Citation Nr: 1325228 Decision Date: 08/08/13 Archive Date: 08/13/13 DOCKET NO. 10-18 487A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for residuals of a left ankle sprain, to include as secondary to varicose veins, left lower leg and left ankle. 2. Entitlement to a disability rating in excess of 10 percent for bilateral hearing loss. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and son ATTORNEY FOR THE BOARD S. Grabia, Counsel INTRODUCTION The Veteran served on active duty from December 1945 to December 1948 and from May 1952 to January 1956 with additional reserve service. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a November 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina which granted an increased rating from 0 to 10 percent for a bilateral hearing disorder, and denied an appeal to reopen a claim for service connection for a left ankle sprain. The Veteran presented testimony in April 2012 during a hearing at the RO before the undersigned Acting Veterans Law Judge. A transcript of the hearing is in the claims file. The Board in May 2012 reopened the claim of entitlement to service connection for residuals of a left ankle sprain; and remanded the claims of entitlement to service connection for residuals of a left ankle sprain, and entitlement to an increased disability rating for bilateral hearing loss for additional development. The claims have now been returned to the Board. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file indicates that there is relevant information to the Veteran's current claims and such evidence has been considered accordingly. 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. The Veteran's left ankle sprain is not the result of, or is aggravated by, the Veteran's military service or any other service-connected conditions. 2. During the appeal period bilateral hearing loss disability has been manifested, at worst, by Level III hearing loss in the right ear and Level IV in the left ear. CONCLUSIONS OF LAW 1. The Veteran does not have residuals of a left ankle sprain which is the result of a disease or injury incurred in or aggravated by active duty, nor may such a disorder be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for a disability evaluation in excess of 10 percent, for bilateral hearing loss disability have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.85, 4.86, Diagnostic Code (DC) 6100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Under the VCAA, 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; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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 of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA 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). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent a letter in June 2009 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). Given the above, no further development is required with respect to the duty to notify. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c) (4). 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 claims file contains the service treatment records, as well as all available post-service reports of VA and private treatment and examination. Moreover, the Veteran's statements and testimony in support of the claims are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence pertinent to the Veteran's claims. Additionally, the Veteran was afforded VA examinations in January and February 2013. The Board has also obtained an expert medical opinion in July 2013 which addresses the issue of service connection for the left ankle sprain. The Board finds the expert medical opinion in combination with the examinations to be adequate because, as shown below, they were based upon consideration of the Veteran's pertinent medical history, his lay assertions and testimony, and current complaints, and because they describe the claimed disabilities in detail sufficient to allow the Board to make fully informed determinations. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). In sum, the Board finds that the duty to assist and duty to notify provisions of the VCAA have been fulfilled and no further action is necessary under the mandates of the VCAA. II. Service connection Legal criteria Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (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 present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curium, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza elements in a claim based on a chronic disease listed in 38 C.F.R. § 3.309(a), is through a demonstration of continuity of symptomatology. Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2012). The issue in this case does not involve a listed chronic disease. Service connection may also 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) (2012); 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. 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). In relevant part, 38 U.S.C.A.1154 (a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Background The service treatment records clearly document the presence and treatment of varicose veins of the left lower leg and left ankle throughout the Veteran's military career. From September to October 1946 the Veteran was treated for varicose veins, mild, left leg, posterior and popliteal fossa. He was treated in November 1955 for varicose veins, left leg and ankle. March 1956 service treatment records note a reported history of strained ligament of the left leg in September 1946. A June 1960 private medical record noted bilateral varicose veins primarily about both ankles, with the left ankle somewhat more prominent. The Veteran in fact is service connected 40 percent for varicose veins of the left lower leg and left ankle. There is however no complaints, treatment, or diagnosis of a left ankle sprain injury during service. In May 2007 the Veteran filed a claim for service connection for a left ankle sprain secondary to varicose veins of the left, lower extremity. In a June 2007 VA examination, the examiner noted a history of chronic leg pain and swelling due to varicose veins. The Veteran reported he began experiencing left ankle pain during basic training in 1945. Examination revealed varicose veins superficially on the left leg and ankle covering nearly all of the surface area of the left leg and ankle. There was 1+ edema noted. The diagnosis was varicose veins lower extremities, left ankle and foot worse. By rating action in August 2007, service connection for a left ankle sprain secondary to varicose veins of the left lower extremity was denied. However the rating for varicose veins, left lower extremity was increased to 20 percent. This was again increased from 20 to 40 percent by rating action in December 2008. In May 2009, the Veteran filed a claim to reopen for service connection for residuals of a left ankle sprain which he now claimed to have occurred in basic training in 1945. In May 2012 the Board reopened and remanded the claim for service connection for residuals of a left ankle sprain. In a January 2013 VA examination, the examiner noted that no claims file or medical records were made available prior to examination. He noted that the Veteran reported that he sprained the left ankle while running during basic training in 1945. He noted that the left ankle began to bother him again in the past few years. The examiner noted that the Veteran was currently in a wheel chair due to pain, edema, and decreased range of motion. The examiner noted range of motion of the left ankle was flexion to 10 degrees and dorsiflexion to 5 degrees both with pain. He was able to perform 3 repetitions with no loss of additional motion. He had functional loss and impairment in that there was less motion than normal. He had swelling of the left ankle and interference with sitting, standing, and weight bearing. Strength was 4/5 with plantar flexion and dorsiflexion. No X-rays were taken and no medical opinion was offered by the examiner. The examination was inadequate for rating purposes and the RO requested an independent medical expert opinion (IME). In a July 2013 IME opinion, the examiner reviewed the records and noted that, "it is less likely than not that the Veteran's claimed ankle condition was caused by, incurred while in military service or aggravated by time in military service." The basis for the opinion was that the Veteran's 1956 discharge examination noted a past history of a strained ligament, left leg which occurred in September 1946. The Veteran developed varicose veins as a result of the ligament strain. There was no evidence of any injury at the level of the ankle. The examiner concluded, "Thus it would be mere speculation to assume left ankle joint instability." The Veteran's active duty and reserve service medical history indicated a long history of varicose veins summarized below: December 1957 reserve examination noted varicose veins involving the left lower leg since 1954, nonsymptomatic. September 1961 reserve examination noted moderate varicose veins, left leg and left ankle. Varicose veins were also mentioned on re-enlistment examinations in November 1964 and December 1966. The IME opined that in his opinion the aforementioned medical notations clearly and unmistakably demonstrate a normal and natural progression of a vascular condition that less likely than not interfered with his 3 tours of military service. service. There was no indication that the varicose veins caused additional weakness or instability of the left ankle. Therefore, "it is less likely than not that the Veteran's claimed ankle condition was proximately due to or a nexus of the varicose veins. Furthermore, "it is less likely than not that the Veteran's claimed condition was aggravated by or aggravated beyond the normal and natural aging process." There was no current medical literature to support the Veteran's claimed ankle joint instability nexus to varicose veins. Therefore, "it is my opinion that it is less likely than not that a vascular condition was proximately due to instability of the ankle joint or tendon sprain." The January 2013 VA examination indicated a limitation of left ankle dorsiflexion (5/20 degrees with discomfort; and plantar flexion 10/45 degrees with discomfort) and slight muscle weak (4/5). The Deluca criteria were met. Swelling was noted. Left ankle stability was indicated by a negative anterior drawer and talar tilt test. There was no functional impairment. X-rays were negative for bone, joint or soft tissue changes. The films were normal. Thus, it is my opinion that the loss of motion with ankle joint stability was as likely as not age appropriate and less likely than not caused by military service" The Board notes that none of the service treatment records reference a left ankle sprain injury, or any injury involving the left ankle. They refer to a left leg ligament strain that caused varicose veins that affected the left leg, ankle, and foot. Moreover, and in contradiction to the Veteran's testimony, the service records clearly indicate that the Veteran's hospitalization was prompted by his varicose veins which, according to the Veteran at the time, pre-existed service and was not precipitated by any trauma. The Board finds the Veteran's contemporaneous description of the history of his left lower extremity problems is entitled to far greater probative weight than his current assertion that there was an actual sprain injury in service to the left ankle. The post-service treatment records on file contain evidence of varicose veins of both lower extremities, and swelling and pain affecting the left ankle and foot; none of the medical treatment records note any orthopedic condition affecting the left ankle. The swelling and pain of the left ankle are shown to be due to the extensive varicose veins of the left lower extremity and left ankle which is service connected. The Board accords great probative value to the July 2013 IME report. The IME opinion was based on a review of the entire evidence of record and offered a sound rationale that is consistent with the evidence on file. The IME in reviewing the file not only had the benefit of reviewing the service treatment records but also had the benefit of reviewing the post-service records documenting the evolution in the diagnoses of the left ankle condition. In addition, the IME offered a rationale, which was supported by the medical records themselves. The Board acknowledges the Veteran's own opinions concerning the origin of his left ankle disability. In some circumstances, a layperson is competent to not only describe the symptoms associated with a disorder throughout the years, but to offer an opinion as to etiology. In this case, the medical history and nature of the disorder is clearly outside the realm of lay expertise to offer any opinion as to etiology. To the extent he offers his lay observations as to continuity of symptoms, the Board finds the probative value of his observations are outweighed by the opinions of the July 2013 IME, who clearly has more education, experience and training in addressing the etiology of medical disorders than the Veteran. In sum, the Board finds that the preponderance of the evidence is against service connection for a left ankle disability. II. Increased rating Criteria Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2012). VA must interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately compensate the elements of disability. 38 C.F.R. § 4.2 (2012). VA will also resolve any reasonable doubt regarding the degree of disability in favor of the claimant. 38 C.F.R. § 4.3 (2012). Where there is a question as to which of two ratings applies, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). VA must also evaluate functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity. 38 C.F.R. § 4.10 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In evaluating the appropriate schedular rating, the Board will only consider the factors as enumerated in the applicable rating criteria. Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). A rating for hearing loss is determined by a mechanical application of the rating schedule to the numeric designations assigned based on audiometric test results. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The severity of hearing loss is determined by comparison of audiometric test results with specific criteria. 38 C.F.R. § 4.85, Diagnostic Codes 6100-6110 (2012). Ratings for bilateral defective hearing range from 0 percent 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 as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 Hertz. The Schedule allows for audiometric test results to be translated into a numeric designation ranging from Level I to Level XI, for profound deafness, in order to rate the degree of disability from bilateral service-connected defective hearing. The ratings derived from the Schedule are intended to make proper allowance for improvement by hearing aids. In addition, an examination for hearing impairment must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. Examinations are to be conducted without the use of hearing aids. 38 C.F.R. § 4.85 (2012). When the pure tone 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. 38 C.F.R. § 4.86 (2012). Further, when the average puretone threshold is 30 decibels 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. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86 (2012). Furthermore, in Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007), the Court noted that VA had revised its hearing examination worksheets to include the effect of the Veteran's hearing loss disability on occupational functioning and daily activities. See Revised Disability Examination Worksheets, Fast Letter 07-10 (Dep't of Veterans Affairs Veterans Apr. 24, 2007); see also 38 C.F.R. § 4.10 (2009). Background Historically service connection for a bilateral hearing loss was granted by rating action in May 2005 and a noncompensable rating was assigned. The Veteran filed the current claim for an increased compensable rating for a bilateral hearing loss in May 2009. In a June 2009 VA examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 40 45 60 90 LEFT 45 35 50 80 90 Average pure tone thresholds, in decibels (dB), were 58.75 dB for the right ear and 63.75 dB for the left ear. Speech audiometry as measured by the Maryland CNC revealed speech recognition scores of 88 percent in the right ear and 76 percent in the left ear. The diagnosis was bilateral sensorineural high frequency hearing loss. The examiner noted that the effect of the hearing disability on his occupation would be significant; while there was no effect on activities of daily living. In a February 2013 VA examination, pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 45 45 55 70 90 LEFT 45 40 55 80 90 Average pure tone thresholds, in decibels (dB), were 65 dB for the right ear and 66 dB for the left ear. Speech audiometry as measured by the Maryland CNC revealed speech recognition scores of 92 percent in the right ear and 84 percent in the left ear. The examiner noted that the effect on activities of daily living was that the Veteran benefited from recently obtained hearing aids but still has difficulty understanding speech with background noise. The diagnosis was bilateral sensorineural high frequency hearing loss. Analysis In considering the evidence of record under the laws and records as set forth above, the Board concludes that the Veteran is not entitled to an evaluation in excess of 10 percent for his bilateral hearing loss, under 38 C.F.R. §§ 4.85 or 4.86, Diagnostic Code 6100. In this regard, the results of the June 2009 VA audio evaluation corresponds to Level III hearing for the right ear and Level IV for the left ear on Table VI, which in turn corresponds to a 10 percent rating on Table VII. The results of the February 2013 VA audio evaluation corresponds to Level II hearing for the right ear and Level III for the left ear on Table VI, which in turn corresponds to a 0 percent rating on Table VII. The Board notes that the evidence of record simply does not show that an evaluation in excess of 10 percent was warranted for bilateral hearing loss. The Board has also considered whether a compensable evaluation for hearing loss is warranted under 38 C.F.R. § 4.86. The Veteran's disability, however, did not meet the requirements of 38 C.F.R. § 4.86. In this regard, the Veteran did not have puretone thresholds of 55 decibels or more at each of the frequencies of 1000, 2000, 3000 and 4000 hertz or a puretone threshold of 30 decibels or less at 1000 hertz and 70 decibels or more at 2000 hertz. The Board notes that improvement has been shown in the most current VA examination and the Veteran no longer meets the criteria for a 10 percent disability evaluation let alone a rating in excess of 10 percent. As such, it is apparent that the currently assigned 10 percent disability evaluation for the Veteran's bilateral hearing loss is accurate and appropriately reflects his hearing loss under the provisions of 38 C.F.R. §§ 4.85 and 4.86(a). Thus, as the criteria for an evaluation in excess of 10 percent for the Veteran's service-connected bilateral hearing loss have not been met, the appeal is denied. In essence, the preponderance of the evidence is against an evaluation greater than 10 percent for the Veteran's bilateral hearing loss. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply. As such, entitlement to an evaluation in excess of 10 percent for service-connected bilateral hearing loss must be denied. The Board notes that the Veteran is retired at this time and in receipt of Social Security age related benefits. The Board has considered staged ratings, under Hart v. Mansfield, 21 Vet. App. 505 (2007), but concludes that they are not warranted. Since the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Extraschedular consideration Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2012). Because, however, the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. Nonetheless, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available scheduler evaluations for that service-connected disability are inadequate. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned scheduler evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the assigned rating inadequate. The Veteran's service-connected bilateral hearing loss is evaluated as impairment of auditory acuity pursuant to 38 C.F.R. § 4.85, Diagnostic Code 6100, the criteria of which is found by the Board to specifically contemplate the levels of occupational and social impairment caused by this disability. During the appeal period, evidence of record shows that the Veteran's bilateral hearing loss has been manifested by no more than Level III hearing for the right ear and level IV hearing for the left ear on Table VI, which in turn corresponds to a 10 percent rating on Table VII. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability picture represented by no more than a 10 percent rating. Increased ratings are provided for by the regulations for certain manifestations of bilateral hearing loss, but the medical evidence demonstrates that those manifestations are not present. The June 2009 and February 2013 VA examinations did not reveal significant effects on his occupation or daily activities. The Veteran was no longer employed and was having difficulty understanding speech or conversing when in areas with background noise. The criteria for the 10 percent rating reasonably describe the Veteran's disability level and symptomatology throughout the pendency of this appeal. Consequently, the Board concludes that the scheduler evaluation is adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.85, Diagnostic Code 6100; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). ORDER Service connection for a left ankle sprain is denied. Entitlement to a rating in excess of 10 percent for bilateral hearing loss is denied. ____________________________________________ Thomas H. O'Shay Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs