Citation Nr: 1341405 Decision Date: 12/16/13 Archive Date: 12/31/13 DOCKET NO. 08-01 229 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for tinnitus, to include as secondary to service-connected bilateral hearing loss. 2. Entitlement to service connection for vertigo, to include as secondary to service-connected bilateral hearing loss. 3. Entitlement to an initial disability rating in excess of 10 percent for bilateral hearing loss. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD M. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1959 to March 1963, May 1963 to October 1974, and November 1974 to June 1979. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, that denied service connection for hearing loss, tinnitus, and dizziness (vertigo), and a November 2007 rating decision from the Nashville RO, that granted service connection for bilateral hearing loss, assigning a 10 percent evaluation effective March 2, 2006. The Veteran was scheduled for a video conference hearing in March 2010. He failed to report for this hearing and provided no explanation for his failure to report. The Veteran's hearing request is considered withdrawn. 38 C.F.R. § 20.704(d) (2013). In December 2011, the Board remanded the case to the Appeals Management Center (AMC) for further evidentiary development. The case has since been returned to the Board for further appellate consideration. FINDINGS OF FACT 1. The Veteran's currently diagnosed tinnitus is as likely as not the result of his service-connected bilateral hearing loss. 2. Vertigo was not shown in service; and, the preponderance of the evidence fails to establish that Veteran's current vertigo disability is the result of a disease or injury during his active duty service or a service-connected disability. 3. For the entire period on appeal, the Veteran's right ear hearing loss has had a Numeric Designation of no more than XI as per Table VI or Table VIA of the VA schedule of ratings; the Veteran's left ear hearing loss has had a Numeric Designation of I as per Table VI of the VA schedule of ratings. CONCLUSIONS OF LAW 1. Tinnitus was caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2013). 2. Vertigo was not incurred in or aggravated by the Veteran's active duty service or by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2013). 3. The criteria for an initial disability rating in excess of 10 percent for bilateral hearing loss have not been met. 38 U.S.C.A. § 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.16, 4.85, Diagnostic Code 6100 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the Agency of Original Jurisdiction (AOJ) of any information and any medical or lay 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 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. The claim for service connection for tinnitus is granted within this decision. Any error related to the duties to notify and assist is moot. As to the Veteran's vertigo and hearing loss claims, neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in May 2006 of the criteria for establishing service connection on a direct and secondary basis, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. The May 2006 letter notified him of how VA determines disability ratings and effective dates. This letter accordingly addressed all notice elements and predated the initial adjudications by the AOJ/RO in April and November 2007. Nothing more was required. VA's duty to assist has also been satisfied. The Veteran's service treatment records, personnel records, VA treatment records, Social Security Administration (SSA) records, and VA examination reports are in the file. Private treatment records have been obtained to the extent possible. No outstanding evidence has been identified that has not otherwise been obtained. The Veteran underwent VA examinations to evaluate his audiological and vertigo disabilities in October 2007 and January 2012. The reports from those examination have been included in the claims file for review. The examinations involved a review of the claims file, a thorough examination of the Veteran, including the appropriate audiometric testing, consideration of the Veteran's lay statements/history, and conclusions that were supported by sufficient rationale. The examinations are thereby adequate for to decide the vertigo and hearing loss claims. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Additionally, the January 2012 audiological examiner addressed the functional effects of the Veteran's hearing loss disability in compliance with Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). The Board recognizes that the last examination of the Veteran's low back disability is nearly two (2) years old. The mere passage of time since that examination is not reason enough, alone, to require reexamination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Here, there is no objective evidence indicating that there has been a material change in the severity of the hearing loss disability since the January 2012 VA examination. The Veteran has not argued the contrary. The report of the January 2012 examination that addressed the nature and etiology of the Veteran's vertigo did not specifically address the questions posed by the Board in its Remand. The Board is satisfied there was substantial compliance with this Remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The examiner did not specifically state the likelihood as to whether the Veteran's vertigo was related to his active service. However, the examiner did provide an opinion that expressly related the vertigo to a post-service, which the Board interprets as a de facto negative opinion with respect to the service question. There was no need to address the Veteran's service, to include in-service head injury, when the examiner concluded that the vertigo was likely related to post-service mini-strokes. In addition to the requested opinion, the matter was remanded in December 2011 to the RO/AMC to obtain updated VA treatment record and SSA records. Those records have been obtained. Accordingly, all remand instructions issued by the Board have been complied with and these matters are once again before the Board. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this claim, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Merits of the Claims A. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110 , 1131 (West 2002). Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). No such disease or disability has been diagnosed or identified. As a result, service connection via the demonstration of continuity of symptomatology is not applicable in the present case. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Alternatively, service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a) (2013). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 39 C.F.R. § 3.310(b) (2013); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. Tinnitus The January 2012 VA audiological examiner diagnosed the Veteran with tinnitus. The Veteran is also service connected for bilateral hearing loss. The first and second elements of Wallin are thereby met. With respect to the remaining element (a medical nexus), the January 2012 VA examiner concluded that the Veteran's tinnitus had its onset in association with sudden right ear hearing loss. The Board reads this opinion to link the Veteran's tinnitus with the 2005 sudden right ear hearing loss. Such seems to suggest that the onset of tinnitus occurred contemporaneous with the 2005 sudden hearing loss and not the pre-2005 hearing loss that has been attributed to service. However, the fact remains that the Veteran is service connected for bilateral sensorineural hearing loss, and that the VA examiner attributed the Veteran's tinnitus to his hearing loss. The opinion does not clearly distinguish the effects of the nonservice-connected 2005 sudden onset right ear hearing loss from the service-connected pre-2005 bilateral hearing loss. In Mittleider v. West, 11 Vet. App. 181 (1998), the United States Court of Appeals for Veterans Claims (Court) held that when it is not possible to separate the effects of the service-connected condition from a nonservice-connected condition, 38 C.F.R. § 3.102, which requires that reasonable doubt on any issue be resolved in the Veteran's favor, clearly dictates that such signs and symptoms be attributed to the service-connected condition. Although Mittleider involved a claim for an increased rating rather than a claim for service connection, the Board finds that it applies here because the VA examiner could not separate the effects of the pre-2005 service-connected bilateral hearing loss and any nonservice-connected 2005 sudden right ear hearing loss. Thus, affording the Veteran the full benefit of the doubt, the Board finds that the VA opinion supports a finding of secondary service connection for tinnitus. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2013). Vertigo A review of the medical evidence reflects that the Veteran has been diagnosed with benign paroxysmal positional vertigo (BPPV). The first elements of Hickson and Wallin are met. Next, while a review of the service treatment records is negative for any findings relating to vertigo, there is evidence that the Veteran was involved in a motor vehicle accident (MVA) resulting in a head injury while in service. He claims this is the cause of his current vertigo. Further, as noted, the Veteran is service connected for hearing loss and now tinnitus. The second elements of Hickson and Wallin have likewise been met. Although an in-service injury/service-connected disability and current disability have been established, as noted above, this is not sufficient to warrant service connection. There still must be competent medical evidence of a nexus between the Veteran's in-service head injury or service-connected bilateral hearing loss and his current vertigo. See Hickson, supra; Wallin, supra. The Veteran was examined to determine the etiology of vertigo in January 2012. At that time, he reported episodes of room spinning sensation and loss of balance since a sudden onset right ear hearing loss in 2005. The examiner diagnosed the Veteran with BPPV and essentially concluded it was not related to his service or service-connected hearing loss. Specifically, referencing the Veteran's self-reported history of multiple mini-strokes, the examiner concluded that the 2005 sudden onset of vertigo symptoms was the result of a sudden vascular event or mini-stroke. He believed that a 2005 mini-stroke was the cause of the Veteran's vertigo symptoms. Such is a de facto basis for finding that there is no link between the Veteran's vertigo and his military service, to include his in-service head injury, or service-connected bilateral hearing loss and tinnitus disabilities, which preexisted the 2005 incident. Put another way, although the examiner did not specifically address whether the Veteran's 2005 onset of vertigo was the result of his in-service MVA and head injury, his statements affirmatively linking vertigo to a 2005 mini-stroke rule out that possibility. Service connection for vertigo on a direct or secondary basis is simply no warranted. In addition to the VA examination, the medical evidence includes VA and private treatment records. These records do not provide an opinion on the etiology of the Veteran's vertigo, but seem to support the January 2012 VA examiner's negative opinion. The treatment records consistently indicate that the Veteran's vertigo symptoms began suddenly in 2005, over 25 years after his separation from service. A December 2006 VA vestibular assessment concluded that the Veteran's results were consistent with an uncompensated peripheral vestibular pathology, such as a lesion. This seems to be consistent with the VA examiner's conclusion that the Veteran's vertigo symptoms were the result of a mini-stroke event, not hearing loss. The only other evidence that purports to link the Veteran's current vertigo to his military service and/or service-connected hearing loss consists of the statements of the Veteran and his representative. Although laypersons, such as the Veteran and his representative, are sometimes competent to provide opinions on certain medical questions, the specific issue in this case falls outside the realm of common knowledge of a lay person as it involves making definitive clinical diagnoses based on knowledge of otolaryngological medicine. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). While the Veteran can describe what he experiences (in this case, dizziness and loss of balance), he is not able to provide competent evidence as to the etiology of his vertigo diagnoses. Providing such an opinion requires medical expertise in the cause and symptoms of vertigo and other balance disorders. The Veteran and his representative have no such expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also 38 C.F.R. § 3.159 (a)(1) (2013). The claim of entitlement to service connection for vertigo must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to service connection, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2013); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). B. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2013). The Veteran's entire history is reviewed when making a disability determination. 38 C.F.R. § 4.1 (2013). Where the Veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the Veteran is entitled to "staged" ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran has been assigned a 10 percent evaluation under Diagnostic Code 6100 for his service-connected bilateral hearing loss. He seeks a higher initial evaluation. The VA rating scheme for the evaluation of hearing loss provides ratings from noncompensable to 100 percent based on the results of controlled speech discrimination tests together with the results of puretone audiometry tests which average puretone thresholds at 1000, 2000, 3000 and 4000 Hertz. 38 C.F.R. § 4.85 (2013). The evaluation of hearing impairment applies a formula which is essentially a mechanical application of the VA Schedule for Rating Disabilities to numeric designations after audiology evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. 38 C.F.R. § 4.85(a) (2013). Using Table VI in 38 C.F.R. § 4.85, the puretone average and speech recognition score are combined to give each ear a numeric designation for use on Table VII to determine the correct disability level. Alternatively, Table VIA uses only the puretone averages to give each ear a numeric designation. The regulations have two provisions for evaluating veterans with certain patterns of hearing impairment that cannot always be accurately assessed under § 4.85 because the speech discrimination test may not reflect the severity of communicative functioning that veterans experience. See 64 Fed. Reg. 25203 (May 11, 1999). 38 C.F.R. § 4.86(a) provides that if puretone thresholds in the specified frequencies of 1000, 2000, 3000, and 4000 Hertz are each 55 decibels or more, an evaluation can be based either on Table VI or Table VIA, whichever results in a higher evaluation. This provision corrects the fact that with a 55-decibel threshold level (the level at which speech becomes essentially inaudible) the high level of amplification needed to attempt to conduct a speech discrimination test would be painful to most people, and speech discrimination tests may therefore not be possible or reliable. See 64 Fed. Reg. 25209 (May 11, 1999). Additionally, 38 C.F.R. § 4.86(b) provides that if the puretone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, an evaluation can be based on either Table VI or Table VIA, whichever results in a higher numeric designation, and that designation will then be elevated to the next higher Roman numeral. This provision compensates for a pattern of hearing impairment that is an extreme handicap in the presence of any environmental noise, and a speech discrimination test conducted in a quiet room with amplification of sound does not always reflect the extent of impairment experienced in the ordinary environment. The audiometric results of record all meet the criteria for use of Table VIA for the right ear. 38 C.F.R. § 4.86(a) (2013). However, none of the audiometric results of record meet these criteria for the left ear under 38 C.F.R. § 4.86(a) or (b). The puretone thresholds are not 55 decibels or greater for either ear at 1000 Hertz and are not 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz for the left ear. As such, the Veteran's right ear hearing loss may be evaluated under either Table VI or Table VIA, but his left ear hearing loss may only be evaluated under Table VI. The Board notes that the Veteran has argued that his hearing loss is more severe than is reflected by his 10 percent evaluation. Although the Veteran is competent to attest to his observations and laypeople may, in some circumstances, opine on questions of diagnosis and etiology, in this case, the Veteran is not competent to diagnose himself with a particular level of hearing impairment. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also 38 C.F.R. § 3.159 (a)(1) (2013) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). Specifically, while the Veteran is clearly competent to describe what he experiences (diminished hearing), he is unable to provide competent evidence as the audiometry or measured level of his hearing loss to support a higher disability rating. The Veteran was first afforded a VA audiological examination for his present claim in October 2007. Puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 100 105+ 105+ 105+ LEFT 20 10 40 55 Speech audiometry revealed speech recognition ability of 0 percent in the right ear and of 98 percent in the left ear. Puretone threshold averages were 103.75 decibels for the right ear and 31.25 decibels for the left ear. The examiner did not note any functional impairments. According to 38 C.F.R. § 4.85, the right ear had a designation of XI and the left ear had a designation of I, both based on Table VI. Table VI provided the higher evaluation for the right ear. The point where XI and I intersect on Table VII indicates a disability rating of 10 percent. He was more recently examined for his hearing loss disability in January 2012. At that time, the puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 85 100 105+ 105+ LEFT 10 10 35 45 Speech audiometry revealed speech recognition ability of 98 percent in the left ear and was not able to be tested in the right ear, equating with a 0 percent score. Puretone threshold averages were 99 decibels for the right ear and 25 decibels for the left ear. The examiner noted that the Veteran's hearing loss did not impact the ordinary conditions of daily life, including his ability to work. According to 38 C.F.R. § 4.85, the right ear had a designation of XI and the left ear had a designation of I, both based on Table VI. Table VI provided the higher evaluation for the right ear. The point where XI and I intersect on Table VII indicates a disability rating of 10 percent. The medical evidence also includes two private audiograms from the appeals period. For the August 2006 private audiogram, the puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 90 100 105+ 105+ LEFT 15 5 30 45 Speech audiometry revealed speech recognition ability of 100 percent in the left ear and was not able to be tested in the right ear, equating with a 0 percent score. Puretone threshold averages were 100 decibels for the right ear and 23.75 decibels for the left ear. According to 38 C.F.R. § 4.85, the right ear had a designation of XI and the left ear had a designation of I, both based on Table VI. Table VI provided the higher evaluation for the right ear. The point where XI and I intersect on Table VII indicates a disability rating of 10 percent. For the January 2007 private audiogram, the puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 105 120+ 115+ 115+ LEFT 20 20 40 40 Speech audiometry revealed speech recognition ability of 96 percent in the left ear and was not able to be tested in the right ear, equating with a 0 percent score. Puretone threshold averages were 113.75 decibels for the right ear and 30 decibels for the left ear. According to 38 C.F.R. § 4.85, the right ear had a designation of XI, based on either Table VI or Table VIA, and the left ear had a designation of I, based on Table VI. The point where XI and I intersect on Table VII indicates a disability rating of 10 percent. The Board notes that the private audiograms do not indicate whether they utilized the Maryland CNC test for determining the Veteran's speech discrimination scores, as required for consideration of an audiogram under VA regulations. 38 C.F.R. § 4.85(a) (2013). However, even if the Board were to accept that these tests utilized the Maryland CNC speech discrimination test, they still could not provide for a higher evaluation as discussed above. In addition to the VA examinations and private audiograms, the medical evidence includes VA treatment and private records pertaining to the Veteran's hearing loss disability. These treatment records note the Veteran's complaints of difficulty hearing and that he has been fitted for hearing aids, but do not include any additional audiometric results. As the Veteran's hearing loss has been tested with reliable results and the Veteran has not claimed that these results were in any way invalid or that his hearing loss has worsened since his January 2012 VA examination, the Board finds that the Veteran's bilateral hearing loss does not warrant an initial rating in excess of the 10 percent evaluation already assigned. Additionally, the Board notes that there is no indication in the medical evidence of record that the Veteran's symptomatology warranted other than the 10 percent evaluation assigned during the appeals period. The assignment of staged ratings is not warranted. See Fenderson, supra. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to an initial evaluation in excess of 10 percent, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2013); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Consideration has also been given as to whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected bilateral hearing loss disability is inadequate. A comparison between the level of severity and symptomatology of the hearing loss disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Veteran has not described any unusual features associated with his hearing loss disability. The Board finds that the evidence does not demonstrate an exceptional or unusual clinical picture beyond that contemplated by the rating criteria. ORDER Entitlement to service connection for tinnitus is granted on a secondary basis. Entitlement to service connection for vertigo is denied. Entitlement to an initial disability rating in excess of 10 percent for bilateral hearing loss is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs