than that assigned. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Accordingly, the Board finds that the benefit-of-the-doubt rule is not applicable as the evidence weighs persuasively against the claim and is not in approximate balance. Therefore, entitlement to an initial compensable rating for the surgical scars is not warranted. 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776. Increased Rating - Gallbladder Removal with IBS The Veteran contends that his gallbladder removal with IBS warrants an initial rating higher than what was assigned. By way of history, the Veteran's gallbladder removal with IBS was initially service connected with a noncompensable rating effective March 28, 2019. Thereafter, the Veteran's rating increased to 30 percent effective December 27, 2021. The Veteran's gallbladder removal with IBS is rated under Diagnostic Codes 7318-7319. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. During the pendency of the appeal, the rating criteria for evaluating digestive disabilities under 38 C.F.R. § 4.114 were amended effective May 19, 2024. These amendments revised select diagnostic codes to ensure that the rating schedule uses detailed and updated criteria for the evaluation of digestive disabilities. Diagnostic Codes 7318 and 7319 were included in this amendment. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to May 19, 2024, and both the old and new rating criteria from May 19, 2024, with regard to the claimed gallbladder removal with IBS. The criteria that is more favorable to the Veteran will be applied. Prior to May 19, 2024, Diagnostic Code 7318, gallbladder, removal of, provides for or a noncompensable evaluation for asymptomatic gallbladder removal; a 10 percent evaluation is warranted for gallbladder removal with mild symptoms; and a 30 percent evaluation is reserved for gallbladder removal with severe symptoms. For IBS, under the "old" criteria for Diagnostic Code 7319, a 10 percent rating is warranted for moderate symptoms, described as frequent episodes of bowel disturbance with abdominal distress. A maximum 30 percent rating is warranted for severe symptoms, described as diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114. For reference, as certain descriptive terms used in the criteria are not defined in the Rating Schedule, the Board will apply the ordinary meanings of the words: "mild" is defined as "gentle in nature or behavior" and "not severe: temperate"; "moderate" is defined as "tending toward the mean or average amount or dimension," "not violent, severe, or intense," and "limited in scope or effect"; and "severe" is defined as "very painful or harmful" and "causing discomfort or hardship." See Merriam-Webster's Collegiate Dictionary 267 (11th ed. 2012). Although a medical examiner's use of descriptive terminology such as "mild" is an element of evidence to be considered by the Board, it is not dispositive of an issue; the Board must evaluate all evidence in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. As of May 19, 2024, Diagnostic Code 7318, Cholecystectomy (gallbladder removal) provides for a noncompensable rating when the removal of the gallbladder does not cause symptoms; a 10 percent rating when there is intermittent abdominal pain and diarrhea characterized by one to two watery bowel movements per day; and a maximum 30 percent rating characterized by recurrent abdominal pain (post-prandial or nocturnal); and chronic diarrhea characterized by three or more watery bowel movements per day. Under the new criteria for Diagnostic Code 7319 ("[IBS]"), a 10 percent rating is warranted for abdominal pain related to defecation at least once during the previous three months; and two or more of the following: (1) change in stool frequency, (2) change in stool form, (3) altered stool passage (straining and/or urgency), (4) mucorrhea, (5) abdominal bloating, or (6) subjective distension. A 20 percent rating is warranted for abdominal pain related to defecation for at least three days per month during the previous three months; and two or more of the concurrent symptoms listed above. A maximum 30 percent rating is warranted for abdominal pain related to defecation at least one day per week during the previous three months; and two or more of the concurrent symptoms listed above. 38 C.F.R. § 4.114. The Board also notes, in accordance with 38 C.F.R. § 4.114, "[r]atings under [Diagnostic Codes] 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other" and "[a] single evaluation will be assigned under the Diagnostic Code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation." In this case, this means that separate ratings are not available under both Diagnostic Codes 7318 and 7319. VA treatment records indicate that the Veteran has been treated for "persistent diarrhea" to the point that he could not "trust himself to pass gas." See November 2020 VA Treatment Records. The Veteran reported having continuous loose stool and gastric distress since his gallbladder removal despite numerous efforts to treat his symptoms. See, for example, January 2023 VA Treatment Records. The Veteran underwent a VA examination for his gallbladder symptoms in November 2020. During the examination, the Veteran reported having recurrent nausea and gastric upset that eventually led him to having his gallbladder removed. That being said, the examiner indicated that the Veteran had no signs or symptoms, or any other pertinent physical findings, associated with his gallbladder removal. The Veteran underwent a VA examination for his IBS in January 2022. During the examination, the Veteran reported having left-sided abdominal pain associated with bloating and gas, and diarrhea. The Veteran further reported that, on average, he had 3 to 4 bowel movements a day but sometimes he had up to 6 a day. The Veteran's symptoms included diarrhea with episodes at least twice a week, although it was noted that the Veteran's stool was always loose, and abdominal distension. The examiner indicated the Veteran's symptoms manifested in frequent episodes of bowel disturbance with abdominal distress. Episodes of exacerbations and/or attacks of the intestinal condition, weight loss, malnutrition, and tumors/neoplasms were not indicated. Other than the scars from his gallbladder removal surgery, no other pertinent physical findings were noted. The Veteran underwent an additional VA examination for his IBS in March 2022. During the examination, the Veteran again indicated that he had diarrhea, bloating, and gas associated with his gallbladder removal. The examiner indicated that the Veteran's symptoms included varying diarrhea with constipation, bloating, and daily vomiting. They further indicated that the Veteran's symptoms manifested in more or less constant abdominal distress with bowel disturbance. Episodes of exacerbations and/or attacks of the intestinal condition, weight loss, malnutrition, and tumors/neoplasms were not indicated. The Veteran underwent a VA examination regarding his gallbladder removal in July 2022. The examiner indicated that the Veteran had no signs, symptoms, or conditions attributable to his gallbladder disability. Other than the scars from his gallbladder removal surgery, no other pertinent physical findings were noted. At the same time, the Veteran underwent a VA examination for his IBS. During the examination, the Veteran indicated that he was still having issues with diarrhea and abdominal pain with gas and bloating. The Veteran indicated he was still having up to 6 bowel movements of loose stool a day. The examiner indicated the Veteran's symptoms included at least 2 bouts of diarrhea a week, although his stool was always loose, and abdominal distension. The examiner indicated the Veteran's symptoms manifested in frequent episodes of bowel disturbance with abdominal distress. Episodes of exacerbations and/or attacks of the intestinal condition, weight loss, malnutrition, and tumors/neoplasms were not indicated. Other than the scars from his gallbladder removal surgery, no other pertinent physical findings were noted. The Board finds that the Veteran's VA treatment records and the post-2020 VA IBS examinations to be the most probative evidence of the Veteran's disability picture. Although both the 2020 and 2022 VA examiners indicated that the Veteran did not have any signs or symptoms associated with his gallbladder, it is clear from the evidence that the Veteran has had near constant diarrhea and abdominal distress since his gallbladder was removed in 2011. Accordingly, based on the foregoing, the Board finds that the Veteran's gallbladder removal with IBS most closely approximates the level of impairment associated with a 30 percent disability rating for the entire period on appeal. In this regard, under the old criteria for Diagnostic Code 7318 the Veteran has presented with "severe" symptoms including daily pain and the hardship of dealing with constant loose stool and/or diarrhea. Similarly, under the old criteria for Diagnostic Code 7319, the Veteran had been indicated to have diarrhea, nausea, and more or less constant abdominal distress. Under the new criteria for 7318, the evidence indicates that the Veteran has recurrent abdominal pain and has chronic loose stool with more than three bowel movements per day. Under the new criteria of 7319, the Veteran has pain associated with his defecation, along with altered passage of stool, abdominal bloating, and abdominal distension. As noted above, 30 percent is the maximum rating available under both the pre-amended and post-amended Diagnostic Codes 7318 and 7319 and separate ratings for each are not available. See 38 C.F.R. § 4.114. Given the criteria for both Diagnostic Codes include consideration of diarrhea, stool urgency, abdominal pain, distension, bloating, gas, and nausea, the Veteran's symptoms, as described above, are consistent with and fully contemplated by these criteria. For these reasons, the Board finds that the evidence persuasively weighs in favor of finding that an initial 30 percent rating, but no higher, for gallbladder removal with IBS is warranted. See 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776. Entitlement to a 10 percent evaluation based upon multiple, noncompensable, service-connected disabilities The Veteran asserts entitlement to a 10 percent rating based upon multiple, noncompensable, service-connected disabilities. Pursuant to 38 C.F.R. § 3.324, a rating of 10 percent may be awarded when a veteran presents with two or more separate, noncompensable, service-connected disabilities, which clearly interfere with normal employability yet are not of a compensable degree under the rating criteria. See 38 C.F.R. § 3.324. Such a rating may not be combined with any other rating. Id. In this case, the Veteran is in receipt of a compensable rating since the effective date of his compensation award, March 9, 2018. As such, there is no legal entitlement to a separate 10 percent rating as such may not be combined with any other rating. Therefore, the issue is moot and is dismissed. TDIU The Veteran contends that his service-connected disabilities rendered him unable to maintain substantially gainful employment prior to May 22, 2018. As discussed in greater detail above, the Veteran is now in receipt of a schedular 100 percent rating for his psychiatric disability for the entire period on appeal. The United States Court of Appeals for Veterans Claims (Court) has recognized that a 100 percent rating under the Schedule for Rating Disabilities means that a Veteran is totally disabled. Holland v. Brown, 6 Vet. App. 443, 446 (1994), citing Swan v. Derwinski, 1 Vet. App. 20, 22 (1990). Generally, if the VA has found a veteran to be totally disabled as a result of a particular service-connected disability or a combination of disabilities pursuant to the rating schedule, there is no need, and no authority to otherwise rate that Veteran totally disabled on any other basis. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001). However, a grant of 100 percent rating does not always render the issue of TDIU moot. In Bradley v. Peake, 22 Vet. App. 280 (2008), the Court determined that a separate TDIU rating predicated on one disability may be awarded if that disability is not ratable at the schedular 100 percent level. However, a separate TDIU rating cannot be awarded based on one service-connected disability if the Veteran is already receiving a 100 percent schedular rating for that disorder. Buie v. Shinseki, 24 Vet. App. 242 (2010). In this case, the Veteran is in receipt of a 100 percent schedular rating for his service-connected psychiatric disability for the entire period on appeal. During the period on appeal, the Veteran is also service connected for gallbladder removal with IBS, rated 30 percent, and surgical scars, rated 0 percent. The Veteran has not alleged, and the evidence does not otherwise suggest, that the gallbladder removal with IBS or the surgical scars, on their own, result in the Veteran's inability to secure and follow substantially gainful employment. Put another way, without consideration of the symptoms and impairment related to the Veteran's psychiatric disability, the Veteran does not have another single service-connected disability that renders him unemployable. As such, while the Board has considered the holding in Bradley, the grant of a 100 percent schedular rating for his psychiatric disability for the entire period on appeal renders the Veteran's TDIU claim moot. Accordingly, the claim for a TDIU is moot and is dismissed. REASONS FOR REMAND Service Connection - PTSD The Veteran contends that he has PTSD that is related to his active service. The Veteran has been afforded a number of VA psychiatric examinations - namely, one in June 2019, one in May 2022, and one in May 2023. The Veteran has also submitted two private examinations - one dated December 2019 and one dated July 2022. The primary question in contention is whether the Veteran has a current PTSD diagnosis for VA compensation purposes. The three VA examinations each indicate that the Veteran does not meet the diagnostic criteria for PTSD under DSM-5 criteria. Specifically, the May 2023 VA examiner indicated that the private examinations of record did not demonstrate valid and/or supported diagnoses of PTSD and called into question the ethics of both private examiners. The May 2023 examiner further stated that after a thorough review of the Veteran's medical history, "he has never carried, nor does he currently carry a valid diagnosis of PTSD." That being said, a review of the Veteran's VA treatment records indicate that the Veteran has been treated for chronic PTSD at a VA medical center since around July 2022 and chronic PTSD has been listed as an "active problem" in the Veteran's VA treatment records. However, it is unclear how such PTSD was diagnosed. Thus, the VA examiners' opinions are inadequate for adjudication purposes because they are based on the factually inaccurate premise that there is no evidence of a valid PTSD diagnosis for VA purposes outside of his private treatment records/private medical opinions. Sklar v. Brown, 5 Vet. App. 140 (1993). The AOJ's reliance on inadequate medical opinions is a pre-decisional duty to assist error requiring corrective action. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, remand is necessary to obtain an addendum opinion. DEA Basic eligibility for DEA exists if a veteran has a permanent, total service-connected disability. 38 U.S.C. §§ 3500, 3501. A total disability may be assigned where the Veteran's service-connected disabilities are rated 100 percent disabling under the rating schedule, or if the veteran is unemployable due to service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341. Permanence of total disability will be taken to exist when such impairment is reasonably certain to continue throughout the life of the disabled person. 38 C.F.R. § 3.340(b). In this case, the Veteran was awarded DEA benefits effective May 22, 2018 - the date that his grant of TDIU went into effect. As outlined above, however, the Veteran has been granted entitlement to a 100 percent rating for his psychiatric disability for the entire period on appeal effective March 9, 2019. Therefore, an effective date prior to May 22, 2018, for the award of DEA benefits may be warranted and should be assigned by the AOJ based on the allowances granted in this decision. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an examiner with appropriate expertise to determine the nature and etiology of any psychiatric disorder that may be present. The claims file must be made available to and reviewed by the examiner. Specifically, the examiner must review and address the Veteran's VA treatment records reflecting treatment for chronic PTSD. If an examination is deemed necessary, one must be scheduled for the Veteran. For each diagnosis identified other than PTSD, the examiner should provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disability manifested during active service or is otherwise causally or etiologically related to the Veteran's active service. With respect to PTSD, the examiner should determine whether the diagnostic criteria to support a diagnosis of PTSD have been satisfied. If a PTSD diagnosis is deemed appropriate, the examiner should then provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any current PTSD symptomatology is attributable to the occurrence of an in-service physical assault or otherwise etiologically related to a verified in-service stressor. A rationale for all opinions expressed must be provided. (Continued on the next page) ? 2. Effectuate the allowances made by the Board in this decision and consider whether an effective date earlier than May 22, 2018, for the grant of entitlement to basic eligibility to DEA benefits. Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Davis, Alexandra J. 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.