Citation Nr: 1325422 Decision Date: 08/12/13 Archive Date: 08/16/13 DOCKET NO. 10-40 601 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a right knee disorder, to include as secondary to post operative residuals of a left knee meniscectomy. 2. Entitlement to a compensable rating for a bilateral hearing loss prior to January 17, 2012. 3. Entitlement to a compensable rating for a bilateral hearing loss since January 17, 2012. 4. Entitlement to service connection for erectile dysfunction, to include as secondary to lumbosacral degenerative joint disease. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Mary E. Rude, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1971 to September 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. A review of the documents in the Veteran's Virtual VA electronic claims file reveals that it includes relevant VA treatment records and a transcript of the February 2013 Board hearing testimony. In a February 2012 statement, the Veteran raised the issues of entitlement to service connection for lower extremity radiculopathy, and entitlement to increased ratings for post operative residuals of a left knee meniscectomy, and for lumbosacral spine degenerative joint disease. These issues have not been adjudicated by the agency of original jurisdiction, and the Board does not have jurisdiction over them. Therefore, they are referred to the agency of original jurisdiction for appropriate action. The issues of entitlement to a compensable rating for a bilateral hearing loss since January 17, 2012 and entitlement to service connection for erectile dysfunction, to include as secondary to lumbosacral degenerative joint disease, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A right knee disorder is not shown to be the result of any incident of the Veteran's active military service, right knee arthritis was not compensably disabling within the first year following separation from active duty, and a right knee disorder is not causally related to or made worse by post operative residuals of a left knee meniscectomy. 2. The Veteran's bilateral hearing loss prior to January 17, 2012 was not manifested by worse than Level I hearing in each ear. CONCLUSIONS OF LAW 1. A right knee disability was not incurred or aggravated during service, nor is it secondary to a service-connected disability; and right knee arthritis is not presumed to have been incurred during service. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. The criteria for a compensable evaluation for bilateral hearing loss prior to January 17, 2012 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.10, 4.85, Diagnostic Code 6100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act In the case at hand, the requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in correspondence dated in March 2009 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability evaluations and effective dates are assigned. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. There is no evidence that additional records have yet to be requested, or that additional examinations for these issues are in order. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran 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), and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Analysis: Right Knee Disorder The Veteran claims entitlement to service connection for a right knee disorder, which he claims was caused or aggravated by post operative residuals of a left knee meniscectomy, due to the excessive weight bearing it has caused him to place on his right knee. Direct service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be demonstrated either by showing direct service incurrence or aggravation, as discussed above, or by use of applicable presumptions, if available. 38 C.F.R. § 3.303(a); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In order to prevail on the issue of service connection there must be medical evidence of a disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection for arthritis may be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from active duty. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This permits service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In the case of aggravation by a service-connected disability, a veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Id. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In this case, the Veteran asserts that he is entitled to service connection for a right knee disorder caused by strain and excessive use made necessary by his weakened and painful left knee. The Veteran was granted service connection for post operative residuals of a left knee meniscectomy in 1991. At the Veteran's February 2013 Board hearing he explained he never injured his right knee in service, but that about five years after separation from service his left knee began to bother him a lot while working at his job maintaining post office machinery. Eventually his right knee began to bother him as well, and he started using a walker and wearing knee braces. He also stated that he has been treated with steroid injections in both knees, and that at one time he used crutches due to excessive pain in his knees. The Veteran's VA treatment records show that he has been treated on numerous occasions during the period on appeal for bilateral knee pain, diagnosed as bilateral knee degenerative joint disease. The Veteran's service treatment records are silent for any complaints or treatments related to the right knee. In June 2009, the Veteran was examined by a VA physician assistant who specializes in orthopaedic surgery. His examination report was cosigned by a physician. The appellant reported having joint pain and weakness and dragging his left leg once or twice a month. The Veteran stated that he did not know when his right knee symptoms began, but that since separation from service he had favored his right knee, which got "worse and worse with stair climbing." The examiner noted that the Veteran was unable to walk more than a few yards, but was able stand up to one hour. Physical examination yielded a diagnosis of a stable right knee joint with osteoarthritis due to age related changes. In May 2010 the Veteran submitted a letter from his private physician, Dr. N.S., a family practioner. Dr. N.S. stated that the Veteran had degenerative changes in his knee joints, that the appellant reported having left knee surgery, and having problems with his right knee afterwards. She reported that the Veteran stated he put a lot of pressure on his right knee, and opined that the appellant had developed right knee degenerative changes by "over tasking this knee in favor of not putting too much weight on the left knee." In October 2010, the physician assistant in orthopaedic surgery provided an addendum. The examiner discussed the Veteran's medical history and stated that the appellant had been vague regarding the date of onset of his right knee problems and that the earliest medical evidence of a right knee disorder is 2009. The examiner noted that other than noting the radiographic impressions, the opinion from Dr. N.S. offered no evidence to timing or date determination of the right knee. The physician assistant opined that the Veteran's right knee disorder was not caused by his left knee disability and that the appellant's weight was a major factor affecting knee pain. (The Veteran was noted to suffer from extreme obesity. The appellant is not service connected for obesity.) In a December 2011 follow-up e-mail, the physician assistant in orthopaedic surgery stated that the Veteran's right knee disorder was not caused by or aggravated by his left knee disability or active duty, and that his right knee disorder was due to normal senescence progression, i.e., aging. In light of the foregoing evidence, the preponderance of the most probative evidence weighs against granting service connection. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. The credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). In this case, the evidence of record includes two conflicting opinions regarding whether the Veteran's service-connected post operative residuals of a left knee meniscectomy caused or aggravated his current right knee disorder. While both the VA examiner and the private physician found that the Veteran had a current right knee disorder, they disagreed on its etiology. After assessing the probative value of each respective opinion, the Board finds that the VA examiner's opinion is far more probative, and therefore the weight of the evidence is against a finding of service connection. See Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994) (the probative value of a physician's opinion depends in part on the reasoning employed by the physician and whether or not (or the extent to which) he reviewed prior clinical records and other evidence). The VA examiner examined the appellant, provided comprehensive and objective findings of his disorders, and reviewed the Veteran's service treatment records, medical records, and all other evidence associated with this claim. The private physician, Dr. N.S., is not shown to have considered any evidence save for the appellant's self-report of surgery in service followed by problems with his right knee. Her letter does not indicate that she had actually examined the Veteran or ever treated him personally. But, even assuming that she did, her report included very little analysis or explanation, including any discussion of whether the Veteran has objective findings of an abnormal gait or abnormal weight bearing. The private physician did not address the impact of aging or the appellant's obesity on the development of right knee degenerative joint disease. Finally, the Board finds that the physician assistant's specialization in orthopaedic surgery allows him to provide an opinion based on greater training than an osteopath who specializes in family medicine. Hence, the opinion of the VA examiner is therefore afforded greater probative weight. See Guerrieri, 4 Vet. App. at 470-71. The Board acknowledges the Veteran's statements indicating that he has right knee pain and that he believes that he must overuse his right leg due to pain and weakness in his left knee. A veteran is generally competent to report on matters observed or within his personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, as a layperson not shown to possess appropriate medical training and expertise, the Veteran is not competent to render an opinion on the etiology of his right knee pain or arthritis, as such requires medical expertise to determine the etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Thus, the Veteran's opinion that his right knee disorder is caused or aggravated by post operative residuals of a left knee meniscectomy, or to any other event or injury during service, is not a competent medical opinion. As such, the medical findings and opinion of the VA examiner warrant greater probative weight than the Veteran's lay contentions. With regard to entitlement to service connection for a right knee disorder on a direct basis, the Veteran's service treatment records are negative for any evidence of arthritis or other injuries of the right knee. There is no competent evidence that right knee arthritis manifested within one year of discharge from active duty, nor has the appellant asserted that it did. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Furthermore, the Veteran has not at any time claimed continuity of symptomatology since service or that right knee arthritis was caused directly by any event or injury during his active duty service. There is therefore no evidence which would allow for a grant of service connection on a direct or presumptive basis. In short, there is no competent and credible evidence that the Veteran's right knee disorder was incurred in service or within a year of separation from active duty. The weight of the evidence is against finding that the Veteran's right knee disorder was caused or aggravated by his service-connected status post left knee meniscectomy. Therefore, the claim of entitlement to service connection is denied. In making its determination, the Board considered the applicability of the benefit of the doubt rule. 38 U.S.C.A. § 5107(b). However, as a preponderance of the evidence is against the claim for entitlement to service connection for a right knee disorder, to include as secondary to service-connected status post left knee meniscectomy, this rule does not apply, and the claim must be denied. Analysis: Hearing Loss prior to January 17, 2012 Service connection for the Veteran's bilateral hearing loss has been in effect since July 2003. The Veteran was assigned a noncompensable rating. In February 2009, the Veteran filed the current claim for an increased rating. In August 2009, the RO continued the noncompensable rating for hearing loss under 38 C.F.R. § 4.85, Diagnostic Code 6100. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history and reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and evaluating functional impairment on the basis of lack of usefulness and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Id. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The hearing loss disability issue decided herein deals only with the period prior to January 17, 2012, the day following the Veteran's last VA examination, and the issue of the appropriate evaluation for the Veteran's hearing loss disability since January 17, 2012 is remanded for further development. Evaluations of defective hearing range from noncompensable (0 percent) to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by puretone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 3.385. To evaluate the degree of disability from bilateral service-connected defective hearing, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. §§ 4.85, Tables VI and VII, Diagnostic Code 6100. Disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). An exceptional pattern of hearing impairment occurs when the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a) (2012). In that situation, 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. Further, when the average puretone 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, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). The Veteran has not indicated that he has received any treatment for hearing loss aside from receiving a hearing aid from the Naval Health Clinic in Corpus Christi, Texas shortly after his separation from service. He reported at his February 2013 Board hearing that since receiving the hearing aid, he has not gone back for any further treatment or adjustment of his hearing aids. The Veteran's VA treatment records do not show any treatment for hearing loss. In September 2008, the Veteran was afforded a VA audiological examination. The Veteran reported that he had experienced hearing loss and tinnitus for 20 years and that he was not receiving any treatment for them. The examiner discussed the Veteran's noise exposure during and after service, including exposure to firearms, power tools, and loud recreational equipment. Puretone thresholds on this examination, in decibels, were as follows: HERTZ 1000 2000 3000 4000 AVERAGE RIGHT 30 50 50 50 45 LEFT 30 45 55 60 47.5 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 100 percent in the left ear. Applying the findings from the September 2008 VA examination to Table VI in 38 C.F.R. § 4.85 yields a finding of Level I hearing loss in the right ear and Level I hearing loss in the left ear. Where hearing loss is at Level I in both ears, a noncompensable rating is assigned under Table VII. Id. After submitting the current claim for an increased rating, the Veteran was afforded a VA examination in June 2009. The Veteran reported that his greatest difficulty was understanding conversations. The examiner noted that the Veteran's hearing loss disability caused significant effects on his occupation due to hearing difficulty, noting that hearing loss would interfere with his speech understanding during daily activities. The examiner diagnosed the Veteran with mild to moderate sensorineural hearing loss at 2000-4000 Hertz in the right ear and mild to moderately severe sensorineural hearing loss at 1000-4000 Hertz in the left ear. Puretone thresholds on this examination, in decibels, were as follows: HERTZ 1000 2000 3000 4000 AVERAGE RIGHT 25 40 40 45 37.5 LEFT 30 45 50 55 45 Speech audiometry revealed speech recognition ability of 98 percent in the right ear and 96 percent in the left ear. Applying the June 2009 findings to Table VI in 38 C.F.R. § 4.85 yields a finding of Level I hearing loss in the right ear and Level I hearing loss in the left ear, which warrants a noncompensable rating under Table VII. Id. In October 2010, an addendum to the June 2009 VA examination was provided by a VA audiologist who reviewed the examination report. The audiologist noted that the Veteran's hearing loss did have the significant effect of hearing difficulty on his occupational functioning, but that the Veteran had received a hearing aid from VA in 2005 and was currently eligible for a new hearing aid from VA at no charge. The examiner opined that if the appellant would actually wear his hearing aid his hearing loss would have no effect on his occupational functioning and daily activities. The Veteran was given an additional VA examination in January 2012. The examiner diagnosed bilateral sensorineural hearing loss possibly due to damage of the hair cells of the cochlea during service. The examiner opined that the Veteran's hearing loss disability did not impact the ordinary conditions of the appellant's daily life, including the ability to work. Puretone thresholds on this examination, in decibels, were as follows: HERTZ 1000 2000 3000 4000 AVERAGE RIGHT 35 50 55 55 48.75 LEFT 35 45 55 55 47.5 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 98 percent in the left ear. Applying the January 2012 findings to Table VI in 38 C.F.R. § 4.85 yields a finding of Level I hearing loss in the right ear and Level I hearing loss in the left ear, which warrants a noncompensable rating under Table VII. Id. The Veteran has provided VA with statements concerning his functional impairment. He has stated that he cannot hear all words spoken in conversations and that he is unable to hear all of the words in dialogue while he is watching television, even when the volume is turned up. He states that people get frustrated with him because he has to ask them to repeat themselves and that his word comprehension is worse in regular life than it was in the VA examination because the examiner's room was quiet and there was no ambient noise. At his February 2013 Board hearing, the Veteran stated that he can hear some pitches and tones better than others, and that as a result, some people are harder for him to understand than others. He also stated that his hearing loss disability could create a safety issue for him at his job working with machinery, but because of his high level of experience he is able to monitor the machinery himself even without hearing what others are saying and that when new machinery is brought in, he is able to examine and read about it as a means to learning without relying on hearing. Considering the evidence of record described above, at no time prior to January 17, 2012 has there been any objective evidence indicating that the Veteran's hearing loss disability warrants a compensable evaluation under Table VII. 38 C.F.R. § 4.85. The June 2009 examination report and October 2010 addendum adequately evaluated the functional impact of the Veteran's bilateral hearing loss disability, noting that the Veteran would have difficulty understanding conversational speech, but could function with no impairment if utilizing a hearing aid. This finding is afforded great probative value in assessing the claim. To the extent there are any perceived deficiencies in the VA examiners' discussions of the Veteran's functional impairment due to hearing loss, the Board has been provided ample additional evidence concerning the appellant's functional impairment in order to accurately evaluate his current disability level. There is no prejudice in deciding the claim. Martinak v. Nicholson, 21 Vet. App. 447 (2007) (even if an audiologist's description of the functional effects of the veteran's hearing disability was somehow defective, the veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination). The Board acknowledges the Veteran's complaints regarding the impact of hearing loss on his daily life and that understanding speech in noisy environments is more challenging than understanding speech in a quiet examiner's room. The law, however, provides that the assignment of disability ratings for hearing impairment is primarily derived from a mechanical formula based on levels of puretone threshold average and speech discrimination. The Board also acknowledges the Veteran's belief that his current hearing impairment is deserving of a higher disability rating. However, because the audiometric examinations during the rating period prior to January 17, 2012 show that his bilateral hearing loss does not warrant a compensable evaluation, the currently assigned noncompensable evaluation is proper. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin. The most probative medical evidence as to the nature of the appellant's hearing loss is the audiometric findings, and those reveal that his hearing loss does not warrant a compensable rating. There is no medical evidence of record which indicates or suggests that the Veteran's measurable hearing loss is worse than has been demonstrated in his previous VA examinations. The Board recognizes that hearing loss causes the Veteran inconvenience in his daily life. There is, however, no competent evidence of record that indicates that the Veteran's hearing disability is worse than has been recorded at his VA examinations or that his hearing loss has functionally affected the appellant in any more severe way than has been discussed in the record and addressed by medical professionals. There is no evidence of record, nor has the Veteran ever averred, that his hearing loss has caused him to miss work or that his earning capacity has been affected. At his February 2013 Board hearing, the Veteran himself explained how he is able to do his job well due to his high level of experience in spite of occasional difficulties with understanding speech. The Veteran has not shown that he is functionally unable to communicate with others, and the October 2010 VA examiner clearly stated that he can be effectively treated through the use of hearing aids. The Board concludes that the medical evidence is of greater probative value than the Veteran's allegations regarding the severity of his hearing loss and that his functional impairment is adequately reflected by those medical findings. Accordingly, the preponderance of the evidence is against the claim of entitlement to a compensable rating for bilateral hearing loss at any time prior to January 17, 2012. As a final matter, the Board has considered whether the Veteran's bilateral hearing loss presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology. 38 C.F.R. § 4.85. The Veteran separate symptom of tinnitus, or ringing in the ears, has been granted service connection separately, and he receives a separate rating for that disorder. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extra-schedular consideration is not warranted. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the appellant's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet.App. 49 (1990). ORDER Entitlement to service connection for a right knee disorder, secondary to post operative residuals of a left knee meniscectomy, is denied. Entitlement to a compensable rating for bilateral hearing loss prior to January 17, 2012 is denied. REMAND The Veteran asserted at his February 2013 Board hearing that his hearing loss disability had become worse than it was the previous year. To ensure that the evidence of record reflects the current severity of the Veteran's service-connected bilateral hearing loss since his last VA audiological examination on January 16, 2012, a more contemporaneous examination is warranted. Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (VA is obligated to provide a new examination when a veteran asserts that the service-connected condition has become more severe.). Accordingly, the RO/AMC should arrange for the Veteran to undergo an additional VA audiological examination. Regarding the Veteran's claim of entitlement to service connection for erectile dysfunction, this claim was denied by the RO in a February 2012 rating decision. In the February 2013 Board hearing, the Veteran clearly expressed his disagreement with this decision. The Board accepts this as a timely notice of disagreement to the February 2012 rating decision. See 38 C.F.R. § 20.201 (2012). The RO has not issued the appellant a statement of the case on this matter; thus, a remand is necessary to correct this procedural deficiency. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 19.26, 19.29, 19.30 (2012); Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: 1. Issue a statement of the case addressing the issue of entitlement to erectile dysfunction, to include as secondary to lumbosacral degenerative joint disease. The appellant is hereby notified that, following the receipt of the statement of the case concerning this issue, a timely substantive appeal must be filed if appellate review by the Board is desired. If, and only if, a timely substantive appeal is filed, should this issue be returned to the Board for appellate review. 2. The RO/AMC should schedule the Veteran for a VA audiological examination by an audiologist to determine the current severity of his service-connected hearing loss. The claims folder, to include Virtual VA and a copy of this remand, must be provided to and reviewed by the examiner as part of the examination. The examiner must specify in the report that the claims file and Virtual VA records have been reviewed. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The findings of puretone decibel loss at 500, 1000, 2000, 3000, and 4000 Hertz must be numerically reported, and speech recognition percentage results derived using the Maryland CNC word list. The examiner must specifically address the effect of the Veteran's hearing loss on his occupational functioning and daily activities. See Martinak, 21 Vet. App. 447. 3. The Veteran is to be notified that it is his responsibility to report for any examination and to cooperate in the development of the claims. The consequences for failure to report for any VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2012). 4. The RO/AMC must ensure that all medical examination reports and opinion reports comply with this remand and the questions presented in the request. The RO/AMC must ensure that all examiners documented their consideration of records contained in Virtual VA. If any report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 5. Thereafter, the RO/AMC should readjudicate the claims. If any benefit sought is not granted, the appellant and his representative must be furnished with a supplemental statement of the case and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs