Citation Nr: 1302298 Decision Date: 01/22/13 Archive Date: 01/31/13 DOCKET NO. 10-14 598 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a right shoulder disorder. 2. Entitlement to service connection for depression. 3. Entitlement to service connection for a heart condition. 4. Entitlement to a compensable disability rating for bilateral hearing loss. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD James G. Reinhart, Counsel INTRODUCTION The Veteran served on active duty from March 1953 to March 1955. This matter comes to the Board of Veterans' Appeals (Board) on appeal from April 2009 and August 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In the April 2009 decision, the RO denied entitlement to a compensable rating for the Veteran's bilateral hearing loss. In the August 2009 decision, the RO denied entitlement to service connection for depression, tendonitis of the right shoulder, and a heart condition. Although the August 2009 decision did not mention hypertension, the statement of the case issued in March 2010 shows that the RO considered hypertension as well as a more specific heart condition in the denial of the claim. This is consistent with the Veteran's claim, in which he requested benefits for a heart condition to include hypertension. In October 2012 argument, the Veteran's representative referred to an October 2012 VA examination conducted in response to a March 2012 claim of entitlement to a total disability rating based on individual unemployability (TDIU). The Board has reviewed that examination report. It addresses only the Veteran's service-connected disabilities of the low back and lower extremities. It is not evidence pertinent to the issues before the Board at this time. There is no indication that the RO has adjudicated a claim since that examination. As the TDIU claim is pending at the RO the Board does not have jurisdiction over it. The issue of entitlement to service connection for depression is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center in Washington, DC. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. A disease or injury of the Veteran's right shoulder did not have onset during his active service, was not caused by his active service, and was not caused or aggravated by a service-connected condition. 2. Neither hypertension, nor a heart disorder had onset during the Veteran's active service, manifested within one year of separation from active service, or was caused by his active service. 3. For the period prior to September 2010, puretone thresholds at the frequencies of 1000, 2000, 3000, and 4000 Hertz, were no greater than 25, 45, 70, and 75 dB, respectively, for the Veteran's right ear; and no greater than 35, 70, 85, and 90 dB, respectively, for the Veteran's left ear; speech discrimination was no lower than 92 percent for the right ear and 68 percent for the left ear. CONCLUSIONS OF LAW 1. The criteria for service connection for a right shoulder disability have not been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). 2. The criteria for service connection for a heart disorder and/or hypertension have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 3. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.655, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.85, Diagnostic Code 6100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 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). 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). For service-connection claims, this notice must address the downstream elements of disability rating and effective date. Dingess v. Nicholson, 19 Vet. App. 473 (2006). With regard to claims for increased disability ratings for service connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant was must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA received the Veteran's claims that led to this appeal in December 2008. The VCAA duty to notify was satisfied by way of a letter sent to the Veteran in January 2009. That letter informed him of what evidence was required to substantiate the claims, and of his and VA's respective duties for obtaining evidence. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of service and other pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's VA treatment records. The Veteran has not requested VA's assistance in obtaining any other evidence. Upon receipt of his original application for VA benefits in October 2004, the RO requested his service treatment records. A December 2004 Personnel Information Exchange System (PIES) response indicates that the Veteran's records are "fire related," that the original service treatment records were moldy and brittle and could not be mailed, and that photocopies of the service treatment records were sent instead. Associated with the claims file are photocopies of several treatment records as well as reports of medical examination and medical history when the Veteran entered active duty, when he was separated from active duty, and from four years after separation from active duty - tor the purpose of participation in the Reserves. In cases where the service records are presumed lost or destroyed, VA has a heightened duty to assist the claimant including the obligation to search for additional records. See Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005). The heightened duty includes informing the Veteran that he may submit alternative information and evidence including corroboration in the form of statements from fellow service members. Id. at 370. VA met the heightened duty in this case. In the January 2009 letter, the RO advised the Veteran to submit evidence from people who knew him during his active service and knew of his claimed disabilities. In May 2006, in connection with an earlier claim, the RO submitted a PIES request including information from a Veteran completed National Archives (NA) Form 13055, asking for additional records. A June 2006 PIES response indicates that no search was possible based on the information provided, and suggested narrowing the search to a 90 day period. After August and September telephone conversations with the Veteran, documented in Reports of Contact, the RO submitted a PIES request with a narrower time frame. Searches of morning reports revealed no mention of the Veteran. As to the claims currently before the Board, the Veteran has never stated that he injured his shoulder during service or that he sought treatment during service for his shoulder, a heart condition, or hypertension. His statements found in treatment reports indicate that none of these conditions were present during service. From the above described development it is clear that the Veteran knows that his service treatment records may be incomplete. Given these facts, the Board finds that VA has no further duty to search for additional records in this case. VA has not provided examinations with regard to the claims of entitlement to service connection for a right shoulder or heart disease / hypertension. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). The third factor has a low threshold. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In October 2012 argument, the Veteran's representative stated that the Veteran had been diagnosed with tendonitis of the right shoulder and asked that VA provide him with a medical examination to decipher if the condition was related to his active service and /or have been aggravated by a service-connected condition. The representative noted that no examination had been provided with regard to the heart disease / hypertension claim. He did not provide any information as to how these conditions are related to the Veteran's active service or how his right shoulder condition is related to a service-connected disability. The Board has considered the Veteran's statement that he wants his right shoulder condition to be considered as secondary to his service connected ankle and knee disabilities. The Veteran's request that VA consider his shoulder condition as related to his service-connected knee and ankle conditions is no more than request; it is not an indication of an association of his shoulder condition to any service-connected condition. As the Court of Appeals for Veteran's Claims (Court) has pointed out, the duty to assist is not a license to continue gathering information in the hopes of finding evidence to support a claim. See Douglas v. Shinseki, 23 Vet. App. 19, 25 (2009); see also Gober v. Derwinski, 2 Vet. App. 470, 472 (1992) (stating that VA's duty to assist is not a license for a fishing expedition to determine if there might be some unspecified information that could possibly support a claim). The Board concludes that VA has no duty to provide the Veteran an examination to determine if a current shoulder disability was caused or aggravated by a service-connected condition. Notably, the service treatment records that were provided included reports of medical examination and history at separation from active service. These show that he had no right shoulder disease or injury, heart condition, or hypertension at that time. The Veteran has not reported that any of these conditions or symptoms of these conditions were present during his active service. Even given the report of damaged service treatment records, the fact that the separation reports are of record coupled with the Veteran's silence as to any in-service aspect of these conditions leads to the conclusion that in-service factor and the indication of an association with service factor for triggering VA's duty to provide an examination are not present in this case. His supposition that there is a relationship between his right shoulder disorder and heart problems, to include hypertension, to his service connected disabilities or active service is without any foundation. There is simply no competent evidence suggesting a link. VA thus has no duty to provide examinations with regard to these claims. Following receipt of his claim for an increased rating for his hearing loss disability, VA provided the Veteran with an adequate examination in June 2009. The RO provided him with an opportunity for adequate examinations in September and October 2010. As explained later in the instant document, hearing loss is rated based on audiometric puretone testing. In the September 2010 examination report, the examiner stated that audiometric pure tone testing was attempted but the Veteran would not provide reliable test results. She recommended that the Veteran undergo a hearing examination with another examiner. In October 2010, an examination was conducted by a different examiner. That examiner stated that the September examination yielded inconsistent pure tone threshold test results as did the October 2010 examination. He explained that the Veteran demonstrated the ability to identify the presence of speech sounds at a mild hearing loss level but did not identify the presence of pure tones in the same ear at a level better than what would be considered a severe to profound hearing loss. The examiner stated that, given that response with regard to right ear testing, his left ear was not tested. The examiner concluded that, based on the September 2009 results and the results of the October 2009 examination, the Veteran was not able and/or willing to provide reliable test results. He recommended that the Veteran not return for follow-up testing at any audiology clinic with regard to his claim. Thus, two different audiologists concluded that the Veteran would not provide reliable results to the necessary testing. The Veteran and his representative have argued that the VA examinations were inadequate. In his November 2010 notice of disagreement, the Veteran contended that he was not given a fair opportunity at the examinations. He argued that it is to be expected that he has inconsistencies in the evaluations because he cannot hear well. In January 2012, he argued that the examiner did not even attempt to test his left ear. In that statement he cited to Barr v. Nicholson, 21 Vet. App. 303, 311 (2007), for the holding that once VA undertakes the effort to provide an examination it must provide an adequate one or, at minimum, notify that claimant as to why one cannot or will not be provided. The audiologist's statements in the October 2010 examination report make it clear to the Board that the reason the examinations did not yield adequate test results is because the Veteran failed to cooperate with the examinations. The October 2010 report explanation that the Veteran demonstrated that he could hear speech sounds at mild hearing loss levels but did not identify pure tones in the same ear at levels better what would be considered severe to profound hearing loss is understood by the Board to mean that the Veteran responded, i.e., could hear speech sounds at given levels but when puretone testing was attempted he did not respond to much higher levels. This is evidence that the Veteran failed to cooperate with the examinations. This is clearly the conclusion reached by the examiner; an expert in administering such testing. It is noted that the October 2010 examination report indicates only attempted testing of the right ear. However, the Veteran has greater hearing acuity in that ear as demonstrated by earlier examination results. It follows that the medical professional had no duty to attempt testing of the worse ear once it was established that the Veteran would not cooperate with testing of the better ear. As to the argument citing Barr, the instant case is distinguishable on the facts; Barr did not involve a claimant who failed to cooperate with an examination. The holding in Barr has no application to this case. Although the Veteran appeared for both examinations, it is clear from the second examiner's description of the Veteran's behavior that he willfully failed to cooperate with the examination. A claimant is obligated to cooperate in the development of evidence, and failure to do so puts him at risk of an adverse adjudication based on an incomplete and underdeveloped record. Kowalski v. Nicholson, 19 Vet. App. 171, 178 (2005). The Board thereby finds that the appellant's failure to cooperate during the necessary VA examinations is the equivalent of a failure to report for the examinations. Consideration of his claim will thereby be based on the evidence of record. 38 C.F.R. § 3.655(a) (2012). Based on these facts, the Board finds that VA discharged its duty to assist the Veteran in this regard by providing two examination opportunities. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (stating that the duty to assist is not a one-way street). The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist under the VCAA. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service Connection At the outset, the Board recognizes that in cases, such as this one, where some of the claimant's service records have been lost or destroyed, the Board has a heightened duty to explain its findings and conclusion and to carefully consider the benefit of the doubt rule. O'Hare v. Derwsinski, 1 Vet. App. 365, 367 (1991). The Board has endeavored to do so. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004 Certain chronic diseases, including arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (2012). The secondary condition shall be considered a part of the original condition. Id. The phrase "due to or the result of" encompasses disability caused by or aggravated by the service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439 (1995). In order to find that a condition has been aggravated, it must be shown that it underwent a permanent worsening. See Davis v Principi, 276 F.3d 1341, 1345 (explaining in the context of in-service aggravation that evidence of a temporary flare-up does not show aggravation). VA received the Veteran's claims of entitlement to service connection for a heart condition to include hypertension and a right shoulder condition in December 2008. He has explained no direct connection of any of these conditions to his active service. In his May 2009 notice of disagreement with the RO's April 2009 denial of the claims, he stated only that he wanted to appeal the denial and that he wanted his shoulder condition reviewed as secondary to his service-connected bilateral ankle and knee conditions. It is noted that service connection has been established for arthritis of both ankles and the left knee and for left knee instability. He offered no additional explanation in his March 2010 substantive appeal or in any other communication. In an October 2012 statement, his representative provided no additional explanation as to how any of these conditions are related to his active service. II.A. Service Connection - Heart Condition to Include Hypertension In both the March 1955 report of medical history at separation from active service and the March 1959 report of medical history for Reserves purposes, the Veteran reported that he did not then have nor had every had palpitation or pounding heart or high or low blood pressure. The associated reports of medical examination include that he had normal clinical heart and vascular system evaluations and include blood pressure measurements. These records are evidence against the claims of entitlement to service connection for heart disease and hypertension because they show that the Veteran did not have either condition or symptoms of either condition when he separated from active service and four years after that separation. This shows that neither heart disease nor hypertension had onset during his active service. Post service, the earliest relevant evidence are records of treatment by "R.S.," M.D. beginning in August 2002. These records include assessments of hypertension, congestive heart failure, and atrial fibrillation then presently controlled. In November 2002 he had a normal cardiac stress test following complaints of chest pain. A contemporaneous echocardiogram showed mild cardiac enlargement and slightly elevated pulmonary pressure. August 2003 chest x-ray study yielded an impression of borderline chronic cardiac enlargement. An assessment in March 2004 included atrial fibrillation by history, and hypertension. VA treatment records include a notation in September 2006 that the Veteran had a heart murmur. These records are not favorable to the Veteran's claims. The records do not refer to any longstanding symptoms of heart disease or hypertension. They are also completely silent with respect to relating these disorders to the Veteran's active service or any service-related disability. The Veteran has not provided any information showing that hypertension or atrial fibrillation had onset during service or within one year of separation from service. The service and post service treatment records show that his atrial fibrillation and hypertension manifested years after service. The Board therefore finds that the preponderance of evidence is against these claims, whether on a presumptive basis for chronic diseases or otherwise. The appeal as to these issues must therefore be denied. There is no reasonable doubt to be resolved as to these issues. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II.B. Service Connection - Right Shoulder The March 1955 report of medical examination for the purpose of separation from active service documents that the Veteran had a normal clinical examination of his upper extremities. The associated report of medical history includes his endorsement that he did not then have nor had ever had painful or trick shoulder or elbow, arthritis or rheumatism, or swollen or painful joints. This is evidence that he had no injury or disease of his right shoulder during service or any symptoms of such and is therefore evidence unfavorable to his claim of entitlement to service connection for a right shoulder disability. The March 1959 report of medical examination related to Reserves duty also tends to show that he had no shoulder disorder several years after service because it documents that he had a normal upper extremities evaluation. This is also evidence against his claim because it tends to show that even several years after service he had no shoulder disorder. In the associated March 1959 report of medical history the Veteran endorsed that he either then had or had previously had painful or trick shoulder or elbow, swollen or painful joints, and arthritis or rheumatism. At most this is evidence that sometime within 4 years after separation from active service he had problems with either his shoulder or his elbow. It is not evidence showing that he had a right shoulder disability during service, that he had a right shoulder disability caused by active service, or that arthritis of his right shoulder manifested within one year of separation from active service. The next evidence that mentions his right shoulder is found in notes of March 2004 treatment by Dr. R.S. These document the Veteran's report that he had right shoulder pain, had been working every day, and thought he probably irritated his shoulder. He reported that he had a history of right shoulder tendonitis. Assessment included tendonitis of the right shoulder. December VA 2008 treatment notes list pain in the shoulder joint region as an item in a past medical history. A June 2009 orthopedic surgery consult includes the physician's opinion that the Veteran's shoulder symptoms are from his cervical radiculopathy, but also noted that he had mild degenerative arthritis of the glenohumeral joint. August 2009 notes include an assessment of chronic neck, back, right knee, and right shoulder pain. February 2010 notes document that the Veteran had cervical spine fusion 8 to 10 years earlier. January 2010 MRI findings were consistent with degenerative changes of his labrum at the glenoid and tendinopathy of the supraspinatus and biceps tendons. May 2011 notes include a diagnosis of seronegative rheumatoid arthritis and mention his shoulders and wrists, with onset in 2010. These post service treatment records show that the Veteran had right shoulder tendonitis that predated March 2004 as he reported such history to Dr. R.S. There are no reports of this history dating back to service and the notes do not support a finding that his shoulder problems dated back to his active service. While the notes include a diagnosis of rheumatoid arthritis, those notes also document that this had onset in 2010 and therefore the Board finds that to the extent that he has rheumatoid arthritis the preponderance of evidence is against a finding that it had onset during his active service or manifested within one year of separation from active service. As to his contention that his right shoulder condition is secondary to his ankle and knee service connected conditions, the Board finds the medical evidence tends to show that this is not the case. His right shoulder symptoms have been related to a non-service connected condition - his cervical spine condition. See June 2009 Orthopedic Consultation. Given that a medical professional provided that etiological connection, it follows that the clinician considered the causes of his shoulder condition and, if it were related to his knees or ankles, or for that matter his service-connected low back condition or his active service, the comment would have included a statement to that effect rather than one relating his shoulder condition only to his cervical spine condition. The Veteran has not stated that he had right shoulder symptoms during service or that he injured his right shoulder in service. The Veteran first filed a claim of entitlement to service connection in October 2004. That claim was for orthopedic disabilities - arthritis of his knees and ankles. He had reported his right shoulder condition to Dr. R.S. prior to filing that October 2004 claim. If he had reason to believe that the right shoulder condition was related to his active service it follows that he would have claimed entitlement to service connection for his right shoulder condition when he claimed entitlement to service connection for his knee and ankle disabilities. This omission of reference to his shoulder leads the Board to the conclusion that the Veteran has no reason to believe that his right shoulder condition is related to his active service. The Veteran's statement that his right shoulder condition is secondary to his ankle and knee conditions has been considered. To the extent that this is an opinion of a nexus between these conditions, the Board finds his statement is not competent evidence. It is error to categorically reject layperson nexus evidence as incompetent; whether a layperson opinion as to a nexus or a diagnosis is competent evidence depends on the facts of the particular case. See Davidson v. Nicholson, 581 F.3d 1313 (Fed. Cir. 2009). One factor for consideration is the complexity of the question to be determined. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (providing an example in footnote 4 that a layperson would be competent to diagnose a simple condition such as a broken leg but not competent to diagnose a form of cancer). Another factor is whether the question can be answered by personal observation alone. See Layno v. Brown, 6 Vet. App. 465, 496 (1994) (explaining that a layperson is competent to report only that which he or she observed). Whether degenerative changes in one joint cause or aggravate degenerative changes or other pathology in another joint is not a question that can be determined by mere observation. The Veteran has provided no explanation as to the nature of such alleged relationship. Given that there is no logical or obvious relationship, it is not a simple question. For these reasons, the Board finds that his opinion in this regard is not competent evidence and therefore not probative of any fact in this case. For these reasons, the Board concludes that the preponderance of evidence is against a grant of VA benefits for disability due to his right shoulder. His appeal as to this issue must therefore be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Increased Rating - Hearing Loss Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Evaluations of defective hearing 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 1,000, 2,000, 3,000 and 4,000 Hertz. To evaluate the degree of disability from defective hearing, the rating schedule requires assignment of a Roman numeral designation, ranging from I to XI. Other than exceptional cases, VA arrives at the proper designation by mechanical application of Table VI, which determines the designation based on results of standard test parameters. 38 C.F.R. § 4.85, Diagnostic Code 6100 (2012). Table VII is then applied to arrive at a rating based upon the respective Roman numeral designations for each ear. Id. For exceptional hearing impairment, 38 C.F.R. § 4.86 (2012), states that when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz ) is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, 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. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Service connection for bilateral hearing loss was established in a June 2007 rating decision at which time the RO assigned a noncompensable rating. VA received his claim for an increased rating on December 16, 2008. Thus the temporal focus is from the period beginning one year prior to receipt of that claim to the present. See Hart, 21 Vet. App. at 509. Following the grant of service connection for hearing loss, the first evidence of record showing the severity of his hearing loss is a June 2009 VA examination report. During that examination, the Veteran reported that his hearing loss had become gradually worse since 2007. He reported that his hearing loss was most noticeable in understanding speech. Audiometric testing at puretones of 1000, 2000, 3000 and 4000 Hz revealed thresholds of 25, 45, 70, and 75 dB respectively for the right ear and 35, 70, 85, and 90 dB, respectively, for the left ear. The average over the four frequencies of interest was therefore 54 dB for the right ear and 70 dB for the left ear. Speech recognition was 92 percent for the right ear and 68 percent for the left ear. The examiner clearly considered the effect of his hearing loss disability on his daily activities as he recorded the Veteran's report of difficulty understanding speech in his daily activities. An exceptional pattern of hearing loss is not shown by these results. Application of Table VI of 38 C.F.R. § 4.85 yields assignment of Roman numeral I for his right ear and Roman numeral VI for his left ear. The intersection of these Roman numerals in Table VII of 38 C.F.R. § 4.85 indicates a zero percent, or noncompensable, rating. This is evidence against assigning a compensable rating for his bilateral hearing loss disability during the time frame of that examination. The remaining evidence fails to include findings to support a higher rating. Any treatment records pertaining to the Veteran's hearing do not include testing results that are sufficient for VA rating purposes. Further, efforts were made to obtain more current findings; and, as discussed, the Veteran failed to cooperate with VA examiners in September 2010 and October 2010. No viable findings could thereby be obtained from those examinations. The Board has considered the Veteran's statements that his hearing has worsened. Those are subjective observations, but objective criteria determine the rating to be assigned under the rating schedule. The examination results just described are therefore more probative than the Veteran's statements for the purpose of determining if a compensable rating for his hearing loss is warranted. For the time period prior to September 2010, the Board finds that the preponderance of evidence is against assigning a compensable schedular rating for his hearing loss disability. Also considered by the Board is whether referral is warranted for a rating outside of the schedule. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2012). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. 38 C.F.R. § 3.321(b). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must 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. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Veteran reports that he has difficulty hearing speech. This symptom is contemplated by the rating schedule as the criteria include speech discrimination testing. To the extent that it is the volume level that is the problem, the puretone testing criteria contemplates his symptoms. The level of his symptoms were tested in the 2009 examination and failed to meet the criteria for a compensable rating. As the schedule provides compensable ratings for levels of speech discrimination and thresholds, the schedule accounts for his level of symptomatology and greater levels of symptomatology. The first prong of the Thun test is therefore not met and the Board declines to remand the issue for referral for extraschedular consideration. For the period prior to September 2010, the preponderance of evidence is against assigning a compensable schedular rating for his hearing loss disability and against remanding the claim for extraschdular consideration. His appeal as to this period must be denied. As to the time period from September 2010 forward, 38 C.F.R. § 3.655(b) requires that when a claimant fails to report for an examination in the context of a claim for increase, and good cause is not shown for that failure, VA must deny the claim. As explained in the Duties to Notify and Assist section of this decision, the Veteran's failure to cooperate with the examinations offered him in September and October 2010 is equivalent to failing to report for the examinations. Good cause has not been shown for the failure to cooperate. Therefore 38 C.F.R. § 3.655(b) requires that VA deny his appeal for the period from September 2010 forward. There is no reasonable doubt to be resolved for any period on appeal. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990 ORDER Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a heart condition, to include hypertension, is denied. Entitlement to a compensable disability rating for bilateral hearing loss is denied. REMAND As noted above, VA's duty to assist a claimant in substantiating a claim includes providing a medical examination and obtaining a medical opinion if certain factors are met. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Here, the factors are met with regard to the claim of entitlement to service connection for depression. Service treatment records include a January 1951 note documenting that the Veteran had "nervous indigestion" characterized by cramps. May 2007 VA treatment records document that he reported depression. August 2009 VA treatment notes document that the Veteran was sad and depressed, his wife was very ill and required a lot of care, and he had just come from a funeral. A psychology consult was ordered and the following month a VA social worker diagnosed major depressive disorder. Later that month, the Veteran identified stressors as back pain and resulting unemployment, and his wife's illness. The psychiatrist diagnosed depressive disorder, not otherwise specified. In October 2010, the VA psychiatrist noted that the Veteran had depressive disorder and comorbid medical pathologies, including atrial fibrillation, lumbar degeneration, hypertension, prostatitis, chronic back pain, and shoulder pain. Psychiatric diagnoses in December 2011 were dementia, Alzheimer's type, and mild depressive disorder (historical). The Board is aware that the term "comorbid" means "pertaining to a disease or other pathologic process that occurs simultaneously with another." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 399 (31st ed. 2007). However, this definition does not necessarily exclude the aggravation of one condition by a comorbid condition. Given the clinician's reference to comorbid conditions, the Veteran's reference to his back pain as a "stressor," and the service treatment note regarding a "nervous stomach," VA must provide the Veteran an examination and obtain a medical opinion as to whether the his depression had onset during his active service, was caused by his active service, or was caused or aggravated by a service-connected disability. A remand is therefore necessary to provide the examination and obtain the opinion. Accordingly, the case is REMANDED for the following action: 1. Obtain all relevant VA treatment records not yet associated with the claims file and associate such records with the claims file. 2. After completing the above, ensure that the Veteran is scheduled for a VA psychiatric examination. All indicated tests and studies are to be performed. Prior to the examination, the claims file and a copy of this remand must be made available to the examiner for review of the case. A notation to the effect that this record review took place should be included in the report of the examiner. Based on a review of the claims folder, examination of the Veteran, and utilizing sound medical principles, the examiner is asked to accomplish the following: (a) Provide an expert opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that a depressive disorder had onset during the Veteran's active service or was directly caused by his active service. The examiner should explain his or her opinion with regard to the report of "nervous indigestion" found in the service treatment records. (b) If the answer to (a) is no, then provide an expert opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's depressive disorder was caused by a service-connected disability, such as his lumbar disc disease. (c) If the answer to (a) and (b) is no, then provide an expert opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's depressive disorder has been aggravated by a service-connected disability, such as his lumbar disc disease. The term "aggravated" in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. If aggravation is present, the examiner should indicate, to the extent possible, the approximate level of severity of the depressive disorder (i.e., a baseline) before the onset of the aggravation. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. Upon completion of the above, readjudicate the issue of entitlement to service connection for depression. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be provided an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, as appropriate. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs