Citation Nr: 0815156 Decision Date: 05/07/08 Archive Date: 05/14/08 DOCKET NO. 97-23 466A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for right ear hearing loss, to include as secondary to service-connected left ear hearing loss. 2. Entitlement to an increased (compensable) disability rating for service-connected left ear hearing loss. WITNESS AT HEARINGS ON APPEAL The veteran ATTORNEY FOR THE BOARD David T. Cherry, Counsel INTRODUCTION The veteran served on active duty from July 1968 to June 1971. This matter has come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office in Cleveland, Ohio (the RO). Procedural history Left ear hearing loss In a January 1997 decision, the Board granted service connection for left ear hearing loss. In February 1997, the RO implemented the January 1997 Board decision by assigning a noncompensable (zero percent) evaluation for left ear hearing loss effective September 25, 1992. The veteran perfected an appeal as to the assignment of a noncompensable disability rating. In November 1999, January 2003, November 2004, and August 2006, the Board remanded the issue of an increased rating for left ear hearing loss to the RO for further development. In December 2007, a supplemental statement of the case (SSOC) was issued by the VA Appeals Management Center (AMC) which continued the previous denial of this claim. This claim is once again before the Board. Right ear hearing loss In a June 2002 rating decision, the RO denied entitlement to service connection for right ear hearing loss on a direct basis and as secondary to the service-connected left ear hearing loss. Later that month, the veteran filed a Notice of Disagreement (NOD) as to that decision. In its January 2003 remand, the Board instructed the RO to provide the veteran with a statement of the case (SOC) regarding the issue of entitlement to service connection for right ear hearing loss. The veteran was provided a SOC on this issue in April 2003, and he perfected his appeal as to that issue later that month. In November 2004 and August 2006, the Board remanded the issue of service connection for right ear hearing loss to the RO for further development. In December 2007, a supplemental statement of the case (SSOC) was issued by the VA AMC which continued the previous denial of this claim. This claim is once again before the Board. Hearings In April 1999, the veteran testified at a hearing held at the RO before a Board member who is no longer employed with the Board. The veteran testified at video conference and Central Office hearings before the undersigned Veterans Law Judge in March 2004 and in May 2004, respectively. Transcripts of these hearings are associated with the veteran's VA claims folder. Motions In March 2005 and in July 2006, the Board denied the veteran's motions to advance his appeal on the Board's docket. See 38 C.F.R. § 20.900(c) (2007). In August 2006, the Board denied the veteran's motion for a new hearing. See 38 C.F.R. §§ 20.707, 20.717 (2007). Representation In December 2006, the veteran revoked the authority of Disabled American Veterans to act on his behalf and indicated that he would represent himself. See 38 C.F.R. § 20.607 (2007). Issues not on appeal In is August 2006 decision, the Board granted service connection for bilateral pes planus and migraine and tension- type headaches. In an October 2006 rating decision which implemented the Board's decision, a 30 disability rating was assigned for bilateral pes planus, effective March 17, 1999; and a noncompensable (zero percent) disability rating was assigned for migraine and tension-type headaches. In a July 2007 RO rating decision, increased ratings for bilateral pes planus, a chronic acquired psychiatric disorder and headaches were denied. The veteran has not, to the Board's knowledge, expressed dissatisfaction with those determinations. See Archbold v. Brown, 9 Vet. App. 124, 130 (1996) [pursuant to 38 U.S.C.A. § 7105(a), the filing of a notice of disagreement initiates appellate review in the VA administrative adjudication process, and the request for appellate review is completed by the claimant's filing of a substantive appeal after a statement of the case is issued by VA]. FINDINGS OF FACT 1. The veteran was exposed to acoustic trauma during service. 2. The veteran has been diagnosed with right ear hearing loss. 3. The competent medical evidence indicates that the veteran's right ear hearing loss is not related to the in- service noise exposure or to any other incident of his military service. 4. The competent medical evidence of record does not support a conclusion that the veteran's right ear hearing loss is caused by or aggravated by his service-connected left ear hearing loss. 5. A February 2007 VA audiological examination shows that the veteran has an average pure tone threshold of 53 decibels in the right ear, with speech recognition ability of 80 percent; and average pure tone threshold of 86 decibels in the left ear, with speech recognition ability of 74 percent. 6. A December 1999 VA audiological examination shows that the veteran has an average pure tone threshold of 21 decibels in the right ear, with speech recognition ability of 86 percent; and average pure tone threshold of 66 decibels in the left ear, with speech recognition ability of 66 percent. 7. A March 1997 VA audiological examination shows that the veteran has an average pure tone threshold of 14 decibels in the right ear, with speech recognition ability of 90 percent; and average pure tone threshold of 49 decibels in the left ear, with speech recognition ability of 80 percent. 8. A January 1993 VA audiological examination shows that the veteran has an average pure tone threshold of 5 decibels in the right ear, with speech recognition ability of 94 percent; and average pure tone threshold of 41 decibels in the left ear, with speech recognition ability of 90 percent. 9. The evidence in this case does not present an exceptional or unusual disability picture with such related factors as a marked interference with employment or frequent periods of hospitalization due to the veteran's service-connected left ear hearing loss, so as to render impractical the application of the regular schedular standards. CONCLUSIONS OF LAW 1. Right ear hearing loss was not incurred in or aggravated by service, and may not be so presumed. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2007). 2. Right ear hearing loss is not proximately due to or the result of the veteran's service-connected left ear hearing loss. 38 C.F.R. § 3.310 (2007). 3. The criteria for an increased disability rating in excess of the currently assigned zero percent rating for the veteran's service-connected left ear hearing loss have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.383, 4.85, 4.86, 4.87, Diagnostic Code 6100 (2007); 38 C.F.R. § 3.383 (2004); 38 C.F.R. §§ 4.85, 4.86, 4.87, Diagnostic Code 6100 (1998). 4. The criteria for referral for increased disability rating for service-connected left ear hearing loss on an extra- schedular basis are not met. 38 C.F.R. § 3.321(b)(1) (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran is seeking service connection for right ear hearing loss and an increased rating for his service- connected left ear hearing loss, which is currently rated zero percent disabling. In the interest of clarity, the Board will initially discuss certain preliminary matters. The Board will then address the pertinent law and regulations and their application to the facts and evidence. Stegall concerns In November 1999, the Board remanded the issue of an increased rating for left ear hearing loss for a VA examination. In December 1999, the veteran underwent a VA audiological examination. In January 2003, the Board remanded the issue of an increased rating for left ear hearing loss to the RO to schedule the veteran for a Travel Board hearing. The Board also remanded the issue of service connection for right ear hearing loss to the RO to furnish the veteran with a SOC on that issue. The veteran was provided a SOC on this issue in April 2003, and he perfected his appeal as to that issue later that month. The veteran testified at a video conference hearing and in person at a Central Office hearing, both of which were before the undersigned Veterans Law Judge in March 2004 and in May 2004, respectively. In November 2004, the Board remanded both issues to the VA AMC to provide the veteran appropriate notice under the Veterans Claims Assistance Act of 2000 (VCAA), to schedule him for another VA examination, and to obtain a medical nexus opinion. Later in February 2005, the AMC provided appropriate VCAA notice to the veteran [this will be discussed in greater detail immediately below]. In April 2005 and June 2005, the veteran underwent VA examinations. The April and June 2005 examiner rendered medical nexus opinions. In August 2006, the Board remanded both issues to the VA AMC to provide the veteran appropriate notice under the VCAA, to obtain a copy of a VA audiological examination that was purportedly completed in June 2000, to schedule him for another VA examination, and to obtain a medical nexus opinion. Later in August 2006, the AMC provided appropriate VCAA notice to the veteran [this will be discussed in greater detail immediately below]. In the August 2006 VCAA letter, the AMC asked the veteran to identify the facility where he underwent a VA audiological examination in June 2000. In a September 2006 statement, the veteran indicated that he underwent the audiological examination in June 2000 at the VA Medical Center in Chillicothe, Ohio. In December 2007, the AMC obtained records from that facility for the period from 1999 to 2000; those records did not reflect that the veteran underwent an audiological examination in June 2000. Rather, the record indicates that the examination in question was done in December 1999. In February 2007, the veteran underwent a VA examination, and the examiner rendered a medical nexus opinion. The agency of original jurisdiction readjudicated the case in the December 2007 SSOC. Therefore, the Board finds that the RO has complied with the directives of the November 1999, January 2003, August 2004, and August 2006 remands. See Stegall v. West, 11 Vet. App. 268, 271 (1998) [where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance]. The VCAA The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist claimants in the development of their claims. The Board has carefully considered the provisions of the VCAA and the implementing regulations in light of the record on appeal, and for reasons expressed immediately below finds that the development of these issues has proceeded in accordance with the provisions of the law and regulations. The VCAA alters the legal landscape in three distinct ways: standard of review, notice and duty to assist. The Board will now address these concepts within the context of the circumstances presented in this case. Standard of review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2007). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (the Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Notice The VCAA requires VA to notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided to VA that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103 (West 2002); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002) [a letter from VA to an appellant describing evidence potentially helpful to the appellant but not mentioning who is responsible for obtaining such evidence did not meet the standard erected by the VCAA]. Crucially, the RO and the AMC informed the veteran of VA's duty to assist him in the development of his claims in letters sent in August 2001, February 2005, and August 2006, which were specifically intended to address the requirements of the VCAA. The August 2001 VCAA letter informed the veteran of the evidence necessary to establish direct service connection. The August 2006 letter informed the veteran of the evidence necessary to establish secondary service connection. The February 2005 and August 2006 VCAA letters informed the veteran of the evidence necessary to establish entitlement to an increased rating. As for the evidence to be provided by the veteran, in the VCAA letters the RO and the AMC asked the veteran to identify and send relevant medical evidence. The RO provided the veteran with VA Form(s) 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), for each private or other non-VA doctor and medical care facility that treated him for his claimed disabilities. Moreover, in the August 2001 and February 2005 VCAA letters, the veteran was informed that VA would provide a medical examination or obtain a medical opinion if it is necessary to make a decision on his claims. [Five VA examinations were conducted during the period from January 1993 to February 2007, and medical nexus opinions were rendered by the April 2005, June 2005, and February 2007 VA examiners.] In the August 2001 VCAA letter, the veteran was informed that VA would make reasonable efforts to help him get evidence to support his claim, such as medical records, employment records, and records from other Federal agencies. In the February 2005 VCAA letter, the veteran was advised that VA was responsible for getting relevant records from any Federal agency, to include records from the military, VA medical centers (including private facilities where VA authorized treatment), and the Social Security Administration. The veteran was also informed that VA make reasonable efforts on his behalf to get relevant records not held by a Federal agency, including records from state and local governments, private doctors and hospitals, and current or former employers. In the August 2001 VCAA letter, the veteran was told that he may submit the evidence relevant to his claim. In the February 2005 and August 2006 VCAA letters, the AMC told the veteran that he should submit any evidence in his possession relevant to his claims, as follows: "If there is any other evidence or information that you think will support your claim, please let us know. If you have any evidence in your possession that pertains to your claim, please send it to us." See the August 31, 2006 VCAA letter, page 2 and the February 16, 2005 letter, page 2. The VCAA letters thus complied with the "give us everything you've got" requirement of 38 C.F.R. § 3.159(b)(1) because the letters informed the veteran that he could submit or identify evidence other than what was specifically requested by VA. In short, the record indicates that the veteran received appropriate notice under 38 U.S.C.A. § 5103 and Quartuccio. The Board is of course aware of the Court's decision in Pelegrini v. Principi, 17 Vet. App. 412 (2004), which appears to stand for the proposition that VCAA notice must be sent prior to adjudication of an issue by the RO. In this case, the service connection claim was initially adjudicated by the RO in June 2002, after the August 2001 VCAA letter. Moreover, the claims were readjudicated in December 2007, after several VCAA letters had been sent to the veteran and he had ample opportunity to respond to them. Therefore, the timing of the VCAA notice which was given with regard to the four elements of 38 U.S.C.A. § 5103 is not at issue as to the service connection claim. As to the left ear hearing loss issue, the claim was adjudicated in February 1997, prior to the VCAA letters. Since the VCAA was not enacted until November 2000, furnishing the veteran with VCAA notice prior to the initial adjudication of the claim in February 1997 was clearly both a legal and a practical impossibility. Indeed, VA's General Counsel has held that the failure to do so under such circumstances does not constitute error. See VAOGCPREC 7- 2004. Crucially, the veteran's increased rating claim was readjudicated following the issuance of VCAA letters, and after that the veteran was allowed the opportunity to present evidence and argument in response. Specifically, the claim was readjudicated in the SSOCs issued in 2005, 2006, and 2007. Therefore, the essential fairness of the adjudication was not affected. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). The veteran has pointed to no prejudice or due process concerns arising out of the timing of the VCAA notice. The Board accordingly finds that there is no prejudice to the veteran in the timing of the VCAA notice which was given with regard to the four elements of 38 U.S.C.A. § 5103 as to this claim. In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court observed that a claim of entitlement to service connection consists of five elements: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. Because a service connection claim is comprised of five elements, the Court further held that the notice requirements of section 5103(a) apply generally to all five elements of that claim. Therefore, upon receipt of an application for a service connection claim, section 5103(a) and section 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this case, with respect to the service connection claim, element (1), veteran status, and element (2), existence of a disability, are not at issue. The service connection claim was denied based on element (3), relationship of such disability, to the veteran's service. As explained above, he has received proper VCAA notice as to his obligations, and those of VA, with respect to this crucial element regarding this claim. Moreover, the AMC specifically addressed elements (4) and (5) in the August 2006 letter. As for the increased rating claim, elements (1), (2) and (3) are not at issue. As explained above, the veteran has received proper VCAA notice as to his obligations, and those of VA, with respect to current level of disability, element (4), in the February 2005 VCAA letter. Also, the AMC specifically addressed elements (4) and (5) in the August 2006 letter. Subsequent to Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) held that a notice letter must inform the veteran: (1) that, to substantiate a claim, the veteran must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity and the effect that worsening has on the claimant's employment and daily life; (2) if the veteran is rated under a Diagnostic Code that contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the notice letter must provide at least general notice of that requirement; (3) that if an increase in disability is found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from 0% to as much as 100% (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life; and (4) of examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation - e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. As to first prong of the holding of Vazquez-Flores, in the February 2005 VCAA letter the veteran was informed that he may submit evidence showing that his service-connected left ear hearing loss had increased in severity. See the February 16, 2005 VCAA letter, page 2. In that letter, the veteran was told that he may submit statements from other individuals who are able to describe from their knowledge and personal observations in what manner his disability had become worse. The AMC also notified the veteran that he may submit his own statement in which he completely described his symptoms, their frequency and severity, and other involvement to include additional disablement. In the August 2006 VCAA, letter the veteran was informed that examples of evidence he should tell VA about or give to VA that may affect how VA assigns a disability evaluation includes recent Social Security determinations; statements from employers as to job performance, lost time, or other information regarding how your condition affects his ability to work; and statements discussing his disability symptoms from people who have witnessed how the symptoms affect you. Therefore, the veteran was informed that to substantiate a claim, he must provide medical or lay evidence demonstrating a worsening or increase in severity and the effect that worsening has on his employment and daily life. In any event, even if the VCAA letters did not provide sufficient notice as to the first prong of the holding Vazquez-Flores, the essential fairness of the adjudication was not affected because the veteran had actual knowledge of what was necessary to substantiate his claim. See Sanders, supra. Actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim. See Vazquez-Flores, slip op. at 12, citing Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007). In this case, at his various hearings, the veteran testified that his left ear hearing loss had worsened, and he discussed how his service-connected left ear hearing loss impacted his ability to work and his daily life. The veteran submitted a statement in July 2005 from a former co-worker who described the veteran's employment impairment from his hearing loss. As for the second prong of the holding in Vazquez-Flores, the notice letters did not provide at least general notice of the requirement that specific tests as to the veteran's left ear are necessary for a higher rating. However, the essential fairness of the adjudication was not affected because the veteran had actual knowledge of this requirement. See Sanders, supra. The various statements of the veteran demonstrate that he has knowledge of the rating criteria for hearing loss. In particular, and significantly, the veteran has submitted to VA copies of the applicable portions of the rating schedule, 38 C.F.R. § 4.85 and 38 C.F.R. § 4.87, Tables VI, VIa, and VII. As to the third prong of the holding in Vazquez-Flores, in the August 2006 letter, the AMC informed the veteran that the rating for his disability can be changed if there are changes in his condition and that depending on the disability involved, VA will assign a rating from zero percent to as much as 100 percent. The AMC stated that VA uses a schedule for evaluating disabilities that is published as title 38 Code of Federal Regulations, Part 4. The AMC indicated that in rare cases, VA can assign a disability level other than the levels found in the schedule for a specific condition if his impairment is not adequately covered by the schedule. The AMC stated that it would consider evidence of the following in determining the disability rating: nature and symptoms of the condition; severity and duration of the symptoms; and impact of the condition and symptoms on employment. As for impact on daily life, the veteran was told that an example of the evidence he should tell VA about or give to VA that may affect how VA assigns a disability evaluation includes statements discussing his disability symptoms from people who have witnessed how the symptoms affected him. With regard to the fourth prong of the holding in Vazquez- Flores, in the February 2005 VCAA letter the veteran was informed that evidence showing an increase in severity may include a statement from his doctor containing the physical and clinical findings, the results of any laboratory tests or x-rays, and the dates of examinations and tests. In that letter, the AMC also told the veteran that he may submit statements from other individuals who are able to describe from their knowledge and personal observations in what manner your disability has become worse. The AMC also notified the veteran that he may submit his statement in which he completely describes his symptoms, their frequency and severity, and other involvement, to include additional disablement. In the August 2006 letter, the AMC stated that examples of evidence that the veteran should tell VA about or give to VA include the following: information about on-going treatment records, including VA or other Federal treatment records, you have not previously told us about; recent Social Security determinations; statements from employers as to job performance, lost time, or other information regarding how his condition affects your ability to work; and statements discussing his disability symptoms from people who have witnessed how they affect him. [As was noted above, the veteran submitted a statement in July 2005 from a former co-worker who described the veteran's employment impairment from his hearing loss.] Because there is no indication that there exists any evidence which could be obtained which would have an effect on the outcome of this case, no further VCAA notice is necessary. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) [VCAA notice not required where there is no reasonable possibility that additional development will aid the veteran]. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claimant's claim, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law provides that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2007). The Board finds that reasonable efforts have been made to assist the veteran in obtaining evidence necessary to substantiate his claims, and that there is no reasonable possibility that further assistance would aid in substantiating them. The evidence of record includes service medical records, private and VA treatment records, and reports of VA examinations, which will be described below. The Board finds that all relevant evidence necessary for an equitable resolution of these issues has been identified and obtained. In short, the Board has carefully considered the provisions of the VCAA in light of the record on appeal, and for the reasons expressed above finds that the development of these issues has been consistent with the provisions of the VCAA. The veteran has been accorded ample opportunity to present evidence and argument in support of his claims. See 38 C.F.R. § 3.103 (2007). Specifically, he testified at three Board hearings. Accordingly, the Board will proceed to a decision on the merits as the issues on appeal. 1. Entitlement to service connection for right ear hearing loss, to include as secondary to service-connected left ear hearing loss. Relevant law and regulations Service connection - in general Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110 (West 2002). Notwithstanding the above, service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303(a) (2007). In order to establish service connection for a claimed disorder, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Service connection - hearing loss For certain chronic disorders, including sensorineural hearing loss, service connection may be presumed to have been incurred in service if the disease becomes manifest to a compensable degree within one year following separation from service. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2007). Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels) over a range of frequencies (in Hertz). See Hensley v. Brown, 5 Vet. App. 155, 158 (1993). The determination of whether a veteran has a disability based on hearing loss is governed by 38 C.F.R. § 3.385 (2007). See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2007). Continuity of symptomatology The mere fact of an in-service injury is not enough; there must be evidence of a chronic disability resulting from that injury. In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the veteran's claim. See 38 C.F.R. § 3.303(b) (2007). The chronicity provision of 38 C.F.R. § 3.303(b) applies when evidence, regardless of its date, establishes that a veteran had a chronic condition in service and still has that condition. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. Secondary service connection Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310(a) (2007); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Analysis The veteran seeks service connection for right ear hearing loss. He has alternatively contended that the right ear hearing loss is directly due to his military service or is secondary to his service-connected left ear hearing loss. With respect to Hickson and Wallin element (1), current disability, there is medical evidence that the veteran currently has a right ear hearing loss as defined by VA. VA examinations from 1993 to the present have consistently shown that the speech recognition score in the right ear has been below 94 percent. See 38 C.F.R. § 3.385 (2007). As is noted elsewhere in this decision, service connection is in effect for left ear hearing loss. Accordingly, Wallin [secondary service connection] element (2) has been satisfied. With respect to Hickson [direct service connection] element (2), in-service disease or injury, the Board will separately address the matters of in-service disease and in-service injury. Concerning in-service disease, a review of service medical records reveals no evidence of hearing loss disability as defined by VA in the right ear. A pre-induction audiogram in March 1968, the results of which were converted from ASA units to ISO(ANSI) units, shows that the auditory thresholds were the following: HERTZ 500 1000 2000 4000 RIGHT 20 10 5 10 An audiogram on separation in May 1971 shows that the auditory thresholds were the following: HERTZ 500 1000 2000 4000 RIGHT 10 10 10 10 In various statements, the veteran asserts that based on the changes in his puretone thresholds, his right ear hearing decreased in service and that therefore he had a hearing loss in service. The Board notes that the veteran is comparing his pre-induction auditory thresholds in ASA units with the separation auditory thresholds in ISO(ANSI) units. The April 2005 VA examiners noted that both audiograms from service showed that hearing in the right ear was in normal range and that there was not a significant 15 decibel threshold shift, as used in Occupational Safety and Health Administration (OSHA) requirements, in the right ear. The examiners indicated that various audiological examinations showed that the veteran's right ear hearing was essentially in the normal range until 8000 Hertz. Thus, according to the April 2005 examination report, regardless of minor changes in service, the veteran's hearing was still within normal limits at the relevant frequencies on both entrance into and separation from service. See Hensley, 5 Vet. App. at 157 [the threshold for normal hearing is from 0 to 20 decibels]. The February 2007 VA examiners, one of whom examined the veteran in June 2005, again noted that both audiograms from service showed that hearing was essentially within the normal range in the right ear and that substantial shifts in thresholds (greater than 15 decibels as per OSHA requirement) were not evident in the right ear throughout military service. The examiners concluded that there was no evidence available to validate a disability of hearing in the right ear during military service. It is now well established that lay persons without medical training, such as the veteran, are not competent to comment on medical matters such as diagnosis and etiology. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992); see also 38 C.F.R. § 3.159 (a)(1) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. The veteran's statement concerning his hearing levels in service carry no weight of probative value. Furthermore, the record does not reflect medical evidence showing any manifestations of hearing loss during the one year presumptive period after separation from service. See 38 C.F.R. §§ 3.307, 3.309. Right ear hearing loss was initially noted in January 1993, over 21 years after service. Accordingly, Hickson element (2) is not met with respect to disease. With respect to in-service incurrence of injury, in-service acoustic trauma has been conceded, and was on of the bases for service connection for the left ear. Therefore, in- service incurrence of injury, that is to say acoustic trauma, has been shown to be sufficient to satisfy Hickson element (2). The critical question, accordingly, is whether Hickson and Wallin element (3), medical nexus, is satisfied. As to direct service connection, there are of record two competent nexus opinions, the reports of the June 2005 and February 2007 VA audiological examinations. Those opinions were not favorable to the veteran's claim. The June 2005 examiners stated that the hearing loss documented on the March 1997 VA examination was due to the veteran's age and other health factors, and that there was no indication of any right ear hearing loss having a relationship to service because that examination was 25 to 30 years after his military service. The examiners opined that it was not likely that his right ear hearing loss was related to military service. The Board observes that the examiners evidently overlooked a report of right ear hearing loss as defined by VA on a January 1993 VA audiological examination. This was approximately 22 years after service. Although somewhat diminishing the probative value of the report, the salient points still remain: the examiners determined that the veteran's right ear hearing acuity did not diminish in service, and many years went by before hearing loss was identified. The February 2007 VA opinion came to the same conclusion, namely "that the veteran's current right hearing loss os less likely than not (not likely) related to his military service." The Board observes that these two opinions appear to be congruent with the evidence of record. As set out above, the veteran's separation physical examination shows normal hearing, and there is no evidence of hearing loss for several decades after service. With respect to the secondary service connection claim, there is of record only one competent nexus opinion, the report of the February 2007 VA audiological examination. That opinion was not favorable to the veteran's claim. The February 2007 VA examiners opined that there was no evidence to support a finding that the left ear hearing loss caused or aggravated any hearing loss in the right ear. The Board has also considered medical treatise evidence submitted by the veteran. The Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) [competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses]. While the article submitted by the veteran discusses acoustic trauma being a common cause of hearing loss, this article contains no information or analysis specific to the veteran's case, and does not draw upon a physical examination of the veteran. The Court has held on several occasions that medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See generally Obert v. Brown, 5 Vet. App. 30, 33 (1993); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). As such, the treatise evidence submitted by the veteran is of no probative value as to the mater of medical nexus. The only other evidence which purports to relate the veteran's right ear hearing loss to events in service or to his left ear hearing loss comes from the statements of the veteran himself. As has been discussed above, such lay evidence is not competent medical evidence and is entitled to no weight of probative value. See Espiritu, supra; see also 38 C.F.R. § 3.159 (a)(1). The veteran has been afforded ample opportunity to furnish medical nexus evidence to VA. He did not do so. See 38 U.S.C.A. § 5107(a) [it is a claimant's responsibility to support a claim of entitlement to VA benefits]. The veteran appears to contend that his right ear hearing loss began in service and continued thereafter. The Board is of course aware of the provisions of 38 C.F.R. § 3.303(b), discussed above, relating to chronicity and continuity of symptomatology. However, supporting medical evidence is required. See Voerth v. West, 13 Vet. App. 117, 120-1 (1999) [there must be medical evidence on file demonstrating a relationship between the veteran's current disability and the claimed continuous symptomatology, unless such a relationship is one as to which a lay person's observation is competent]. Such evidence is lacking in this case. Specifically, as discussed above the veteran's service medical records are pertinently negative, and there is no competent medical evidence that the veteran was diagnosed with or treated for right ear hearing loss until over two decades after his separation from service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) [noting that it was proper to consider the veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised]; see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) [affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of the claimed condition]. Moreover, the veteran initially claimed a left ear hearing loss in his September 1992 claim. He did not claim until 2000 that he had a right ear hearing loss that began in service and continued to the present time. It does not stand to reason that the veteran would file a claim for his left ear hearing loss which he believed was related to service without mentioning his right ear hearing loss. See Shaw v. Principi, 3 Vet. App. 365 (1992) [a veteran's delay in asserting a claim can constitute negative evidence that weighs against the claim]. The veteran's assertions of continuity of symptomatology are not credible in light of a review of the entire record. Also, the June 2005 VA examiners in essence rejected his assertion of continuity of symptomatology and did not link his current right ear hearing loss to the claimed continuity of symptomatology. See Voerth, supra. Accordingly, the competent medical evidence of record does not demonstrate that there is a relationship between in- service incurrence of noise exposure and the current right ear hearing loss or between the service-connected left ear hearing loss and the current right ear hearing loss. Element (3) has not been met and the service connection claim fails on this basis. In summary, in the absence of the required third Hickson and Wallin element, medical nexus, a preponderance of the evidence is against the claim of entitlement to service connection for right ear hearing loss on both a direct and a secondary basis. The benefit sought on appeal is accordingly denied. 2. Entitlement to an increased (compensable) disability rating for service-connected left ear hearing loss. The veteran is seeking an increased disability rating for his service-connected left ear hearing loss, which is currently evaluated as noncompensably disabling under both 38 C.F.R. § 4.85 (2007) and 38 C.F.R. § 4.85 (1998). He essentially contends that his left ear hearing loss disability has so severely compromised the quality of his life that monetary compensation is warranted. Pertinent law and regulations Increased disability ratings - in general Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2007). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2007). The Court has held that an appeal from an initial rating is a separate and distinct claim from a claim for an increased rating. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Specific schedular criteria The veteran's left ear hearing loss is rated as noncompensable under Diagnostic Code 6100. In general, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). During the pendency of this appeal, effective June 10, 1999, the VA Rating Schedule, 38 C.F.R. Part 4, was amended with regard to evaluating hearing impairment and other diseases of the ear. See 64 Fed. Reg. 25,208, 25,209 (1999) (codified at 38 C.F.R. §§ 4.85-4.87). Effective December 6, 2002, 38 C.F.R. § 3.383 was amended as to evaluating hearing impairment when hearing loss in one ear is service connected and hearing loss in the other ear is not. See 69 Fed. Reg. 48,148 (2004) (codified at 38 C.F.R. § 3.383). The Board notes that the veteran was provided with the amended regulations as to 38 C.F.R. §§ 4.85-4.87 and 38 C.F.R. § 3.383 in the February 2000 and December 2007 SSOC's, respectively. Accordingly, there is no prejudice to the veteran in deciding this appeal based on those regulations. See Bernard v. Brown, 4 Vet. App. 384 (1993) [when the Board addresses in its decision a question that has not been addressed by the RO, it must consider whether the veteran has been given adequate notice to respond and, if not, whether he has been prejudiced thereby]. Where a law or regulation changes after the claim has been filed, but before the administrative or judicial process has been concluded, the version most favorable to the veteran applies unless Congress provided otherwise or permitted the Secretary of VA to do otherwise and the Secretary did so. VAOGCPREC 7-2003. The Board will therefore evaluate the veteran's service-connected left ear hearing loss under both the former and the current criteria of 38 C.F.R. §§ 4.85-4.87 and both the former and current 38 C.F.R. § 3.383, keeping in mind that the revised criteria may not be applied to any time period before the effective dates of the changes. See 38 U.S.C.A. § 5110(g) (West 2002); 38 C.F.R. § 3.114 (2007); VAOPGCPREC. 3-2000; Green v. Brown, 10 Vet. App. 111, 117 (1997). Specifically, the pertinent regulations as 38 C.F.R. §§ 4.85- 4.87 do not contain any substantive changes that affect this particular case, but add certain provisions that were already the practice of VA. See 38 C.F.R. § 4.85. The frequencies used for the evaluation of hearing loss, the percentage of speech discrimination used for the evaluation of hearing loss, and the tables used to determine the level of hearing impairment and the disability evaluation of each level of hearing impairment have not been changed. (i.) The former criteria The former version of the rating schedule indicated that evaluations of defective hearing ranged from non-compensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level measured by puretone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). To evaluate the degree of disability from service- connected defective hearing, the schedule established 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. §§ 4.85, 4.87, Tables VI and VII, Diagnostic Codes 6100-6110 (1998). 38 C.F.R. § 4.85(c) (1998) stated that Table VIa provides numeric designations based solely on puretone averages and is for application only when the Chief of the Audiology Clinic certifies that language difficulties or inconsistent speech audiometry scores make the use of both puretone averages and speech discrimination inappropriate. As was discussed above, service connection has not been granted for right ear hearing loss. In situations where, as here, service connection has been granted only for defective hearing involving one ear, and the veteran does not have total deafness in both ears, the hearing acuity of the non service-connected ear is considered to be normal. In such situations, a maximum 10 percent evaluation is assignable where hearing in the service-connected ear is at level X or XI. See 38 C.F.R. §§ 3.383, 4.85(f), (h) (2004). (ii.) The current criteria The current rating Schedule provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, established by a state-licensed audiologist including a controlled speech discrimination test (Maryland CNC), and based upon a combination of the percent of speech discrimination and the puretone threshold average which is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four. Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. See 38 C.F.R. § 4.85 (2007). When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. See 38 C.F.R. § 4.86(a) (2007). Under the current version of 38 C.F.R. § 3.383, compensation is payable for hearing loss in both ears as if both disabilities were service-connected if (1) hearing impairment in the service-connected ear is compensable to a degree of 10 percent or more; (2) hearing impairment in the nonservice- connected ear, as measured by audio thresholds or speech discrimination scores, meets the criteria to be considered a disability under 38 C.F.R. § 3.385; and (3) the nonservice- connected disability is not the result of the veteran's own willful misconduct. The current criteria of 38 C.F.R. § 3.383 is clearly more favorable to the veteran's claim. Therefore, the Board will apply only the current criteria of 38 C.F.R. § 3.383 to the veteran's left ear hearing loss claim effective from December 6, 2002. Analysis Schedular rating (i.) 38 C.F.R. §§ 3.383, 4.85 As explained in the law and regulations section above, the resolution of this issue involves determining the level of hearing acuity in each ear, notwithstanding the fact that only the left ear is service connected. The Board will review all audiology examination reports of record which are amenable to interpretation. See Kelly v. Brown, 7 Vet. App. 471, 474 (1995) [the Board may not interpret graphical representations of audiometric data]. The February 2007 VA audiology examination report revealed the following: HERTZ 1000 2000 3000 4000 Average RIGHT 40 55 55 60 53 LEFT 65 80 95 105 86 Puretone threshold averages were 53 decibels in the right ear and 86 decibels in the left ear. Speech discrimination scores at that time were 80 percent in the right ear and 74 percent in the left ear. Treating the right ear hearing loss as normal hearing for purposes of determining whether the left ear hearing loss is to a compensable degree and, thus, whether the right ear hearing loss should be considered pursuant to the new 38 C.F.R. § 3.383, this examination report yielded a numerical designation of I in the right ear [treating the right ear hearing loss as normal hearing] and a numerical designation of VII for the service-connected left ear [82 to 89 percent average puretone decibel hearing loss, with between 68 and 74 percent speech discrimination]. However, the report reflects that the veteran has an exceptional pattern of hearing impairment in the left ear because all of the specified puretone thresholds are over 55 decibels. Entering the puretone threshold average into Table VIA, a numerical designation of VIII for the service-connected left ear is warranted. Entering the category designations of I in the right ear and of VIII in the left ear into Table VII, a disability percentage evaluation of 0 percent, or noncompensable, is for assignment under Diagnostic Code 6100 for the left ear hearing loss impairment alone. The hearing impairment in the veteran's left ear is not to a compensable degree. Therefore, the hearing impairment in the non service- connected right ear is not for consideration in evaluating the service-connected left ear hearing loss. [The veteran underwent a VA audiological examination in June 2005, but the examiners noted that the test results, especially in the right ear, were questionable during the word recognition test. The veteran had a pattern of responses that were atypical. He was counseled but continued with some inconsistent responses. The speech recognition threshold in the right ear was 25 decibels, which was 10 decibels below the anticipated level from the best puretone threshold results obtained in the right ear. Similarly, the speech recognition threshold in the left ear was 40 decibels, which was 20 to 25 decibels below the anticipated level from the best puretone threshold results obtained in the left ear. The examiners concluded that the examination showed poor interest consistency and even poor reliability within a specific test item. The veteran also underwent a VA audiological examination in April 2005, but he had bilateral cerumen impaction. Also, the inner test consistency on the examination was poor; the examiners also noted that there was some non-organic element. The examiners recommended that the examination results not be used for any adjudication or change in his rating. Therefore, the Board will not consider the results of the June 2005 and April 2005 VA examinations in determining whether an increased rating is warranted for the left ear hearing loss.] The December 1999 VA audiology examination report revealed the following: HERTZ 1000 2000 3000 4000 Average RIGHT 15 20 20 30 21 LEFT 30 45 85 105 66 Puretone threshold averages were 21 decibels in the right ear and 66 decibels in the left ear. Speech discrimination scores at that time were 86 percent in the right ear and 66 percent in the left ear. Since the veteran did not have total deafness in his right ear, this examination report yielded a numerical designation of I in the right ear [treating the right ear hearing loss as normal hearing] and a numerical designation of VII for the service-connected left ear [66 to 73 percent average puretone decibel hearing loss, with between 60 and 66 percent speech discrimination]. Entering the category designations of I in the right ear and of VII in the left ear into Table VII, a disability percentage evaluation of 0 percent, or noncompensable, is for assignment under Diagnostic Code 6100. The March 1997 VA audiology examination report revealed the following: HERTZ 1000 2000 3000 4000 Average RIGHT 15 10 10 20 14 LEFT 15 25 70 85 49 Puretone threshold averages were 14 decibels in the right ear and 49 decibels in the left ear. Speech discrimination scores at that time were 90 percent in the right ear and 80 percent in the left ear. Since the veteran did not have total deafness in his right ear, this examination report yielded a numerical designation of I in the right ear [treating the right ear hearing loss as normal hearing] and a numerical designation of III for the service-connected left ear [42 to 49 percent average puretone decibel hearing loss, with between 76 and 82 percent speech discrimination]. Entering the category designations of I in the right ear and of III in the left ear into Table VII, a disability percentage evaluation of 0 percent, or noncompensable, is for assignment under Diagnostic Code 6100. In various statements and at the April 1999 hearing, the veteran argues that uncomfortable loudness readings from the March 1997 evaluation, instead of the air conduction readings from that evaluation, should be used for determining the severity of his left ear hearing loss. See April 1999 hearing transcript, pages 24-25. The Board notes that the veteran is not competent to determine which testing method should be used to determine his puretone threshold readings. See Espiritu, supra; see also 38 C.F.R. § 3.159 (a)(1). The January 1993 VA audiology examination report revealed the following: HERTZ 1000 2000 3000 4000 Average RIGHT 5 5 0 10 5 LEFT unk 10 unk unk 41 Puretone threshold averages were 5 decibels in the right ear and 41 decibels in the left ear. The Board notes that the printout of the report of the January 1993 VA examination makes it impossible to determine that puretone thresholds for 1000, 3000, and 4000 Hertz in the left ear. However, it appears that the puretone threshold average for the left ear was 41 decibels. Speech discrimination scores at that time were 94 percent in the right ear and 90 percent in the left ear. Since the veteran did not have total deafness in his right ear, this examination report yielded a numerical designation of I in the right ear [treating the right ear hearing loss as normal hearing] and a numerical designation of II for the service-connected left ear [0 to 41 percent average puretone decibel hearing loss, with between 84 and 90 percent speech discrimination]. Entering the category designations of I in the right ear and of II in the left ear into Table VII, a disability percentage evaluation of 0 percent, or noncompensable, is for assignment under Diagnostic Code 6100. The Board has considered the report of a private audiological evaluation dated in November 1996. Some parts of the reports cannot be interpreted by the Board. See Kelly v. Brown, supra. The private audiological evaluation does contain speech recognition scores, however. Consideration of those speech discrimination scores, which reveal 100 percent in the right ear and 96 percent in the left ear, and consideration of the puretone threshold averages found on the January 1993 VA audiological examination [5 decibels in the right ear and 41 decibels in the left ear] yielded a numerical designation of I in the right ear and a numerical designation of I for the left ear [0 to 41 average puretone decibel hearing loss, with between 92 and 100 percent speech discrimination]. Entering the category designations into Table VII, a disability percentage evaluation of zero percent, or noncompensable, is for assignment under Diagnostic Code 6100. Applying the foregoing criteria to the facts in this case, the Board finds that the veteran's left ear hearing loss was properly assigned a noncompensable evaluation under Diagnostic Code 6100. (ii.) 38 C.F.R. § 4.86 The Board has considered the application of 38 C.F.R. § 4.86(c) (1998) [exceptional patterns of hearing impairment] and 38 C.F.R. § 4.86 (2007) [exceptional patterns of hearing impairment]. The veteran's hearing loss does not meet the criteria under either section. More specifically, the Chief of the Audiology Clinic did not certify that language difficulties or inconsistent speech audiometry scores make the use of both puretone averages and speech discrimination inappropriate. Therefore, 38 C.F.R. § 4.86(c) (1998) is not applicable to the veteran's claim. In addition, the veteran's hearing tests do not show a result of 30 dB or less at 1000 Hz and 70 dB or more at 2000 Hz, as would be required for application of table VIa under 38 C.F.R. § 4.86(b). The veteran also does meet the criteria for 38 C.F.R § 4.86(a). Each of the four specified frequencies is not 55 dB or more in the left ear. Accordingly, the rating under 38 C.F.R. § 4.85 is the correct rating under the regulations for this veteran. In short, the medical evidence does not support a compensable evaluation for the veteran's left ear hearing loss under any pertinent criteria. The Board has no reason to doubt that the veteran experiences left ear hearing loss. Indeed, the presence of hearing loss is a prerequisite for service connection. See 38 C.F.R. § 3.385 (2007). As for the level of hearing loss, as explained above this must be determined by appropriate studies, and in this case the studies performed indicate a noncompensable level of hearing loss. Fenderson considerations As was discussed in the law and regulations section above, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings". See Fenderson, 12 Vet. App. at 126. In this case, the medical evidence of record, which has been discussed above, supports the proposition that the veteran's service-connected left ear hearing loss has not changed appreciably since the veteran filed his claim. There are no medical findings or other evidence which would allow for the assignment of a compensable disability rating at any time during the period of time here under consideration. Based on the record, the Board finds that a noncompensable disability rating was properly assigned for the entire period from the date of service connection, September 25, 1992. Extraschedular consideration Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2007). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Floyd v. Brown, 9 Vet. App. 88, 95 (1996), the Board cannot make a determination as to an extraschedular evaluation in the first instance. See also VAOPGCPREC 6-96. The RO has considered 38 C.F.R. § 3.321(b)(1) in the veteran's case. Accordingly, the Board will address the possibility of the assignment of an extraschedular rating for the increased disability rating at issue. The Board has been unable to identify an exceptional or unusual disability picture. The record does not show that the veteran has required frequent hospitalizations for his left ear hearing loss. Indeed, it does not appear from the record that he has been hospitalized at all for that disability. Additionally, there is not shown to be evidence of marked interference with employment due to the disability. The evidence shows that the veteran worked as a service representative for the Social Security Administration and that he last worked in August 2005. There is no indication that he had not missed any work because of his left ear hearing loss, and there is nothing in the current evidence of record to indicate that his left ear hearing loss alone causes any unusual employment impairment. In addition, there is no evidence in the medical records of an exceptional or unusual clinical picture, or of any other reason why an extraschedular rating should be assigned. The Board therefore has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Conclusion For the reasons stated above, the Board finds that a preponderance of the evidence is against the veteran's claim for an increased (compensable) disability rating for his service-connected left ear hearing loss. The claim is therefore denied. ORDER Service connection for right ear hearing loss is denied. Entitlement to an increased (compensable) disability rating for service-connected left ear hearing loss is denied. ____________________________________________ Barry F. Bohan Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs