Citation Nr: 1342330 Decision Date: 12/20/13 Archive Date: 12/31/13 DOCKET NO. 06-13 149 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE 1. Entitlement to an increased (compensable) evaluation for bilateral mixed hearing loss, with postoperative residuals of otosclerosis in the right ear, prior to August 13, 2013. 2. Entitlement to an evaluation in excess of 10 percent for bilateral mixed hearing loss, with postoperative residuals of otosclerosis in the right ear, effective from August 13, 2013, the date of a right tympanomastoidectomy. REPRESENTATION Appellant represented by: Virginia Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL The appellant and his spouse ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The Veteran served on active duty from May 1965 to June 1985. This case originally came before the Board of Veterans' Appeals (Board) on appeal of a February 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In August 2007, the Veteran's case was remanded by the Board for additional development. Upon completion of that development, the Veteran's case was returned to the Board, which, in a decision of April 2009, denied entitlement to a compensable evaluation for bilateral hearing loss. The Veteran subsequently appealed the Board's April 2009 decision to the United States Court of Appeals for Veterans Claims (Court), which, in a March 2011 Memorandum Decision, set aside the Board's April 2009 decision, and remanded the case for additional proceedings. The Veteran's case was then remanded on three additional occasions, in January and June 2012, and March 2013, for further development. The case is now, once more, before the Board for appellate review. For reasons which will become apparent, the appeal as to the issue of an increased schedular rating for bilateral mixed hearing loss, with postoperative residuals of otosclerosis in the right ear, effective from August 13, 2013, the date of a right tympanomastoidectomy, is being REMANDED to the RO via the Appeals Management Center (AMC) in Washington, D.C. VA will notify you if further action is required on your part. FINDINGS OF FACT 1. The Veteran currently exhibits no more than Level VI hearing impairment in his service-connected right ear, and Level I hearing impairment in his service-connected left ear. 2. Evaluation of the Veteran's service-connected bilateral mixed hearing loss with postoperative residuals of otosclerosis of the right ear presents such an exceptional or unusual disability picture as to render inadequate the criteria contained in the Rating Schedule prior to August 13, 2013. 3. The Veteran's service-connected bilateral mixed hearing loss, with postoperative residuals of otosclerosis in the right ear, is currently productive of mild, though constant, functional impairment of the Veteran's ordinary activities sufficient to warrant the assignment of a compensable evaluation prior to August 13, 2013. CONCLUSIONS OF LAW 1. The schedular criteria for a compensable evaluation for the Veteran's service-connected bilateral mixed hearing loss with postoperative residuals of otosclerosis in the right ear have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 4.7, 4.10, 4.85, 4.86(a), 4.87 and Part 4, Diagnostic Codes 6100, 6202 (2013). 2. The criteria for an extraschedular 10 percent evaluation for the Veteran's service-connected bilateral mixed hearing loss, with postoperative residuals of otosclerosis in the right ear, have been met, prior to August 13, 2013. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 4.3, 3.321(b)(1) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) In the case at hand, the requirements of 38 U.S.C.A. §§ 5103 and 5103A (West 2002) have been met. There is no issue as to whether the Veteran was provided an appropriate application form, or the completeness of his application. VA notified the Veteran in September 2004, March 2006, October 2007, and January and June 2012, of the information and evidence needed to substantiate and complete his claim, to include notice of what part of that evidence was to be provided by him, and what part VA would attempt to obtain. VA has also fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claim, and, as warranted by law, affording VA examinations. Currently, there is no evidence that additional records have yet to be requested, or that additional examinations are in order. Moreover, there is currently no error or issue which precludes the Board from addressing the merits of the Veteran's appeal. Increased Rating In reaching this determination, the Board has reviewed all the evidence in the Veteran's claims file, which includes his multiple contentions, and those of his spouse, offered during the course of a hearing before the undersigned Veterans Law Judge in March 2007, as well as both VA (including Virtual VA and Veterans Benefits Management System) and private treatment records and examination reports. 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 Veteran's claim, and what the evidence in the claims file shows, or fails to show, with respect to that 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). The Veteran in this case seeks an increased evaluation for service-connected bilateral mixed hearing loss with postoperative residuals of otosclerosis in the right ear. In pertinent part, it is contended that manifestations of that disability are more severe than presently evaluated, and productive of a greater degree of impairment than is reflected by the noncompensable schedular evaluation now assigned. In that regard, disability evaluations, in general, are intended to compensate for the average impairment of earning capacity resulting from a service-connected disability. They are primarily determined by comparing objective clinical findings with the criteria set forth in the Rating Schedule. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). Where there is a question as to which of two evaluations apply, the higher evaluation will be assigned 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 (2013). The basis of disability evaluations is the ability of the body as a whole, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. Whether the eyes or ears are affected, evaluations are based upon lack of usefulness of these parts or systems, especially in self-support. This imposes upon a medical examiner the responsibility of furnishing, in addition to the etiological, anatomical, pathological, laboratory, and prognostic data required for ordinary medical classification, a full description of the effects of disability upon the person's ordinary activity. 38 C.F.R. § 4.10 (2013). In order to evaluate the level of disability and any changes in the Veteran's condition, it is necessary to consider the Veteran's complete medical history. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, where an increase in the level of service-connected disability is at issue, the primary concern is the present level of that disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). Nonetheless, the Board acknowledges that a Veteran may experience multiple distinct degrees of disability which might result in different levels of compensation from the time an increased rating claim is filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Accordingly, analysis in the following decision will be undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Ratings shall be based as far as practicable upon the average impairment of earning capacity, with the additional proviso that the Secretary shall, from time to time, adjust the schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluation is found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve, on the basis of the criteria set forth in 38 C.F.R. § 3.321 (2013), an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as a marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2013). In the present case, at the time of a VA audiometric examination in October 2004, it was noted that the Veteran had undergone seven stapedectomy procedures for his service-connected otosclerosis. Further noted was that the Veteran experienced functional impairment as a result of his service-connected hearing loss. In that regard, the Veteran reportedly was unable to clearly understand people in daily conversation, and experienced difficulty with telephone conversations. While the Veteran had lost no time from work, by his own admission, he did miss a great deal of conversation at meetings and conferences, which degraded his level of participation at those events. Audiometric examination revealed pure tone air conduction threshold levels, in decibels, as follows: HERTZ 1000 2000 3000 4000 RIGHT EAR 45 50 55 over 55 LEFT EAR 40 40 40 45 The pure tone average for the frequencies 1,000, 2,000, 3,000, and 4,000 Hertz in the Veteran's right ear was 51.25 decibels, while that same average in the Veteran's left ear was 41.25 decibels. Speech discrimination ability obtained at a presentation level of 80 decibels was100 for both the right and left ears. The pertinent diagnosis noted was bilateral mixed hearing loss/otosclerosis in the right ear changed to bilateral otosclerosis, somewhat greater on the right than the left. A service medical facility audiometric examination conducted on November 6, 2008 revealed pure tone air conduction threshold levels, in decibels, as follows: HERTZ 1000 2000 3000 4000 RIGHT EAR 100 75 75 70 LEFT EAR 55 40 45 50 The pure tone average for the frequencies 1,000, 2,000, 3,000, and 4,000 Hertz in the Veteran's right ear was 80 decibels, while that same average in the Veteran's left ear was 47.5 decibels. Speech recognition ability obtained at a presentation level of 115 decibels in the Veteran's right ear was 100 percent, while speech recognition ability obtained at a presentation level of 90 decibels in the Veteran's left ear was likewise 100 percent. Noted at the time of examination was that, compared to a test in March 2007, the Veteran's air conduction thresholds had worsened bilaterally, more so on the right than the left. At the time of a subsequent VA audiometric examination on November 14, 2008, which examination involved a full review of the Veteran's claims folder and medical records, the Veteran complained that his hearing loss made it difficult for him to participate in meetings, conferences, and training sessions. According to the Veteran, he found it difficult and at times almost impossible to understand information which was presented in meetings and training sessions. Moreover, he experienced difficulty communicating with co-workers due to his hearing loss, which difficulty led to distress, anger, frustration, stress, and embarrassment. According to the Veteran, he was subject to criticism and "cold remarks" from others when he missed or misinterpreted conversation, in particular, during important discussions. In fact, in the Veteran's opinion, this had resulted in his being passed over for promotion. When further questioned, the Veteran indicated that his inability to hear often led to arguments with his wife, resulting from frustration on her part with the need to repeat conversation so frequently. The Veteran additionally reported that his hearing loss impacted his ability to interact with friends in social situations, such as in restaurants, where competing noise might be present. According to the Veteran, he was unable to participate in conversations in such settings, which made him feel isolated, and at times, caused him to withdraw. The Veteran additionally indicated that his hearing loss affected both his and his wife's safety. More specifically, according to the Veteran, he had slept through two tornadoes which had destroyed structures around him. The Veteran additionally reported that he was concerned at not being able to hear his wife should she call for assistance after a fall or in a medical emergency. Audiometric examination revealed pure tone air conduction threshold levels, in decibels, as follows: HERTZ 1000 2000 3000 4000 RIGHT EAR 80 65 60 65 LEFT EAR 45 35 35 45 The pure tone average for the frequencies 1,000, 2,000, 3,000, and 4,000 Hertz in the Veteran's right ear was 67.5 decibels, while that same average in the Veteran's left ear was 40 decibels. Speech recognition ability was 92 percent in the Veteran's right ear, and 96 percent in his left ear. The pertinent diagnosis noted was moderately severe to severe mixed hearing loss with good word recognition ability at elevated intensity levels in the right ear, and mild to severe mixed hearing loss with good word recognition ability at elevated intensity levels in the left ear. At the time of a VA audiology consultation/hearing aid evaluation in mid-April 2011, the Veteran gave a history of otosclerosis, with multiple surgeries on the right ear, the most recent having occurred in 2003. Reportedly, results of recent audiometric testing showed a severe to profound mixed hearing loss in the right ear, with a mild to severe mixed hearing loss in the left ear. Word recognition ability was reported as excellent bilaterally at elevated intensity levels. Noted at the time of evaluation was that the Veteran had been counseled re: the limitations of hearing aids, and advised that he could expect to have some difficulty hearing and understanding conversation, in particular, when competing noise was present. The Veteran was advised that, given the severity of his loss, he could also expect to have some difficulty understanding television, especially if he were not using his FM unit. It was explained to the Veteran that, although his word recognition scores were excellent when he was tested in a sound booth, the intensity levels there were elevated above normal levels (in fact, at equipment limits for the right ear). The Veteran was further advised that the environment in a sound booth is not representative of his everyday listening environment, where competing noise was often present, and where the distance from the speaker and rate of speech might vary. Under the circumstances, the Veteran could expect to have some difficulty hearing and understanding in his normal everyday environment, even when wearing his hearing aids, and despite having good word recognition scores. At the time of a VA audiometric examination in February 2012, which examination involved a full review of the Veteran's claims folder and medical records, the Veteran complained that his conductive hearing loss was worsening, and that his worst situation was at "various times and in background noise." Audiometric examination revealed pure tone air conduction threshold levels, in decibels, as follows: HERTZ 1000 2000 3000 4000 RIGHT EAR 70 70 70 60 LEFT EAR 45 35 35 50 The pure tone average for the frequencies 1,000, 2,000, 3,000, and 4,000 Hertz in the Veteran's right ear was 67.5 decibels, while that same average in the Veteran's left ear was 41.25 decibels. Speech recognition ability was 80 percent in the Veteran's right ear, and 100 percent in the left ear. According to the examiner, performance intensity function testing was performed on the Veteran's right ear, resulting in improvement from 76 percent to 80 percent. However, that procedure was not necessary in evaluating the Veteran's left ear. The pertinent diagnosis noted was severe mixed loss in the right ear, and moderate mixed loss in the left ear. According to the examiner, the Veteran's audiometric evaluation and a previous examination conducted in April 2011 were in close agreement. Further noted was that the current evaluation included speech discrimination testing utilizing recorded Maryland CNC word lists, initially at a most comfortable listening level of 95 decibels in the Veteran's right ear resulting in a score of 76 percent, and then at 100 decibels, resulting in a score of 80 percent. According to the examiner, those presentation levels were utilized due to the Veteran's report of comfort/discomfort at those loudness levels. Speech discrimination ability was 100 percent in the Veteran's left ear at a presentation level of 80 decibels. Regarding a comment in the Court's March 2011 Memorandum Decision that "all but the most profoundly deaf clients could achieve satisfactory speech recognition scores if the volume were sufficiently increased," the examiner noted that speech must be analyzed and processed by the auditory cortex of the brain upon successful sound transfer. In that regard, in an auditory system where there was physical damage to the ear, the auditory system did not function in a normal linear manner as some would believe. In fact, in the Veteran's case, given the severe amount of hearing loss in his right ear, he "picked up" the test frequencies at a very soft threshold level. However, speech had to be presented at a sufficiently louder and comfortable listening level, above the Veteran's threshold, in order to be physically and electrically moved through the system, so that the brain might be able to clearly perceive and decode the sound and process it into meaning. In other words, louder didn't necessarily mean better or clearer. According to the examiner, this was evidenced by the Veteran's speech discrimination scores on current examination. More specifically, making speech louder in the Veteran's right ear than the left ear did not improve his speech discrimination/understanding ability over that of the left ear. On subsequent VA audiometric examination in August 2012, which examination involved a full review of the Veteran's claims folder, the Veteran's history and complaints were recounted. Audiometric examination revealed pure tone air conduction threshold levels, in decibels, as follows: HERTZ 1000 2000 3000 4000 RIGHT EAR 75 70 65 70 LEFT EAR 45 35 35 45 The pure tone average for the frequencies 1,000, 2,000, 3,000, and 4,000 Hertz in the Veteran's right ear was 70 decibels, while that same average in the Veteran's left ear was 40 decibels. Speech recognition ability was 88 percent in the Veteran's right ear, and 98 percent in his left ear. The pertinent diagnosis noted was bilateral mixed hearing loss. Noted at the time of examination was that a performance intensity function had been completed for both ears in order to determine the phonetically balanced maximum discrimination score, given that the highest presentation level did not necessarily produce the best score. This was because, while the sound might be sufficiently loud to be audible, were it to be too loud, it might be distorted. A maximum score of 88 percent was obtained for the Veteran's right ear, while a maximum discrimination score of 98 percent was obtained for the Veteran's left ear, both at a presentation level of 95 decibels. Noted at the time of examination was that, while the maximum discrimination score reflected the Veteran's ability to recognize speech at a level of 95 decibels in a sound booth, his ability to recognize speech in daily life would vary from situation to situation, and depend on several factors, including whether the speaker was male or female, the level and rate of speech, the level of competing noise and the location of the noise, the proximity of the speaker or distance between the speaker and the Veteran, and contextual cues. According to the examiner, the discrimination test done in the sound booth was done in a very controlled environment, and was designed to eliminate most of the aforementioned factors, so that the test was standardized, and would yield fairly repeatable results no matter which clinician administered it unless there had been a change in hearing. However, the speech discrimination test didn't necessarily reflect how a Veteran would function in a normal everyday environment. This was the case because, in addition to situational factors, consideration would also have to be given to how the Veteran's hearing aid circuit functioned in different environments. More specifically, in hearing aids with newer technology, the parameters of the hearing aid changed automatically based on the type of environment. For example, in very quiet environments, the hearing aid would pick up sound from all directions, and provide more gain or volume. However, as the surrounding noise level increased, the hearing aid gain level was reduced, particularly for sound to the rear and sides. Moreover, in crowded noisy areas such as restaurants and automobiles, hearing aids typically switched to a "comfort setting" which permitted the user to hear sound, but did not provide enough gain to understand speech. Accordingly, the Veteran would be expected to have difficulty understanding conversation in social settings with groups where a great deal of competing noise was present even when wearing hearing aids. In summary, the Veteran's ability to recognize speech in daily life would vary based on factors such as proximity of the speaker, male or female speaker, level and rate of speech, level and location of competing noise, and contextual cues, as well as the hearing aid parameters/settings which would automatically change based on the surrounding environment. In an addendum to the aforementioned August 2012 VA audiometric examination dated in April 2013, the same VA audiologist who had conducted the August 2012 examination wrote that the Veteran's claims folder had been reviewed, and that, in response to the Board's question, it was not possible to extrapolate the Veteran's audiometric performance in a soundproof booth to his everyday performance in the real world. This was the case because the Veteran's performance in the real world was dependent upon several different factors, in particular, those noted at the time of the August 2012 examination. However, the examining audiologist did state that standard procedures were employed in conducting the August 2012 VA audiometric examination. More specifically, a performance intensity function was completed as required in the Handbook of Standard Procedures and Best Practices for Audiology Compensation and Pension Examinations. Noted by the examiner was that the Rating Schedule provided that organic loss of hearing was to be determined according to findings reported as the result of a standardized hearing examination. This was the case because such a procedure permitted a standardization of methods and uniformity of conditions so that the performance of each Veteran could be compared with that of normal hearers. Moreover, it had been found that the ability to hear appropriately selected words and repeat them accurately, as shown by speech audiology tests in conjunction with the findings demonstrated in pure tone audiometry in a quiet environment, correctly reflected hearing ability for everyday speech. In a decision of July 2013, the Chief of VA Compensation and Pension Service indicated that, in light of evidence showing that it was not possible to extrapolate the Veteran's audiometric performance in a soundproof booth to his everyday performance in the real world, entitlement to an extraschedular evaluation for the Veteran's service-connected hearing loss with postoperative residuals of otosclerosis in the right ear was denied. This was the case given the fact that there was no evidence showing that the Veteran's case presented such an exceptional or unusual disability picture, with such related factors as a marked interference with employment or frequent periods of hospitalization, as to render impractical the application of the regular schedular standards. Pursuant to applicable law and regulation, otosclerosis is to be evaluated on the basis of its associated hearing impairment. 38 C.F.R. § 4.87, Diagnostic Code 6202 (2013). Evaluations of bilateral defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination (recognition) tests, together with the average hearing threshold level, as measured by pure tone audiometry tests in the frequencies of 1,000, 2,000, 3,000, and 4,000 cycles per second (Hertz). To evaluate the degree of disability from bilateral service-connected defective hearing, the Rating Schedule establishes 11 auditory acuity levels designated from Level I for essentially normal acuity to Level XI for profound deafness. 38 C.F.R. § 4.85 and Part 4, Code 6100 (2013). Finally, when the pure tone threshold for each of the four frequencies (1,000, 2,000, 3,000, and 4,000 Hertz) is 55 decibels or more, the Roman numeral designation for hearing impairment is to be determined from either Table VI or Table VIa, whichever results in the higher numeral, with each ear to be evaluated separately. 38 C.F.R. § 4.86(a) (2013). In the case at hand, it is clear that, at the time of the aforementioned VA audiometric examination in October 2004, the Veteran exhibited no more than Level I hearing impairment in either ear. Moreover, as of the time of a subsequent VA audiometric examination on November 14, 2008, the Veteran exhibited no more than Level V hearing impairment in his right ear, and Level I hearing in his left ear. At the time of a VA audiometric examination in February 2012, the Veteran exhibited no more than Level V hearing impairment in his right ear, and Level I hearing impairment in his left ear. Finally, at the time of a subsequent VA audiometric examination in August 2012, the Veteran exhibited no more than Level VI hearing impairment in his right ear, and Level I hearing impairment in his left ear. Significantly, over the course of this appeal, and on multiple VA audiometric examinations, the Veteran has cumulatively exhibited no more than Level VI hearing impairment in his right ear, and Level I hearing impairment in his left ear. Such findings are commensurate with no more than a noncompensable schedular evaluation for the Veteran's service-connected bilateral mixed hearing loss. Nonetheless, evaluation of the Veteran's service-connected bilateral hearing loss involves more than a mechanical application of the Rating Schedule, as initially determined in Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). More specifically, while in Martinak v. Nicholson, 21 Vet. App. 447 (2007), the Court held that VA's policy to conduct audiometric testing in sound-controlled rooms was neither plainly erroneous nor otherwise inconsistent with VA's regulations concerning medical evaluations, the Court further held that, in addition to objective test results, VA audiometric evaluations must fully describe the functional effects caused by a hearing disability. Based on the aforementioned evidence, it is clear that, at least in this Veteran's case, the "functional effects" caused by his service-connected bilateral mixed hearing loss are not adequately represented by the Rating Schedule. More specifically, and as noted at the time of the aforementioned VA hearing aid evaluation in April 2011, while the Veteran's word recognition scores were excellent on evaluation in a soundproof booth, in that setting, intensity levels were elevated above normal levels, with the result that the testing environment was not representative of the Veteran's everyday listening environment, where competing noise was often present, and the distance from the speaker and rate of speech varied widely. Accordingly, notwithstanding the Veteran's good word discrimination scores on testing, he could nonetheless expect to experience some difficulty in both hearing and understanding in his normal everyday environment, even when wearing his hearing aids. As noted at the time of the aforementioned VA audiometric examination in August 2012, a person's ability to recognize speech in daily life varies from situation to situation, and depends on several factors, including whether the speaker is male or female, the level and rate of speech, the level of competing noise and the location of that noise, the proximity of the speaker or distance between the speaker and the person, and contextual cues. Significantly, while discrimination testing done in a soundproof booth is done in a very controlled environment designed to eliminate most of the aforementioned factors, it does not necessarily reflect how a person functions in a normal everyday environment. Based on the aforementioned, the Board is of the opinion that the Veteran's service-connected bilateral mixed hearing loss presents such an exceptional or unusual disability picture as to warrant the assignment of a 10 percent extraschedular evaluation for that disability. This is particularly the case given the fact that, in a manner similar to recurrent tinnitus, the Veteran's bilateral hearing loss is currently productive of mild, although constant, functional impairment of the Veteran's ordinary daily activities. 38 C.F.R. §§ 4.20, 4.87 and Part 4, Diagnostic Code 6260 (2013). ORDER Entitlement to an extraschedular 10 percent evaluation for bilateral mixed hearing loss, with postoperative residuals of otosclerosis in the right ear, is granted, subject to those regulations governing the award of monetary benefits. REMAND As noted above, an extraschedular 10 percent evaluation has now been awarded for the Veteran's service-connected ear pathology. However, in late November 2013, subsequent to the issuance of the most recent Supplemental Statement of the Case in September 2013, there was received from the Veteran correspondence dated in September 2013 to the effect that he had undergone a ninth surgery (a tympanomastoidectomy) on his right ear on August 13, 2013. Accompanying that correspondence were records of the surgery, performed at the Portsmouth (Virginia) Naval Medical Center, along with a postoperative audiometric examination conducted the following month. Significantly, none of the aforementioned records have yet been considered by the RO in the context of the Veteran's claim for increased benefits. See 38 C.F.R. § 20.1304(c) (2013). Moreover, given that the Veteran has now undergone an additional surgery on his right ear, potentially affecting his hearing, an additional VA audiometric examination is warranted prior to a final adjudication of his entitlement to a schedular evaluation in excess of 10 percent effective the date of that surgery. Accordingly, in light of the aforementioned, the case is REMANDED to the AMC/RO for the following action: 1. Any pertinent VA or other inpatient or outpatient treatment records, subsequent to April 2013, the date of the most recent pertinent evidence of record, should be obtained and incorporated in the claims folder. The Veteran should be requested to sign the necessary authorization for release of any private medical records to the VA. All attempts to procure such records should be documented in the file. If the AMC/RO cannot obtain records identified by the Veteran, a notation to that effect should be included in the claims file. In addition, the Veteran and his representative should be informed of any such problem. 2. The Veteran should then be afforded an additional VA audiometric examination in order to more accurately determine the current severity of his service-connected ear disability/hearing loss. The Veteran is hereby notified that it is his responsibility to report for the examination, and to cooperate in the development of his claim. The Veteran is further advised that the consequences for failure to report for a VA examination without good cause may include denial of his claim. 38 C.F.R. §§ 3.158, 3.655 (2013). In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examination was sent to his last known address. It should also be indicated whether any notice sent was returned as undeliverable. The claims folder must be made available to and reviewed by the examiner prior to completion of the examination. In addition, the examiner must specify in his report that the claims file, as well as the Veteran's Virtual VA and Veterans Benefits Management System electronic records, have been reviewed. 3. The AMC/RO should then review the examination report to ensure that it is in complete compliance with the directives of this REMAND, and that the examiner has documented his consideration of all records contained in the Veteran's claims folder, as well as Virtual VA and the Veterans Benefits Management System. If the report is deficient in any manner, the AMC/RO must implement corrective procedures. 4. The AMC/RO should then adjudicate the issue of entitlement to a schedular evaluation in excess of 10 percent for bilateral mixed hearing loss, with postoperative residuals of otosclerosis in the right ear, effective from August 13, 2013, the date of a right tympanomastoidectomy. Should the benefit sought on appeal remain denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case (SSOC). The SSOC must contain notice of all relevant action taken on the claim for benefits since the issuance of the most recent Supplemental Statement of the Case (SSOC) in September 2013. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome in this case. The Veteran need take no action unless otherwise notified. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs