Citation Nr: 1031077 Decision Date: 08/18/10 Archive Date: 08/24/10 DOCKET NO. 04-24 651 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to an increased initial (compensable) rating for bilateral defective hearing. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. A. Booher, Counsel INTRODUCTION The Veteran had active service from November 1966 to October 1969 and from September 1970 to September 1974. He was born in 1945. These claims come before the Board of Veterans' Appeals (Board) on appeal of a February 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified in support of these claims at a Travel Board hearing held at the VARO in February 2007, before the undersigned Veterans Law Judge. In a decision in September 2007, the Board denied entitlement to service connection for posttraumatic stress disorder (PTSD), tinnitus, and diabetic retinopathy. The Board also held that new and material evidence had been submitted and accordingly, the claims for entitlement to service connection for hepatitis and left ear hearing loss were reopened; that left ear hearing loss was a result of service; and remanded the case for the consideration on the substantive merits of the hepatitis issue, as well as hypertension and the evaluation of the now service- connected bilateral hearing loss. In subsequently effectuating the Board's grant with regard to the hearing loss in the left ear, the date assigned was from the date of the original claim (June 27, 2003); a noncompensable rating was assigned for the bilateral defective hearing and that issue is now before the Board as stated on the front cover of this decision for further appellate review. In a rating action in October 2009, service connection was also granted for hepatitis, resolving that appellate issue; a noncompensable rating was assigned for that disability. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) [where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection]. In February 2010, the appellant's claim was referred for a medical opinion by an expert of the Veterans Health Administration (VHA) pursuant to 38 U.S.C.A. § 7109 (West 2002). In April 2010, the expert medical opinion was received and was referred to the appellant for review and the submission of any additional evidence or argument. In June 2010, the Veteran's representative presented additional written arguments on the Veteran's behalf. FINDINGS OF FACT 1. The aggregate evidence preponderates against a finding that the Veteran developed hypertension in or as a result of service or as a result of any service-connected disability to include diabetes mellitus. 2. Repeated audiometric testing reveals that the Veteran's service-connected hearing loss is consistently no worse than Level I or II in either ear, does not present an unusual type of loss, has not required hospitalization and had not caused him to have unusual time lost from work; he utilizes amplification aids. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by service, may not be so presumed and is not due to service-connected disability(ies). 38 U.S.C.A. §§ 1110, 1131, 1137, 1153 (West 2002 & Supp. 2009); 38 C.F.R. § 3.310 (2006); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306, 3.307, 3.309 (2009) . 2. The criteria for an initial compensable rating for bilateral hearing loss have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.85-4.87, Diagnostic Code (DC) 6100 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2009). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim, and this correspondence was sent to him initially after his claim and on subsequent occasions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2009). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). As to claims for increase, the U.S. Court of Appeals for Veteran Claims (Court) previously held that a detailed notice, tailored to the specific aspects of each claim, must be provided under 38 U.S.C.A. § 5103(a). Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). However, the Federal Circuit Court reversed that decision, holding that what is required is generic notice of the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment and earning capacity, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez- Flores v. Shinseki, No. 08-7150, 2009 WL 2835434 (Fed. Cir. Sept. 4, 2009). See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board notes that the Veteran's claim for a higher initial rating for his hearing loss is a downstream issue from his claim for entitlement to service connection for such bilateral disability. The RO effectuated the Board's September 2007 grant of service connection for left ear hearing loss in a February 2008 rating decision, and continued a 0 percent rating for bilateral hearing loss. The Veteran then argued that he should have received a higher rating for this disability. In these types of circumstances, VA is not required to issue a new VCAA letter. See VAOPGCPREC 8-2003. In this precedential opinion, the General Counsel held that although VA is required to issue a statement of the case (SOC) if the downstream issue is not resolved, 38 U.S.C.A. § 5103(a) does not require separate notice of the information and evidence that is necessary to substantiate the newly raised issue. Id. Here, the Veteran's claim was readjudicated and a supplemental statement of the case (SSOC) was issued in October 2009. The U.S. Court of Appeals for the Federal Circuit previously held that any error in VCAA notice should be presumed prejudicial, and that VA must bear the burden of proving that such an error did not cause harm. Sanders v. Nicholson, 487 F.3d 881 (2007). However, the U.S. Supreme Court has recently reversed that decision, finding it unlawful in light of 38 U.S.C.A. § 7261(b)(2), which provides that, in conducting review of decision of the Board, a court shall take due account of rule of prejudicial error. The Supreme Court in essence held that the burden of proving harmful error must rest with the party raising the issue, the Federal Circuit's presumption of prejudicial error imposed an unreasonable evidentiary burden upon VA and encouraged abuse of the judicial process, and determinations on the issue of harmless error should be made on a case-by-case basis. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). As to the issue of service connection, the Board finds that the RO has satisfied the duty to notify and assist under the VCAA. The Board finds that the content of the August and October 2003 and March 2006 letters letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. Although some of the notices were not sent until after the initial rating denying the claim, the Board finds that any defect with respect to the timing of the required notice was harmless in that his claim was fully developed and readjudicated after notice was provided. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Then and since including at the hearing and via the substance of the earlier remand, the Veteran was advised of the opportunities to submit additional evidence after which additional data was obtained and entered into the record. The Board finds that the purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of the claim. He has indicated that he has no other information or evidence to substantiate the claim. The appellant has demonstrated actual knowledge of, and has acted on, the information and evidence necessary to substantiate the pending claims for a higher rating and service connection, including secondary service connection. See, e.g., Dalton v. Nicholson, 21 Vet. App. 23, 30 (2007) (Court was convinced that appellant had demonstrated actual knowledge of the information and evidence necessary to establish the claim). Moreover, the Veteran has not demonstrated any prejudicial or harmful error in VCAA notices provided. See Shinseki v. Sanders, supra. In addition, it appears that all obtainable evidence identified by the appellant relative to the claim has been obtained and associated with the claims file, and that he has not identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of the current appeal, nor has he suggested in any way that there is any prejudice due to a lack of proper VA notice or assistance. The Veteran was afforded VA examinations pertinent to both claims, during which examiners addressed whether the disabilities at issue in this decision were present and to what extent, and as appropriate, a nexus opinion was provided. Since then, the veteran has not alleged that the reports of these examinations are inadequate to decide the claims now at issue in this decision. In ensuring that all appropriate opinions were of record, the Board also obtained a VHA expert opinion. Accordingly, we find that VA has satisfied its duty to assist the appellant in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claim under the VCAA. Hypertension Criteria Service connection may be granted for disability resulting from personal injury suffered or disease contracted during active military service, or for aggravation of a pre-existing injury suffered, or disease contracted, during such service. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.303(a), 3.304. Where there is a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. When a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Such evidence must be medical unless it relates to a condition as to which, under the Court case law, lay observation is competent. Savage v. Gober, 10 Vet. App. 488, 498 (1997). The Court has held that, in order to prevail on the issue of service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of incurrence or aggravation of a disease or injury in service; and (3) medical evidence of a nexus between the claimed in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999). In addition, the law provides that, where a Veteran served ninety days or more of active military service, and certain chronic diseases, including hypertension, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. § 1101, 1112, 1113, 1137; 38 C.F.R. § 3.307, 3.309(a). Secondary service connection may also be established for disability which is proximately due to or the result of service- connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995). 38 C.F.R. § 3.310, the regulation concerning secondary service connection, was amended effective October 10, 2006. See 71 FR 52744-47, (Sept. 7, 2006). The intent was to conform to the regulation to Allen v. Brown, a U.S. Court of Appeals for Veterans Claims decision that clarified the circumstances under which a Veteran may be compensated for an increase in the severity of an otherwise nonservice-connected condition caused by aggravation from a service-connected condition. Any increase in severity of a nonservice- connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice- connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice- connected disease or injury. See 38 C.F.R. § 3.310 (2009). The new regulation appears to place additional evidentiary burdens on claimants seeking service connection based on aggravation, specifically, in terms of establishing a baseline level of disability for the non-service-connected condition prior to the aggravation. Because the new law appears more restrictive than the old, and because the Veteran's appeal was already pending when the new provisions were promulgated, the Board will consider this appeal under the law in effect prior to October 10, 2006. See, e.g., Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (new regulations cannot be applied to pending claims if they have impermissibly retroactive effects). Hypertension, standing alone and not the result of diabetes- induced renal disease, i.e., essential hypertension, is not found among the complications of diabetes mellitus. Flynn v. Brown, 6 Vet. App. 500, 506 (1994). There are also two notes to DC 7101, which sets forth the criteria for the evaluation of service-connected hypertensive cardiovascular disease and in the first note it is stated that "[f]or purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm." For VA purposes, hypertension means that the diastolic blood pressure [the bottom number] is predominantly 90 mm or greater, and isolated systolic hypertension means that the systolic blood pressure [the top number] is predominantly 160 mm or greater with a diastolic of less than 90 mm. 38 C.F.R. § 4.104, Diagnostic Code (DC) 7101, NOTE (1) (2001). Further, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, NOTE (1) (2009) When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 61 (1991). It is also noted that in this as in any other case, it remains the duty of the Board as the fact finder to determine credibility in any number of contexts, whether it has to do with testimony or other lay or other evidence. See Culver v. Derwinski, 3 Vet. App. 292, 297 (1992). In general, lay individuals may not render medical conclusions ( see Espiritu v. Derwinski, 2 Vet. App. 492 (1992)); however , a lay statement may be made which relays the visible symptoms of a disease or disability or the facts of observed situations or circumstances, see Caldwell v, Derwinski, 1 Vet. App. 466, 469 (1991), after which a decision must be made as to the credibility thereof in the context of probative medical evidence, see Rowell v. Principi, 4 Vet. App. 9, 19 (1993). The Court has held that "where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required." Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In determining whether documents submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995); see also Pond v. West, 12 Vet. App. 341, 345 (1999) In any event, the Board has the clear duty to assess the credibility and weight to be given the evidence. The Board is not competent to supplement the record with its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991); however, following the point at which it is determined that all relevant evidence has been obtained, it is the Board's principal responsibility to assess the credibility, and therefore the probative value of proffered evidence of record in its whole. Owens v. Brown, 7 Vet. App. 429, 433 (1995); Elkins v. Gober, 229 F. 3d 1369 (Fed. Cir. 2000). The Federal Circuit has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Board has an obligation to provide adequate reasons and bases supporting this decision, but there is no requirement that every item of evidence submitted by the appellant or obtained on his behalf be discussed in detail. The Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Factual Background and Analysis The Veteran asserts that he either developed hypertension in service or soon thereafter, or that his hypertension is due to his service-connected diabetes. Blood pressure readings were taken on a number of occasions in service and all were within normal range as defined above and he denied that he had a history of hypertension. Specifically, the following readings were recorded: 129/74 (September 1966); 124/85 (October 1969); 124/78 (February 1974); 118/88 (August 1987); 118/80 (June 1988); 110/70, 122/78 (July 1988); 114/68 (July 1989); 118/82 (May 1990); 110/80 (December 1991). Private treatment records after service commencing in 1998 show repeated normal blood pressure readings with occasional elevations (e.g., 144/90, 146/92 (March 2000) and more frequently since 2004 for which he has been given medications. On VA examination in January 2004, the Veteran reported having borderline hypertension but this was inconsistent. On examination, readings were 143/79, 140/80 and 140/82. He did not claim or manifest any heart disease. He said he had had a diagnosis of diabetes for about 7 years and he took Glycophage with fair control. The examiner concluded that he had no heart disease and no definite hypertension. Clinical reports in January 2005 showed periodically elevated readings (e.g., 159/79) and a diagnosis of "elevated blood pressure without hypertension". A similar finding was recorded in October 2006. At the personal hearing, the Veteran testified that he was not told in service or at separation that he had hypertension. Tr. at 15. He said he had been diagnosed with hypertension when he went to VA. Tr. at 15-16. It was his belief that it was due to his diabetes and followed soon thereafter. Tr. at 16. On VA examination in May 2008 and addendum, the examiner noted that his diagnosis of hypertension had been about 4 years before. He continued to take medications. The examiner opined that he saw no evidence of elevated blood pressures or hypertension during service or for some time thereafter, and thus hypertension was less likely than not due to service. In February 2010, the Veteran's claims file was reviewed by a VHA specialist for the purpose of providing a nexus opinion as to secondary service connection, including the aggravation aspect of such claim. The doctor first stated that it had been noted by other reviewers that there is no medical evidence that diabetes is a cause of hypertension; otherwise, the doctor recognized that the purpose of the opinion was to include possible aggravation. The doctor indicated that there was no current medical evidence that the Veteran had any complications of hypertension, particularly cardiovascular disease and renal disease. In the event of some future complications, then a connection might be established between diabetes and the long-term effects of hypertension. The conclusion by the doctor was no evidence of any current relationship. Initially, the Board observes that the Veteran is entitled to make observations but he cannot provide a competent opinion that his hypertension is causally related to military service or his diabetes. The Board acknowledges that the Veteran's own lay statements may in some instances be sufficient to establish a current diagnosis. In Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007), the Federal Circuit determined that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient in a particular case is a fact issue. Competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F .3d 1331, 1337 (Fed.Cir.2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept 14, 2009). Here, the Board finds that the Veteran is not competent to offer a medical opinion as to whether service- connected diabetes or service is related in some way to his current hypertension. The Board is sympathetic with the Veteran. Nonetheless, competent medical evidence is still required to support this claim. Opinions as to etiology, hypertension in this case, are within the realm of medical personnel and not laypersons, such as the Veteran. See Espiritu v. Derwinski, 2 Vet. App. 492, 494- 95 (1992). The evidence of the passage of many post-service years before documentation of hypertension along with otherwise normal interim findings contradict any assertions that he has had hypertension in or soon after service. As such, service connection on a presumptive basis is not in order. 38 C.F.R. §§ 3.307, 3.309. The Veteran's sworn testimony was that he was not told that he had hypertension during service or for years thereafter. Tr. 15. Accordingly, service connection based on continuity of symptomatology is not in order. 38 C.F.R. § 3.303(b). Further, a prolonged period without medical complaint can be considered, along with other factors concerning the claimant's health and medical treatment during and after military service, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability which still exists currently. See Maxson v. Gober, 230 F. 3d 1330 (Fed. Cir. 2000). Of great probative weight are the medical expert opinions that clearly and unequivocally dissociate the disorder with the Veteran's service and service-connected diabetes. Therefore, to the extent that lay testimony/statements have some probative value, they are far outweighed by the nexus opinions provided by several experts. See Buchanan v. Nicholson, supra. The 2004 and 2008 VA examiners are competent to render such diagnoses (or lack thereof) and/or an opinion as to etiology. Moreover, the 2008 examiner reviewed the file, including prior relevant examinations and provided reasons for his conclusions as to a nexus opinion. The examination was adequate and the examiner's conclusion carries much probative weight. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The VHA expert also reviewed the Veteran's claims file and provided a response and rationale as to secondary service connection. Again, this deliberative approach lent to a sufficient opinion. The Veteran's other physicians have never linked his hypertension to service or diabetes and the medical evidence does not otherwise link the current disorder with military service or any service-connected disability. In summary, the record fails to show competent and probative evidence of hypertension in service or for years thereafter, and the preponderance of the evidence is against a finding that the condition is due to or aggravated by service or service-connected disability. Therefore, the Board finds that the preponderance of the evidence is against the claim, and the appeal must therefore be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Bilateral Defective Hearing Criteria Disability ratings are based upon schedular requirements that reflect the average impairment of earning capacity occasioned by the state of a disorder. 38 U.S.C.A. § 1155. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In determining the level of impairment, the disability must be considered in the context of the entire recorded history, including service medical records. 38 C.F.R. § 4.2. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which code or codes are most appropriate for application of the case, and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). When there is an approximate balance in the 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. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. The Board notes that this is a case in which the Veteran has expressed continuing disagreement with the initial rating assignment. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). See also Hart v. Mansfield, 21 Vet. App. 505 (2007). Evaluations of defective hearing range from noncompensable to 100 percent for service-connected bilateral hearing loss. These evaluations are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 hertz (Hz). To evaluate the degree of disability from defective hearing, the Rating Schedule establishes eleven auditory acuity levels from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. §§ 4.14, 4.85, Diagnostic Code 6100 (2007). In sum, a zero percent evaluation is provided where hearing in the better (or in this case, nonservice-connected and not totally deaf) ear is I and hearing in the other ear is I through IX. 38 C.F.R. § 4.85, Table VII, Diagnostic Code 6100. Hearing tests will be conducted without hearing aids but the impact thereof is contemplated in the schedular evaluations; the results of the above-described testing are charted on Table VI and Table VII. See 38 C.F.R. § 4.85. Under 38 C.F.R. § 4.86(a), when the pure tone thresholds at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hz) 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 is to be evaluated separately. Id. When the puretone threshold is 30 decibels or less at 1000 Hz, and 70 decibels or more at 2000 Hz, 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. 38 C.F.R. § 4.86(b). The application of these provisions is not applicable in this case. Where there is an exceptional pattern of hearing impairment as defined in 38 C.F.R. § 4.86, numeric designations of hearing acuity may be alternatively derived based on pure tone thresholds alone, under Table VIA. 38 C.F.R. § 4.85(c). The Court has noted that the assignment of disability ratings for hearing impairment are basically arrived at by a mechanical application of the numeric designations assigned after audiological evaluations are rendered. See Acevedo-Escobar v. West, 12 Vet. App. 9, 10 (1998); Lendenmann v. Principi, 3 Vet. App. 345 (1992). However, a recent Court decision has admonished that audiologists must describe the effects of the hearing loss on occupational functioning and daily activities so that it can be determined whether an extraschedular evaluation may be assigned. See Martinak v. Nicholson, 21 Vet. App. 447 (2007). In Martinak, the Court specifically pointed out that, unlike the schedular rating criteria for rating hearing loss, the extraschedular provisions do not rely exclusively on objective results to determine entitlement. In exceptional cases where the schedular evaluation is found to be inadequate, 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." 38 C.F.R. § 3.321(b)(1). The Board has the clear duty to assess the credibility and weight to be given the evidence, and is not competent to supplement the record with its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). However, following the point at which it is determined that all relevant evidence has been obtained, it is the Board's principal responsibility to assess the credibility, and therefore the probative value of proffered evidence of record in its entirety. Owens v. Brown, 7 Vet. App. 429, 433 (1995); Elkins v. Gober, 229 F. 3d 1369 (Fed. Cir. 2000). The Federal Circuit Court has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Similarly, it is well established that while someone who is a layperson is not considered capable of opining on matters requiring medical knowledge, they are permitted to provide observations. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Board has reviewed all the evidence in the appellant's claims file. Although there is an obligation to provide adequate reasons or bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Factual Background and Analysis Audiometric and other evaluations in service are of record for comparison purposes. The Veteran's initial VA audiometric evaluation of record was in January 2004. On the authorized audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -- 15 65 70 70 LEFT -- 15 15 40 35 Speech audiometry revealed speech recognition ability of 88 percent in the right ear and of 100 percent in the left ear. The examiner certified that only the results which reflected his actual loss had been reported. Clinical records from about the same time show that he was fitted for a hearing aid. On a VA audiometric evaluation in May 2008, on the authorized audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 55 65 75 LEFT 10 15 15 10 35 Speech audiometry revealed speech recognition ability of 100 percent in both ears. Clinical records at about the same time show hearing aid reevaluation. In this case, there is no basis for finding that the audiometric results as certified are not reflective of the Veteran's actual hearing loss. These results are internally consistent and have been reported above in pertinent part. The Board acknowledges the Veteran's contention that his hearing loss is disabling to a compensable degree. However, the noncompensable rating assigned reflects the greatest degree of disability objectively shown (by repeated official audiometry) during the period of the appeal. As the evaluation of hearing loss must be based on authorized objective testing, the Board predicates its determination on the results of the most recent series of audiometry. And since there has been no significant fluctuation in the test results, there is no need to stage the ratings. See Fenderson, Hart, supra. A doubt is not raised in that regard to be resolved in his favor. Finally, the Board has considered whether the Veteran's claim warrants referral to the Chief Benefits Director of VA's Compensation and Pension Service under 38 C.F.R. § 3.321. The Board is aware of the Veteran's complaints that his bilateral defective hearing disability affects him daily, and the VA examination reports did contain the pertinent history. However there are no aspects of this disability which are not contemplated in the schedular rating criteria. See 38 U.S.C.A. § 1155 (Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity). Therefore, referral to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321 is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Court has clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. Such is the case here. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a total disability rating by reason of individual unemployability due to service-connected disability (TDIU) claim is part of an increased rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the Board finds that a claim for a TDIU is not raised by the record as the evidence of record fails to show that the Veteran is unemployable. ORDER Service connection for hypertension is denied. An increased initial (compensable) rating for bilateral defective hearing is denied. ____________________________________________ M. SABULSKY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs