Citation Nr: 1532732 Decision Date: 07/31/15 Archive Date: 08/05/15 DOCKET NO. 09-09 023 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to an initial rating higher than 10 percent prior to January 18, 2013, and a rating higher than 40 percent since January 18, 2013, for service-connected bilateral hearing loss. 2. Entitlement to an initial compensable rating for bilateral external otitis. 3. Entitlement to service connection for a skin disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Adams, Counsel INTRODUCTION The Veteran had active service from June 1967 until June 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the Wichita, Kansas, Regional Office (RO) of the Department of Veterans Affairs (VA). This case was remanded in November 2012 for further development. The claims are now ready for disposition. In March 2013, the Veteran signed an expedited waiver of the 30 day waiting period. The Board has not only viewed the Veteran's physical claims file, but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. The Veteran served on the ground in Vietnam and it is presumed that he was exposed to herbicides. 2. The Veteran's skin disability was not manifested during service and is unrelated to service, to include exposure to herbicide exposure and/or chemical exposure. 3. Prior to January 18, 2013, the most probative evidence demonstrates that the Veteran's bilateral hearing loss was manifested by hearing impairment corresponding to no higher than an auditory acuity of Level II hearing in the right ear and Level VII hearing in the left ear. 4. Since January 18, 2013, the most probative evidence demonstrates that the Veteran bilateral hearing loss has been manifested by hearing impairment corresponding to no higher than an auditory acuity of Level VI in the right ear and Level IX in the left ear. 5. The most probative evidence of record at this time does not demonstrates that the Veteran's bilateral external otitis is manifested by chronic otitis externa with swelling, dry and scaly or serous discharge, and itching requiring frequent and prolonged treatment. CONCLUSIONS OF LAW 1. A chronic skin disability was not incurred in or aggravated by service, to include exposure to herbicides and chemicals. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.307, 3.309 (2014); Combee v. Brown, 34 F.3rd 1039 (Fed. Cir. 1994). 2. The criteria for an initial disability rating higher than 10 percent prior to January 18, 2013, and a rating higher than 40 percent since January 18, 2013, for bilateral hearing loss, have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.86, Diagnostic Code (DC) 6100 (2014). 3. The criteria for an initial compensable disability rating for bilateral external otitis, have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.86, DC 6210 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Service Connection Claim Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (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, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Diseases associated with exposure to certain herbicide agents used in support of military operations in the Republic of Vietnam (Vietnam) during the Vietnam era will be considered to have been incurred in service. 38 U.S.C.A. § 1116(a)(1). If a veteran was exposed to an herbicide agent during active military, naval, or air service, diseases including chloracne or other acneform disease consistent with chloracne and porphyria cutanea tarda shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) (2014) are also satisfied. 38 C.F.R. § 3.309(e). As the record reflects that the Veteran served in Vietnam from March 1969 to March 1970, exposure to herbicides is presumed. However, despite his presumed exposure to an herbicide agent, presumptive service connection under 38 C.F.R. § 3.307(a)(6) is still not for application. Service connection is only warranted on this basis for a specific list of diseases set forth under 38 C.F.R. § 3.309(e). While sarcomas (cancer) are included on the list of diseases subject to presumptive service connection on the basis of herbicide exposure and the Veteran was diagnosed as having a basal cell carcinoma in April 1998, basal cell carcinomas are not included. Id. As the Veteran has not been diagnosed with a skin disability listed under 38 C.F.R. § 3.309(e) an award of presumptive service connection based on herbicide exposure is not warranted. The absence of a disease from the presumptive list does not preclude a veteran from otherwise proving that his disability resulted from exposure to Agent Orange or otherwise linking his carcinoma to service. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Accordingly, the Board will still consider whether entitlement to service connection can be granted on a direct basis for a chronic skin disability. The Veteran contends that he has a skin disability related to his service. Specifically, he contends that during service in the Republic of Vietnam he was exposed to herbicides, including Agent Orange and a "rainbow of toxic herbicides." In a September 2008 notice of disagreement, he stated that during service he worked with sentry dogs on trails around the perimeter of the base sprayed with chemicals to kill the vegetation which he contends may have caused his skin disability. The service treatment records include a June 1967 enlistment examination which reflects a normal clinical evaluation of the skin. An October 1970 report documents a complaint of a possible boil on the right upper arm. However, a May 1971 separation examination reflects a normal clinical evaluation of the skin. An accompanying report of medical history shows that the Veteran denied having a history of skin diseases. Private treatment records reflect treatment for a recurrent skin rash beginning in March 1995 and treatment for and diagnoses of stucco keratosis, sebaceous hyperplasia due to chronic sun exposure, non-inflamed seborrheic keratosis, xerosis cutis and actinic keratosis. Specifically, a March 1995 report reflects diagnoses of sebaceous hyperplasia, face, secondary to chronic sun exposure and damage; skin tags irritated, left lateral neck and left axillary area; and irritated seborrheic keratoses, back. In November 1996, he complained of a two year history of a rash on his thighs. An April 1998 biopsy pathologic report shows that he appeared with a history of two lesions one present for three months. The clinical diagnosis was basal cell carcinoma. In December 1998, he complained of pruritic eruption present on his trunk, specifically his back and chest for the past several years reportedly ever since he returned from Vietnam. The assessment was irritated acrochordon, left axillary vault area; actinic keratosis, right cheek and dorsum right forearm; and miliaria with keratosis cutis, trunk. In October 2001, he complained of extremely dry skin on his arms, legs and trunk for the past several years since his service in Vietnam. In a January 2008 statement, the Veteran stated that he had bad rashes mainly on his back, arms, and chest began during service which his family thought was related to his service. He complained of moles and small warts which had to be removed and stated that he believed it was related to chemical exposure, but did not believe it was specifically related to Agent Orange exposure. In a March 2009 statement, the Veteran stated that when he returned from Vietnam in 1970 many of his relatives saw him with his shirt off and inquired about his rash. He stated that a VA doctor did not believe that the skin condition was caused by chemical exposure, but did not examine his arms, chest, or back. To address this issue, pursuant to the Board's November 2012 remand, the Veteran was afforded a VA skin diseases Disability Benefits Questionnaire examination in January 2013 diagnosed actinic keratosis and seborrheic keratosis since 1998. The examiner noted a rash that began as red and itchy with bumps and then he developed little warts and moles on the shoulder and back. He had warts burned off and used creams, but they continued to reoccur. The rash had improved but the growths worsened. No rash was noted on his hands, neck or face. In the remarks section, the examiner noted that the Veteran had an irrigation systems company and raised cattle. It was noted that he had seborrheic keratosis with an underlying rash all over his back with several on his chest and shoulders and inside of his thighs. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness based on the rationale that the STRs do not show treatment for a chronic skin rash. Private medical records show treatment for actinic keratosis on December 1998, greater than 25 years after military separation. The examiner explained that actinic keratosis is caused by sun exposure. Veteran also has TNTC (too numerous to count) seborrheic keratosis on his back which is caused by and gets worse with age. With no nexus of treatment and no presumptive connection between actinic keratosis or seborrheic keratosis with Agent Orange, it is less likely than not that the Veteran's skin conditions were caused by military service. The Board acknowledges that in a November 2012 Written Brief Presentation, the Veteran, through his representative, reiterated that his skin disability began after his Vietnam service. The representative argued that there was a "rainbow of toxic herbicides" used in Vietnam including Agent Blue which was high in arsenic and implied that there could be an etiologically link between this herbicide and the Veteran's skin condition. In the July 2015 Written Brief Presentation, the Veteran, through his representative, complained that the January 2013 VA examiner's medical opinion "fails the common sense test." In this regard, the Board disagrees. The Board has reviewed this case in great detail: While the Veteran's exposure to herbicides in service is clear (and not in dispute - in fact little of the facts of this case are in dispute), this fact does not suggest, or imply, that any skin disability the Veteran has (for example, one caused normally by sun exposure) is the result of this exposure. In light of the Veteran's contentions and herbicide exposure the Board remanded this case for a medical opinion, which has provided clear evidence against the claim that the skin disorder the Veteran has had any connection to the Veteran's service more than 40 years ago. The representative stated that the Veteran had no rash on his hands, neck, or feet, but that the examiner related actinic and seborrheic keratoses (on his back with several on his chest and shoulders and inside of his thighs) "to sun exposure only" citing to an article from the American Academy of Dermatology. See, Brief at 2. He suggested that covered areas of the Veteran's body that were diagnosed with a skin disability could not possibly be due to sun exposure. However, while the examiner related actinic keratosis to sun exposure he related the seborrheic keratosis on his back to the aging process. This opinion is supported by a well-reasoned rationale. The representative also argued that the Veteran's skin rashes may be related to exposure to arsenic in Agent Blue. However, there is no evidence of record which confirms the Veteran was exposed to Agent Blue during service. None of the evidence of record supports a finding that the Veteran's herbicide and/or chemical exposure during service caused his current skin condition. Specifically, in a November 2012 and July 2015 Written Brief Presentations the Veteran's representative argues that the Veteran was exposed to arsenic from Agent Blue during service which, based on internet research, is known to cause of facilitate skin conditions. The representative cited to several articles which suggest an etiological relationship between arsenic exposure and skin conditions. These articles, however, contain no opinion as to the relationship between the cause of the Veteran's skin condition and his service, including herbicide exposure therein. These articles reference by the Veteran's representative simply provide speculative generic statements. As these articles do not specifically state an opinion as to the relationship between the cause of the Veteran's skin condition and his service, the have limited probative value in the consideration of the Veteran's claim. See Sacks v. West, 11 Vet. App. 314 (1998). Again, no one is suggesting that the Veteran was not exposed to herbicides during service (including Agent Blue), the only question is whether the current problem has any association with service or the herbicide exposure. Here, the only evidence that possible in-service exposure to herbicides or chemicals is related to the Veteran's skin disability are the conclusory generalized lay statements of the Veteran, his family, and his representative and internet articles and commentary which are found to lack much probative value. The evidence of record overall does not support the Veteran's overall contention that his skin disabilities are as likely as not (50% or greater) caused by herbicide or chemical exposure during service, and, in fact, provides evidence against such a finding. The Board finds that the claim must be denied. In this case, records do not reflect treatment for a chronic skin condition until March 1995. The mere absence of medical records does not contradict a Veteran's statements about his symptom history. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In this case, with the exception of the October 1970 report which reflects a possible boil on the Veteran's arm, the service treatment records are complaint void of any diagnosed skin condition and the earliest post-service medical evidence of skin problems is dated in March 1995, which is over 23 years after service. Finally, there is no competent medical evidence to show that the Veteran has a skin disability that is related to his service, including herbicide/chemical exposure. Both service, post-service records, and the medical opinion obtained provide highly probative evidence against this claim, clearly outweighing the positive evidence. The Board has taken seriously the contention that the Veteran's claimed skin condition was caused by his service. The Board has also closely reviewed the medical and lay evidence in the Veteran's claims file and finds no evidence that may serve as a medical nexus between the Veteran's service and his claimed disability. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the etiology of a skin condition, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the claim is denied. II. Increased Rating Claims Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities, which are based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2014). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2014). Reasonable doubt regarding the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3 (2014). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2014). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2014). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Hearing Loss The Veteran contends that his bilateral hearing loss disability is worse than the currently assigned ratings. Disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are made. Bruce v. West, 11 Vet. App. 405 (1998); Lendenmann v. Principi, 3 Vet. App. 345 (1992). The regulations set forth eleven auditory acuity levels, designated from Roman numerals I to XI, in escalating order of hearing impairment. 38 C.F.R. § 4.85 (2014). The appropriate auditory acuity level is determined based on a combination of the percentage of speech discrimination and the puretone threshold average. Additional considerations apply when exceptional patterns of hearing loss are demonstrated, which are defined as either a) puretone averages of 55 or greater at 1000, 2000, 3000, and 4000 Hertz , or; b) a puretone threshold of 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86(a) (2014). Once an acuity level is established for each ear, Table VII, Percentage Evaluations for Hearing Impairment, is used to determine the appropriate disability evaluation. The appropriate rating is determined based on a combination of the levels of hearing impairment established for each ear. 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 Court also noted, however, that even if an audiologist's description of the functional effects of the veteran's hearing disability was somehow defective, the veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination. Id. Historically, in July 2008, the RO granted service connection for a bilateral hearing loss disability, evaluated as 10 percent disabling under Diagnostic Code 6100, effective November 30, 2007. In February 2013, the RO increased the evaluation from 10 to 40 percent, effective from January 19, 2013, the date of the most recent VA examination. However, since this increase did not constitute a full grant of the benefit sought, including consideration of a rating higher than 40 percent prior to September 2, 2014, the higher evaluation issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). Turning to the merits of the claim, in January 2008 statement in support of the Veteran's claim, he complained of trouble hearing when using a telephone. His wife stated that he had trouble hearing on the phone and in a crowded room and that he relied on reading lips. The Veteran's friend stated that his hearing had progressively worsened. On June 2008 VA audiology examination, the Veteran stated that he had trouble hearing in the presence of background noise, especially during meetings at work, and while using the telephone. Pure tone thresholds for the right ear, in decibels, at 1000, 2000, 30000, and 4000 Hertz (Hz) were as follows: 60, 45, 65, and 70, for an average of 60 decibels and pure tone thresholds for the left ear, in decibels, at 1000, 2000, 3000, and 4000 Hz as follows: 65, 60, 75, and 80, for an average of 70 decibels. The CNC word list revealed 92 percent on the right and 64 percent on the left. The examiner diagnosed mild sensorineural hearing loss in the right ear and moderate sensorineural hearing loss in the left ear. Applying the puretone threshold averages of 60 for the right ear and 70 for the left ear, these values to the rating criteria results in a numeric designation of Level II in the right ear and Level VII in the left ear. See 38 C.F.R. § 4.85, Table VI. Application of the levels of hearing impairment in each ear to Table VII at 38 C.F.R. § 4.85 produces a rating of 10 percent. There likewise remains no basis for assigning a higher rating under 38 C.F.R. § 4.86. VA treatment records show that in September 2008 the Veteran denied any change in his hearing since the June 2008 VA examination. However, in October 2008 he was fitted for hearing aids. On January 2013 VA hearing loss and tinnitus Disability Benefits Questionnaire examination, the Veteran indicated that his hearing loss disability impacted his ordinary conditions of daily life. He reported difficulty understanding what people are saying frequently. He reported he heard things just fine with the hearing aids, but had continual trouble understanding what is being said. He had bilateral moderately-severe to profound sensorineural hearing loss, with good speech discrimination in the right ear and poor speech discrimination in the left ear Pure tone thresholds for the right ear, in decibels, at 1000, 2000, 30000, and 4000 Hz were as follows: 65, 55, 75, and 95, for an average of 70 decibels and pure tone thresholds for the left ear, in decibels, at 1000, 2000, 3000, and 4000 Hz as follows: 65, 65, 85, and 90, for an average of 76. The CNC word list revealed 80 percent on the right and 48 percent on the left. The examiner diagnosed bilateral sensorineural hearing loss. The examiner opined that his current hearing loss would not impact his ability to obtain/maintain gainful employment. Applying the puretone threshold averages of 70 for the right ear and 76 for the left ear, these values to the rating criteria results in a numeric designation of Level VI in the right ear and Level IX in the left ear. See 38 C.F.R. § 4.85, Table VIa. Application of the levels of hearing impairment in each ear to Table VII at 38 C.F.R. § 4.85 produces a rating of 40 percent. There likewise remains no basis for assigning a higher rating under 38 C.F.R. § 4.86. Based on these findings the Board finds that prior to January 18, 2013 the manifestations of the Veteran's bilateral hearing loss disability were more consistent with a 10% rating. The Board also finds that since January 18, 2013, the manifestations of the bilateral hearing loss disability are more consistent with a 40% rating. The Board finds that a preponderance of the evidence is against a finding that the service-connected bilateral hearing loss disability warranted a higher 20% rating prior to January 18, 2013, or a higher 50% rating since January 18, 2013. The Board is mindful that an audiologist must provide a description of the functional effects caused by a hearing loss disability. Martinak v. Nicholson, 21 Vet. App. 447 (2007). On June 2008 and January 2013 VA examination, the Veteran complained of trouble hearing in the presence of background noise and when using the telephone. The Board finds these comments are sufficient to comply with the applicable VA policies. Martinak v. Nicholson, 21 Vet. App. 447 (2007) (VA audiologist's indication in report that Veteran's hearing loss affected his ability to sleep was sufficient to comply with requirements of VA's own internal guidance documents that VA audiologists describe the effects of a hearing disability on occupational functioning and daily activities). Additionally, the Board has considered various lay statements from the Veteran, his spouse, and his friend attesting to the impact of his hearing loss. The Board finds that the functional effects of the Veteran's bilateral hearing loss disability are adequately addressed by the record. While the Board understands the Veteran's central concern that his bilateral hearing loss disability has negatively impacted his quality of life and that he has difficulty hearing in social situations and at work, it is important for Veteran to also understand that without some problems associated with his bilateral hearing loss disability there would be no basis for a compensable evaluation (zero), let alone the 10 and 40 percent disability ratings for his bilateral hearing loss disability. Findings made on June 2008 and January 2013 VA examinations do not support the assignment of a higher rating of 20% prior to January 18, 2013 or a higher rating of 50% since January 18, 2013, for his bilateral hearing loss disability. Moreover, without consideration of the problems he cited with his bilateral hearing loss disability at this time, the current evaluations could not be justified. The problems he has cited have not been ignored. Without consideration of the problems he has cited and other issues he has due to his hearing loss, the current evaluations could not be justified. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial rating higher than 10 percent prior to January 18, 2013, or higher than 40 percent since January 18, 2013, for his bilateral hearing loss disability. Bilateral otitis externa The Veteran contends that his bilateral otitis externa is more severe than his current noncompensable rating pursuant to Diagnostic Code 6210, which addresses chronic otitis externa. 38 C.F.R. § 4.86 (2014). Under DC 6210, a maximum rating of 10 percent is assignable for chronic otitis externa with swelling, dry, and scaly or serous discharge, and itching requiring frequent and prolonged treatment. 38 C.F.R. § 4.87. On June 2008 VA examination, the Veteran presented with complaints of ear pain with otitis externa. He had bilateral ear infections that were suppurative (purulent or mucopurulent) and occurred monthly with no constant drainage. There was no evidence of middle or inner ear infection. On examination, the tympanic membranes, mastoids, and external ear canals were normal. He was employed full time at an irrigation company for more than 20 years and not lost any time in the past 12 months due to his disability. The examiner diagnosed chronic ear infections without current evidence of external otitis. On January 2013 VA ear conditions DBQ examination the Veteran presented with a history of chronic otitis externa since 1969. Examination of the ears was normal. The examiner stated that "the Veteran has no current indication of otitis externa. The Veteran has no current symptoms of swelling, dry and scaly external ear canal or serous discharge and itching. In a January 2008 statement and in a November 2012 Written Brief Presentation, the Veteran complained of monthly ear infections that required treatment with antibiotic ear drops. However, applying the relevant rating criteria, the Board notes that bilateral external otitis is not warranted. The evidence of record does not show that the Veteran has chronic otitis externa with swelling, dry and scaly or serous discharge, and itching requiring frequent and prolonged treatment. The Veteran's examinations and treatment records show normal ears and ear canals. Therefore, an initial compensable rating for his service-connected bilateral otitis externa is not warranted at this time. Additionally, the Veteran is not shown to have loss of auricle, tympanic membrane perforation, benign neoplasm, or malignant neoplasm of the ear to warrant a higher schedular rating under any other potentially applicable diagnostic code pertaining to diseases of the outer ear. 38 C.F.R. § 4.87, Diagnostic Codes 6207-6211. For these reasons, the Board finds a schedular rating greater than the currently assigned noncompensable (0 percent) rating for bilateral otitis externa is not warranted. While the Board understands the Veteran's disagreement that he has constant ear infections that require the use of ear drops, it is important for Veteran to also understand that the Board does not suggest that the Veteran does not have problems with his ears. The question is whether these problems provide a basis to grant a compensable evaluation for his otitis externa at this time. Based on the foregoing the Board finds the Veteran's current bilateral externa otitis does not warrant the assignment of a compensable 10 percent rating at this time. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial compensable rating for bilateral external otitis. Additional Considerations The Veteran is competent to report his current problems hearing and need for ear drops at this time as these observations come to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board also acknowledges the Veteran's belief that his symptoms are of such severity as to warrant higher ratings. He is not, however, competent to identify a specific level of disability of his hearing loss and externa otitis disabilities according to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's bilateral hearing loss and otitis externa disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. In sum, the totality of the evidence fails to support the assignment of an initial rating higher than 10 percent prior to January 18, 2013, and a rating higher than 40 percent since January 18, 2013, for bilateral hearing loss or an initial compensable disability rating for bilateral externa otitis. Additionally, with respect to an extraschedular rating under 38 C.F.R. § 3.321 for his increased disability claims, the applicable rating criteria contemplate all impairment resulting from his bilateral hearing loss and otitis externa disabilities. The criteria reasonably describe the Veteran's disability level and symptomatology, specifically his complaints of pain and difficulty hearing due to his disabilities. The assigned schedular rating is, therefore, adequate and referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. However, the evidence reflects the Veteran continues to be employed. See, January 2013 VA examinations which indicate full-time employment. Thus, the Board finds that Rice is inapplicable since there is no evidence of unemployability due to the Veteran's service connected cardiovascular and bilateral leg disabilities. Finally, the Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, after applying the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (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 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of her claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir., 2004). The RO sent the Veteran letters in December 2007, April 2009, and December 2012, which informed him of all three elements required by 38 C.F.R. § 3.159(b). As such, the VCAA duty to notify was satisfied. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA treatment records, and the Veteran's written assertions. No outstanding evidence has been identified that has not otherwise been obtained. Next, relevant VA examinations and opinions were obtained in June 2008 and pursuant to the Board's November 2012 remand in January 2013. In sum, the Board finds that the examination reports and opinions, as a whole, shows that the examiners considered the evidence of record and the reported history of the Veteran, conducted thorough examinations, noting all findings necessary for proper adjudication of the matters, and explained the rationale for the opinions offered. Hence, the Board finds that the VA examinations and medical opinions obtained in this case are adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). With regard to the Veteran's claim for service connection for a skin disability, as cited above, the Board acknowledges the Veteran's complaints about the January 2013 VA examiner's opinion that the skin disability is not related to his service, including herbicide exposure, and is instead related to sun exposure. However, it is important for the Veteran to understand that this report is not the only piece of evidence against this claim. Even if the Board ignored this evidence, there is still significant evidence against this claim, as cited above. Without reference to this medical opinion, the claim would still be denied. Under the circumstances, the Board finds that there has been substantial compliance with its remands. See Dyment v. West, 13 Vet. App. 141 (1999) (a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where there is substantial compliance with the Board's remand instructions); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. ORDER An initial rating higher than 10 percent prior to January 18, 2013, and a rating higher than 40 percent since January 18, 2013, for service-connected bilateral hearing loss, is denied. An initial compensable rating for bilateral external otitis, is denied. Service connection for a skin disability, is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs