Citation Nr: 1342952 Decision Date: 12/26/13 Archive Date: 01/07/14 DOCKET NO. 09-39 286 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to an initial compensable rating for bilateral hearing loss. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESSES AT HEARING ON APPEAL The Veteran, his mother, his father and J.B. ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran had active duty service from June 2004 to June 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. In a March 2012 decision, the Board granted an initial 50 percent rating for PTSD. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court or Veterans Court). In May 2013, the Court granted a Joint Motion for Partial Remand and remanded the claim for an initial rating in excess of 50 percent for PTSD back to the Board for action consistent with the Joint Motion. In March 2012, the Board remanded the claim for an initial compensable rating for bilateral hearing loss. The Board is satisfied that there has been substantial compliance with the remand directives set out in March 2012. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. For the initial rating period prior to October 24, 2008, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity, due to such symptoms as anxiety and panic attacks. 2. From October 24, 2008, PTSD was manifested by occupational and social impairment with deficiencies in most areas. 3. For the entire initial rating period, the Veteran had no worse than Level I hearing acuity in each ear. CONCLUSIONS OF LAW 1. For the initial rating period prior to October 24, 2008, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.321, 3.159, 4.1-4.14, 4.125-4.130, Diagnostic Code 9411 (2013). 2. The criteria for a 70 percent rating, but no higher, for PTSD, have been met from October 24, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.1-4.16, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.85, 4.86 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist As provided for by VCAA, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the AOJ, in this case the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, a June 2008 letter addressed the notice elements for a service connection claim. Because the appeal stems from the Veteran's disagreement with the initial ratings following the grant of service connection for PTSD and bilateral hearing loss, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Veterans Court have held that, once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d. 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The record indicates that the RO obtained all information relevant to the Veteran's claim. The service treatment records have been obtained, as well as post-service VA treatment records identified by the Veteran. The Veteran had VA examinations for PTSD in August 2008 and April 2010. He had VA examinations for hearing loss in September 2008 and April 2012. When VA undertakes to provide a VA examination or obtain a VA examination or opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran has been afforded adequate examinations on the issues decided herein. The claims file and treatment records were reviewed, the Veteran's history was taken, and complete examinations were conducted. The April 2012 VA examination also addressed the functional impact of the Veteran's hearing loss disability. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the available relevant records, and has provided adequate examinations to the Veteran. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Initial Rating for PTSD Disability evaluations (ratings) are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2013). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the policy of the VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Veteran has appealed the initial rating assigned following a grant of service connection. Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for the disability is disputed, separate or "staged" evaluations may be assigned for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). See also Hart v. Mansfield, 21 Vet. App. 505 (2008). PTSD is evaluated (rated) under the general rating formula for mental disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation or name. A Global Assessment of Functioning score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed.1994) (DSM-IV). A score of 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A score in the range of 51 to 60 indicates moderate symptoms (e.g., a flattened affect, circumstantial speech, occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., having few friends or having conflicts with peers or co-workers). A GAF score of 41 to 50 reflects a serious level of impairment (e.g., suicidal ideation, severe obsessive rituals, frequent shoplifting), or serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). Service connection for PTSD was granted in a November 2008 rating decision. In a March 2012 decision, the Board granted a 50 percent rating for PTSD throughout the initial rating period. The Veteran had a VA examination in August 2008. The Veteran reported multiple awakenings and nightmares of Afghanistan and that he had not had a remission of symptoms which began while during his tour in Afghanistan. The Veteran reported that he had lived with his parents since he was discharged in 2004. The Veteran reported that he was employed in his father's welding shop. He reported that he worked an eight-hour day. The Veteran reported that he would go and meet with friends at times and would swim on the lake and try to relax. He reported that he was soon going to start college to study business management and marketing. Mental status examination revealed that the Veteran was appropriately dressed, and hygiene was intact. His eye contact with consistent throughout the evaluation, and his speech was of normal tone, rate and rhythm. His mood appeared calm, and his affect was appropriate to subject matter. His thought processes were logical and goal directed, and he did not endorse or manifest psychotic symptoms. He denied thoughts to harm himself or others. Cognitively, the Veteran was oriented to time, place and person. His memory, both remote and recent, was intact, and there were no abnormalities in his ability to concentrate and attend. His fund of knowledge appeared well above the normal level of functioning, and his insight into his symptoms appeared very good. The VA examiner indicated that impairment of thought processes and communication was discussed in depth. The Veteran stated that, after Afghanistan, he did not think he was able to deal with reality. The Veteran denied hallucinations and delusions and had no inappropriate behavior. He denied suicidal or homicidal thoughts, ideations, plans or intent. The VA examiner assigned a GAF score of 60 to 65. The VA examiner noted that the Veteran was able to work eight hours a day and engage in recreational activities with friends. The VA examiner stated that PTSD signs and symptoms appeared to be transient and mild, and a decrease in work efficiency and ability to perform occupational and social tasks occurred only during periods of significant stress. A VA psychiatry consultation dated October 24, 2008 reflects that the Veteran reported increased anxiety and worries. He stated that he worried about the people in his life, school and his friends who were still in the military. The Veteran reported frequent panic attacks characterized by palpitations, dyspnea, parasthesias in the hands and feet and anxious ruminations. The Veteran reported that the attacks usually occurred randomly throughout the day, without a clear trigger. The Veteran reported intermittent passive suicidal ideation. He denied suicidal intent or plan. On mental status examination, the Veteran had good grooming and hygiene. The rate, tone and volume of speech were within normal limits. His mood was anxious, and his affect was congruent. He had good organization of thoughts. The Veteran denied current suicidal or homicidal ideation, urges, intent or plan. He denied visual or auditory hallucinations. The VA psychiatrist noted that the Veteran's insight and judgment were fair. A GAF score of 45 was assigned. A VA psychiatry clinic note dated in April 2009 shows that the Veteran reported that he lost his job in Toledo and had moved back in with his parents. The Veteran reported that he was working in his father's welding shop. The Veteran reported that he struggled to maintain functionality, which was primarily limited by his mood (irritability, quick to anger) and felt provoked by his cousins working there and had a difficult time keeping in check. The Veteran reported that there were no physical altercations. In addition to irritability, the Veteran also reported that he was easily distracted, had trouble concentrating and worse memory, and that this caused him to stop the majority of his classes. The Veteran attributed this difficulty with concentration to his low mood and poor sleep (early and middle insomnia at least two times a week with no nightmares). The Veteran reported experiencing daily intrusive thoughts. The Veteran denied suicidal and homicidal ideation and was future oriented. He reported that his relationship with his girlfriend had deteriorated, and he felt that they might break up. On mental status examination, the Veteran had good grooming and hygiene and was cooperative. His psychomotor behavior showed no agitation or slowing. Speech rate, tone and volume were within normal limits. His mood was "crappy." His affect was constricted but reactive. He did not appear significantly depressed or anxious. His thought process was logical and goal-directed. The Veteran denied suicidal and homicidal ideation, urges, intent or plan and did not have visual or auditory hallucinations. His insight and judgment were fair to good. No GAF score was assigned. A May 2009 psychiatry treatment note shows that the Veteran reported that his mood was significantly worse over the last month. He endorsed feeling tired all of the time and having significantly irritable mood. He reported that he broke up with his girlfriend. Mental status examination showed that the Veteran had excellent grooming and hygiene. His speech rate and tone were within normal limits. His mood was terrible. His affect was constricted but reactive. His thought process was logical and goal-directed. The Veteran denied current suicidal ideation or plan. Insight and judgment were fair to good. A VA psychiatry note dated in June 2009 shows that the Veteran endorsed suicidal ideation with plan (gun) but adamantly denied intent. He reported thoughts of choking his cousin but denied intent. He denied past suicide or homicide attempts. Mental status examination showed that the Veteran was dressed and groomed casually. He was polite and cooperative. The Veteran was oriented to time, place and person. His speech was normal in rate, tone and rhythm. His mood was euthymic. He had a normal range of affect. This thought processes and content were normal. The Veteran reported some problems with concentration but was able to focus during the interview. The Veteran denied hallucinations or delusions, and none were present during the interview. The VA psychiatrist noted that judgment and insight were good. The VA examiner noted that the Veteran reported that his symptoms interfered with his relationships and occupational functioning. A GAF score of 53 was assigned. The Veteran had a VA examination in April 2010. The Veteran reported mild, daily depressed mood, anhedonia, sleep disturbance, fatigue, appetite disturbance, difficulty with concentration, feeling worthless, and suicidal plan without intent. The Veteran reported that his symptoms were present since leaving Afghanistan. The Veteran denied manic symptoms. However, the Veteran reported that he was no longer spending time with his friends and would cut himself off from others. He indicated that he was spending most of his time at home. The Veteran reported that he was attending college for business administration but had taken the semester off and did not want to return. The Veteran reported that he had been living with his girlfriend but had asked her to move out. The Veteran reported that he maintained a good relationship with his parents. He reported that he had recently found out that he had a four-year-old son and was working on building a relationship with him. On mental status examination, the Veteran's general appearance was clean and casually dressed. His speech was unremarkable. His affect was normal. Mood was agitated. The Veteran was oriented to time, place and person. His thought process and thought content were unremarkable. There were no delusions. With respect to judgment, the examiner noted that the Veteran understood the outcome of his behavior. There was no evidence of hallucinations. The Veteran did not display inappropriate behavior. The examiner noted that the Veteran had obsessive or ritualistic behavior. The Veteran reported that he locked the door twice when he got in the car and had a specific way that he brushed his teeth. The Veteran reported that he had panic attacks three to four times a week, which lasted 30 seconds to several minutes. The Veteran reported the presence of homicidal thoughts. He reported thoughts with no intent which were triggered by people of Middle Eastern descent or when he was in arguments with people. The Veteran reported that he had daily suicidal ideation with plan, but no intent. The Veteran reported that he had a safety plan which he would follow. The examiner noted that the Veteran's impulse control was fair. The Veteran reported getting in arguments with co-workers 4 to 5 times a week. The Veteran reported that he was able to maintain minimum personal hygiene. The Veteran denied problems with activities of daily living. The VA examiner noted that the Veteran's memory was normal. His recent memory was mildly impaired. His immediate memory was normal. The Veteran reported some problems with short term memory. The Veteran was employed full-time as a welder. The Veteran denied missing time from work in the prior 12-month period. He reported that problems related to occupational functioning included decreased concentration, difficulty following instructions, inappropriate behavior, increased tardiness, memory loss and poor social interaction. The VA examiner assigned a GAF score of 53. The VA examiner noted that the Veteran reported changes in functional status and quality of life since the last VA examination. He reported that he had dropped out of school. He reported that he avoided his mom since they did not live together. Socially, he reported that he lost a 10-month relationship with his significant other and lost friends. The Veteran reported yelling at co-workers and reported that he had difficulty with concentration and was often late to work. The VA examiner indicated that PTSD resulted in deficiencies in most areas, such as judgment, thinking, family relations, work, mood and school. The VA examiner indicated that the Veteran did not have total occupational and social impairment due to PTSD. The Board finds that the criteria for a rating in excess of 50 percent were not met during the period prior to October 24, 2008. Prior to October 24, 2008, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity. The Veteran was employed in his father's shop. He was able to work eight hours a day and engaged in social activities with friends. The GAF score of 60 to 65 assigned on VA examination in April 2008 reflects moderate impairment. The evidence for the period prior to October 24, 2008 does not show that the Veteran's PTSD symptoms met the criteria for the rating of 70 percent, which requires occupational and social impairment with deficiencies in most areas. During the period prior to October 24, 2008, there was no objective evidence of suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. The Board finds that the criteria for a 70 percent rating were met from October 24, 2008, as the VA psychiatric consultation of that date reflects an increase in the severity of PTSD. The October 2008 VA psychiatry consultation noted frequent panic attacks. The frequency of panic attacks described approximates near-continuous panic attacks, based upon the Veteran's report that his panic attacks occurred throughout the day. The GAF score of 45 assigned in October 2008 reflects serious impairment. The Veteran reported passive suicidal ideation in October 2008, in contrast to his prior VA examination which indicated that he denied any suicidal ideation. VA treatment records reflect that the Veteran continued to report suicidal ideation in June 2009 and in April 2010. The evidence for this the period from October 24, 2008 shows occupational and social functioning which more nearly approximate the criteria for a 70 percent rating. Socially, in April 2010, the Veteran reported a good relationship with his parents and his son but indicated that he did not spend time with friends and had cut himself off from others. The Veteran demonstrated occupational impairment, as he reported in April 2009 that he had lost his job. In April 2010, the Veteran was working full-time, but he reported arguments with co-workers and difficulty with concentration and following instructions. The Veteran also reported he had dropped out of school. The April 2010 VA examiner indicated that PTSD resulted in deficiencies in most areas, such as judgment, thinking, family relations, work, mood and school. For the reasons set forth above, the Board finds that the criteria for a 70 percent rating, but no higher, have been met from October 24, 2008. Accordingly, the Board finds that a 70 percent rating is warranted from October 24, 2008, as the severity of PTSD approximated occupational and social impairment with deficiencies in most areas due to such symptoms as suicidal ideation, near-continuous panic affecting the ability to function independently, appropriately, and effectively, difficulty in adapting to stressful circumstances and an inability to establish and maintain effective relationships. The Board concludes that the Veteran's PTSD symptomatology has not approximated the criteria for a 100 percent rating under DC 9411. 38 C.F.R. § 4.130 at any point during the appeal period. The evidence does not show that the Veteran had total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Initial Rating for Bilateral Hearing Loss A November 2008 rating decision granted service connection for hearing loss and assigned a non-compensable (zero percent) rating. The Veteran seeks a higher initial rating for bilateral hearing loss. The Rating Schedule provides a table (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, based on puretone thresholds and controlled speech discrimination (Maryland CNC) testing. Table VII is used to determine the rating assigned by combining the Roman numeral designations for hearing impairment of each ear. 38 C.F.R. § 4.85. The "puretone threshold average" as used in Table VI is the sum of the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz , divided by four. This average is used in all cases to determine the Roman numeral designation for hearing impairment from Table VI or VIa. 38 C.F.R. § 4.85(d). Ratings for hearing impairment are derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Where there is an exceptional pattern of hearing impairment as defined in 38 C.F.R. § 4.86, the rating may be based solely on puretone threshold testing. An exceptional pattern of hearing impairment occurs when the puretone thresholds in each of the four frequencies 1000, 2000, 3000, and 4000 Hertz are 55 decibels or greater, or when the puretone threshold at 1000 Hertz is 30 decibels or less and the threshold at 2000 Hertz is 70 decibels or more. 38 C.F.R. § 4.86(a), (b). The Board finds that the criteria of 38 C.F.R. § 4.86 are not met in this case. The Veteran had a VA examination in September 2008. Audiological testing obtained the following puretone thresholds, in decibels: HERTZ 1000 2000 3000 4000 RIGHT 20 20 25 30 LEFT 15 20 10 30 Average puretone thresholds were 23.75 decibels for the right ear and 18.75 decibels for the left ear. Speech recognition scores were 92 percent in both ears. Using Table VI, a numeric designation of I is obtained for both ears. Table VII provides that a 0 percent evaluation is warranted for those numeric designations. The Veteran had a VA examination in April 2012. Audiological testing obtained the following puretone thresholds, in decibels: HERTZ 1000 2000 3000 4000 RIGHT 15 10 10 10 LEFT 15 10 5 0 Average puretone thresholds were 11.25 decibels for the right ear and 7.5 decibels for the left ear. Speech recognition scores were 94 percent in both ears. Using Table VI, a numeric designation of I is obtained for both ears. Table VII provides that a non-compensable evaluation is warranted for those numeric designations. In Martinak v. Nicholson, 21 Vet. App. 447 (2007), the Court held that, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak, 21 Vet. App. at 455. The April 2012 VA examiner indicated that patients with high frequency sensorineural hearing loss may experience difficulty hearing in background noise (which the Veteran reported). The VA examiner indicated that hearing loss this mild should not significantly impact communication nor prevent gainful employment. Based upon the foregoing, the Board finds that the criteria for a compensable rating have not been met. As the preponderance of the evidence is against the claim for an initial compensable rating for bilateral hearing loss, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). The threshold factor for extraschedular 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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, the Board finds that the impairments due to PTSD and hearing loss are adequately contemplated by the rating schedule. The rating criteria specifically contemplate the occupational and social impairment caused by PTSD. The schedular rating criteria for hearing loss contemplate ratings based on all levels of hearing loss, including exceptional patterns, which are not demonstrated in this case, and as measured by both audiological testing and speech recognition testing. Consequently, the Board finds that the schedular rating criteria are adequate to rate the Veteran's PTSD and hearing loss disabilities, and referral for extraschedular consideration is not warranted. 38 C.F.R. § 3.321(b)(1). ORDER Prior to October 24, 2008, a rating in excess of 50 percent for PTSD is denied. From October 24, 2008, a 70 percent rating is granted for PTSD, subject to regulations governing the payment of monetary benefits. An initial compensable rating for hearing loss is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs