Citation Nr: 1632507 Decision Date: 08/16/16 Archive Date: 08/24/16 DOCKET NO. 13-23 521 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for a neck injury. 2. Entitlement to service connection for a head injury. 3. Entitlement to service connection for peripheral neuropathy of the right lower extremity. 4. Entitlement to service connection for peripheral neuropathy of the left lower extremity. 5. Entitlement to an initial rating higher than 50 percent for PTSD, including whether the Veteran is entitled to a temporary total rating under 38 C.F.R. § 4.29 for inpatient treatment. 6. Entitlement to a compensable rating for bilateral hearing loss. REPRESENTATION Appellant represented by: Molly Steinkemper, Attorney ATTORNEY FOR THE BOARD G. Slovick, Counsel INTRODUCTION The Veteran served on active duty from July 1968 to February 1971. These matters are before the Board of Veterans' Appeals (Board) on appeal from December 2012 and November 2014 (neuropathy claims) rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The Veteran was scheduled to have a personal hearing before a member of the Board in March 2014; however, he withdrew his request. He has not asked for another hearing to be scheduled. In May 2015, the Board remanded the issues on appeal from the December 2012 rating decision. The Board determined that the issue of entitlement to a total disability rating due to individual unemployability (TDIU) was inferred as part of the Veteran's increased rating claims and, on remand, the Board instructed the RO to provide the Veteran with a claims form for TDIU. As the Veteran failed to submit the claim form for TDIU, sent to him on July 14, 2015 and November 17, 2015, the Board finds that the Veteran does not wish to make a claim for TDIU, and that issue will not be considered below. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (the duty to assist is not a one-way street). The issues of entitlement to service connection for a head injury and entitlement to service connection for peripheral neuropathy of the right and left lower extremities are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A current neck disability is not due to active service. 2. The Veteran's PTSD manifests as occupational and social impairment with reduced reliability and productivity due to recurrent thoughts and memories, which he tries to avoid, nightmares; difficulty sleeping; reexperiencing; hyperarousal; symptoms of depression and anxiety; low motivation; suspiciousness; isolating behavior; and substance abuse and dependence. 3. From April 1, 2015 to April 17, 2015, the Veteran received in-patient treatment for PTSD, which totals less than 21 days. 4. Audiometric tests conducted during the period on appeal demonstrate that the Veteran's hearing loss is manifested at worst by level I hearing in his right ear and level II hearing loss in his left ear. CONCLUSIONS OF LAW 1. The criteria for service connection for a neck disability have not been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2014); 38 C.F.R. § 3.303 (2015). 2. The criteria for an evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.29, 4.126-4.130, DC 9411 (2015). 3. The criteria for assignment of an initial compensable rating for service connected bilateral hearing loss, have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.85, 4.86, Diagnostic Code 6100 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to provide notice of the information and evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2015). Standard August 2012, November 2012, April 2013, May 2013 and November 2015 letters satisfied the duty to notify provisions. VA also has a duty to provide assistance to substantiate a claim. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c). The Veteran's service treatment records have been obtained. Post-service VA private treatment and VA medical center records have also been obtained, as well as written statements from the Veteran. In a December 2015 correspondence, the Veteran stated that he had no additional evidence to submit in support of his claims. The Veteran was provided VA examinations in October 2012, May 2013, September 2015 and October 2015 in connection with the claims. As previously noted, the Board remanded this case for further development in May 2015. The Board specifically instructed the RO to locate and obtain any and all VA treatment and examination records for the Veteran's claimed neck disability, PTSD and hearing loss. The Board additionally specified that the results of a May 2014 audiogram be associated with the claims file. Subsequently, the RO requested additional private treatment records, VA treatment records and the Veteran's May 2014 VA audiological findings, which were associated with the claims file. The Board additionally requested that the Veteran be afforded new VA examinations for his neck service connection claim, as well as his PTSD and hearing loss claims. Such examinations were held in September and October 2015. Moreover, the Board instructed the RO to confirm with the Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) the dates of the Veteran's in-patient treatment in April 2015. While a letter was not sent to SARRTP, records pertaining to that treatment are now associated with the claims file and, in an August 2015 correspondence, the Veteran confirmed that the Veteran was an inpatient between April 1, 2015 and April 17, 2015. Thus, there is compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Therefore, VA's duty to further assist the Veteran in locating additional records has been satisfied. See 38 U.S.C.A. § 5103A; see also 38 C.F.R. § 3.159 (2015); Wells v. Principi, 327 F. 3d 1339, 1341 (Fed. Cir. 2002). In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issues on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. II. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2015). "To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service treatment records are silent as to any neck injury during service. In a June 2003 private treatment record, it was noted that the Veteran was working at the railroad when he was rear ended by two other locomotives in May 2003. The Veteran stated that he hit his head and did not lose consciousness. He stated that he experienced neck pain thereafter. It was noted that the Veteran had had past back problems and suffered an injury approximately sixteen years earlier where he hurt his lower back. Physical examination revealed normal range of motion. The Veteran's physician, Dr. M.M. stated that the Veteran's MRI scan studies demonstrated some disc bulging in the cervical spine without other abnormalities. Dr. M.M. stated that he believed that the Veteran suffered a whiplash type injury. A September 2006 private treatment record noted that the Veteran reported a history of chronic neck pain since the 1980s. It was noted that the Veteran had been involved in several accidents to include a motor vehicle accident and most recently a 2003 whiplash injury. An MRI demonstrated diffuse degenerative changes in the cervical spine. The Veteran's VA medical center treatment records include an October 2012 record in which he noted that during service a canon swung and hit him in the side of the head causing whiplash. It was noted that the Veteran had two motor vehicle accidents with whiplash and an injury on a locomotive as well. A December 2014 demonstrates that the Veteran's report that he was struck in the side of the head by a cannon during service. At a September 2015 VA examination the Veteran reported neck pain, stiffness and achiness. The VA examiner noted that the Veteran had evidence of a long-standing cervical spine condition. The examiner stated that he could find no specific evidence by way of a review of records or by review of Veteran's own testimony or history that he had an injury while on active military duty which likely accounted for his current cervical spine condition. The examiner noted the Veteran's report that he was struck in the side of the head by the recoil of a cannon or large gun but that the Veteran did not describe the onset of any neck condition relative to that incident as persistent since that timeframe until present. The examiner noted that the Veteran was unable to provide any details and unable to remember any particular details of an incident in which he was knocked down by any specific explosion while on active military duty that caused any specific neck pain. This examiner stated that he was unable to identify any evidence to support the Veteran has had an ongoing neck condition that had its onset while on active military duty that has been persistent since that timeframe until present. The examiner noted the Veteran's post-service injuries to include the 1980 whiplash injury and May 2003 railroad injury which the examiner stated likely resulted in some degree of neck injury as well. The examiner explained that given that the Veteran reported no specific incident of a neck injury with subsequent neck pain which was persistent and which occurred while on active military duty until present, it was less likely as not that the Veteran's currently claimed neck condition and currently diagnosed neck condition are due to or the result of military service. The examiner stated that the Veteran was able to relate history of injuries and incidents including whiplash injury in 1980 and an on-site injury from 2003 which were likely more provocative of his current cervical spine condition. Based on a review of the evidence, the Board concludes that service connection for a neck disability must be denied. The service treatment records do not demonstrate an in-service disability of the neck. Even assuming that the Veteran did sustain an injury as he described in service, it is significant that he is shown to only report symptoms after a 1980 injury. Moreover, as mentioned by the September 2015 examiner, multiple post-service injuries are shown and the VA examiner has stated, following a review of the evidence, that those post-service incidents, are more likely the cause of the Veteran's cervical symptoms. As the 2015 VA examiner's opinion was formed after interviewing and examining the Veteran, and includes a well-reasoned rationale, the Board accords it great probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when there is factually accurate, fully articulated, and sound reasoning for the conclusion, not just from mere review of the claims file). Consequently, the evidence fails to support a finding that the Veteran's cervical disability is related to service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), a determination as to the etiology of neck symptoms, especially where intervening post-service injuries are shown and where the Veteran did not have continuous symptoms, falls outside the realm of common knowledge of a lay person. See Jandreau at 1377 n.4. The Veteran's own assertions as to etiology have no probative value. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for a neck disability is denied. See 38 U.S.C.A §5107 (West 2014). III. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 ; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Increased Rating for PTSD The Veteran contends that he is entitled to a higher disability rating for PTSD due to the severity of his symptoms. The Veteran's service-connected PTSD is currently rated at 50 percent under 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted for 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. A 70 percent rating is warranted for 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for 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. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002); see also Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (explaining that the symptoms that could give rise to a given rating are those in like kind, i.e., of similar duration, severity, and frequency, to those provided in the non-exhaustive lists). The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health- illness." DSM-IV at 32. GAF scores ranging from 61 to 70, for example, reflect 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. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). While not determinative, a GAF score is probative as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). The Board notes that the American Psychiatric Association 's Diagnostic and Statistical Manual for Mental Disorders (DSM-V) no longer utilizes GAF scores. DSM-V is applicable for cases certified to the Board on or after August 4, 2014. This case was certified to the Board in February 2014. At an October 2012 VA examination, the Veteran reported being married and divorced twice with a troubled relationship with his children. The Veteran reported having a female friend. The Veteran reported that he was employed as a locomotive engineer. He reported taking Clonazepam as needed. He described anxiety attacks but that he had not had a panic attack since 2010. Following examination of the Veteran, the examiner assigned GAF scores of 64 for PTSD and 65 for alcohol dependence. The examiner stated that the Veteran's PTSD caused occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress; or symptoms which were controlled by medication. In a May 2013 VA examination, the Veteran reported that he had retired. It was noted that the Veteran had not spoken to one of his daughters in a while, the Veteran reported that he and his female friend continued to maintain contact. The Veteran reported varied use of Clonazepam. The examiner noted that there was no depression, anxiety or other mental symptoms. It was noted that the Veteran's symptoms for PTSD or alcohol dependence did not reach an objective level in which the examiner could note symptoms. The Veteran reported that he had what he believed was an anxiety attack a year prior. The Veteran stated that he thought he had depression, noting that he cried occasionally while watching a move or the Veteran show. Energy levels were reported as alright but since retiring he felt he needed more activity. The Veteran denied suicidal ideation, intent or plan. The Veteran described slight hopelessness or helplessness but not worthlessness. GAF scores of 65 for PTSD and 65 for alcohol dependence were provided. The examiner stated that the Veteran's PTSD caused occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress; or symptoms which were controlled by medication. VA treatment records include an October 2013 report of low motivation; the Veteran explained that he had not socialized with anyone and was being a hermit. Mental status examination revealed good grooming moderate eye contact the Veteran's mood was mildly depressed and anxious and affect was congruent and appropriate with normal range. The Veteran was assigned a GAF of 54. Treatment notes dated in February 2014 noted that the Veteran had finished a PTSD education group the month prior. The Veteran stated that he had relapses of drinking occasionally but had the most sobriety he had since returning from Vietnam over the last eighteen months. The Veteran reported that since his focusing on getting sober, re-experiencing and hyperarousal symptoms had increased. On examination, the Veteran had good grooming and hygiene, normal motor behavior, and good eye contact. Mood was neutral and affect was constricted language and thought was normal. Insight was adequate. There was no suicidality. A March 2014 VA treatment note noted that the Veteran had a relapse of alcohol use but then stopped after five days. The Veteran reported that he medicated himself for his PTSD symptoms with substances. He stated that his capacity for socialization and making age appropriate decisions were impaired but his PTSD and this resulted in lower social functioning over the years. The Veteran's treating physician agreed. The treating physician, Dr. M.D., noted that the Veteran's developmental trajectory was pushed downwards as a result of his traumatic experiences and that it was his opinion that the Veteran had clinically significant decreased capacity to function since he left the military. On examination, the Veteran had good grooming and hygiene, normal motor behavior, and good eye contact. Mood was neutral and affect appropriate, language and thought were normal. Insight was good. In an April 2014 VA mental health treatment note, the Veteran reported complete abstinence from alcohol for an extended period of time. He stated that depression and anxiety had stopped being a problem since that time. It was noted that the Veteran denied suicidal or homicidal ideation, hopeless and helpless feelings, nightmares and flashbacks. The Veteran appeared to be mentally stable and in control of his emotions and behaviors. Affect was appropriate, speech and thought was normal, and insight was good. The treating physician noted that the Veteran was at a good baseline mental state. An August 2014 treatment record noted Veteran had good grooming and hygiene, normal motor behavior and good eye contact. Mood was neutral, and affect, appropriate language, and thought were normal. Insight was adequate. There was no suicidality or homicidality. The Veteran's psychologist stated that the Veteran's symptoms were in the mild to moderate range. Treatment notes demonstrate that the Veteran sought in-patient treatment for substance abuse between April 1, 2015 and April 17, 2015. A nursing note reported that he was having trouble with constipation and did not wish to continue inpatient treatment until that had been resolved. A May 2015 treatment note reported that the Veteran remained clean and sober, he denied suicidal or homicidal ideation, hallucinations and hopeless and helpless feelings. The Veteran reported that he felt mentally stable. He reported a good energy level and concentration. Hygiene was good, eye contact was good and the Veteran's attitude was cooperative mood and affect ere normal as was language and thought. Insight was good, and thought content was optimistic. In an October 2015 VA examination, the examiner stated that the Veteran's level of impairment due to PTSD was best summarized as occupational and social impairment with reduced reliability and productivity. The examiner stated that since his October 2012 examination, there were no changes in social, marital and family history. The Veteran reported living alone with his cat. Symptoms were reported as suspiciousness, chronic sleep impairment and disturbances of motivation and mood. The Veteran was found to be polite and cooperative. He had good eye contact and normal speech and thought process. Mood was slightly down and affect was congruent. There was no suicidal or homicidal ideation. The Veteran was fully oriented. Memory appeared intact, the Veteran had improved insight and judgment. It was noted that the Veteran had a long history of substance and alcohol use and completed residential treatment. The Veteran reported sobriety since April and was followed for PTSD. The Veteran reported taking Paxil, Vistaril and Ambien. Throughout the course of his appeal, the Veteran's PTSD has been manifested by sleep disturbance, anxiety, and social isolation. The Veteran has denied suicidal or homicidal ideation throughout, and grooming and hygiene are noted as good throughout the period on appeal. The Veteran has taken varied amounts of medications with varying regularity for his symptoms. The treatment records and VA evaluations do not show that the Veteran has symptoms manifested by impaired thought processes; obsessional rituals; illogical, irrelevant or obscure speech; near-continuous panic or depression that affects his ability to function independently, appropriately and effectively; impaired impulse control; or spatial disorientation. Moreover, none of the VA treatment records or the VA examination reports indicated that there was any neglect of his personal appearance or hygiene. In fact, the VA examiners prior to the October 2015 examination suggested that the Veteran's level of impairment might be less than that described by the 50 percent rating criteria, and the October 2015 VA examiner noted that the Veteran's PTSD led to occupational and social impairment with reduced reliability and productivity, the level of impairment described in the 50 percent rating criteria. The Veteran is shown to report mental stability in April 2014 and May 2015. The Veteran's GAF scores are shown to demonstrate mild to moderate symptoms. A 50 percent disability rating, when considered alongside the symptoms demonstrated by the record as well as the findings of the VA examiners, is appropriate. While the Veteran is competent to report on his personal knowledge of his symptoms, and his statements are accepted as credible, he is not competent to provide a probative opinion on the severity of such symptoms in relation to the applicable rating criteria. Such is a medically complex matter that requires particular expertise in clinical psychology and psychiatry, which he simply does not possess. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In contrast, the Veteran's VA examinations took into consideration all of the Veteran's subjective complaints, his social and occupational history, and the results of the objective mental status evaluations in determining the overall severity of the manifestations attributed to his service-connected PTSD. In light of the foregoing, the preponderance of the evidence is against a rating higher than 50 percent at any time during the appeal period, there is no doubt to be resolved, and a disability rating in excess of 50 percent for PTSD is not warranted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Temporary Total Rating A total rating (100 percent) will be assigned without regard to other provisions of the rating schedule when it is established that a service-connected disability has required hospital treatment in a Department of Veterans Affairs or an approved hospital for a period in excess of 21 days or hospital observation at Department of Veterans Affairs expense for a service-connected disability for a period in excess of 21 days. Subject to certain provisions, this increased rating will be effective the first day of continuous hospitalization and will be terminated effective the last day of the month of hospital discharge (regular discharge or release to non-bed care) or effective the last day of the month of termination of treatment or observation for the service-connected disability. Notwithstanding that hospital admission was for disability not connected with service, if during such hospitalization, hospital treatment for a service-connected disability is instituted and continued for a period in excess of 21 days, the increase to a total rating will be granted from the first day of such treatment. If service connection for the disability under treatment is granted after hospital admission, the rating will be from the first day of hospitalization if otherwise in order. 38 C.F.R. § 4.29. The basic facts in this case are not in dispute. The Veteran's VA medical center records demonstrate that the Veteran was an in-patient at the SARRTP program for substance abuse, beginning on April 1, 2015. The Veteran is shown, on April 17, 2015 to have voluntarily left the program. The Veteran confirmed these dates in an August 2015 statement. This clearly indicates that the Veteran was admitted on April 1, 2017 and discharged on April 17, 2015. Such in-patient treatment was for a period of less than 21 days. Based on the foregoing, the Board concludes that the Veteran is not legally entitled to a temporary total rating due to hospital treatment in excess of 21 days for a service-connected disability. Where the law and not the evidence is dispositive, the claim must be denied due to lack of entitlement under the law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). As the Veteran was hospitalized for less than 21 days, he is not legally entitled to a temporary total rating. Therefore, a temporary total rating due to hospital treatment in excess of 21 days for a service-connected disability is not warranted. Increased Rating for Hearing Loss Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests together with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1,000, 2,000, 3,000, and 4,000 cycles per second (hertz). To evaluate the degree of disability for service-connected hearing loss, the rating schedule establishes eleven (11) auditory acuity levels, designated from level I for essentially normal acuity through level XI for profound deafness. 38 C.F.R. § 4.85. Examinations are conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). Disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Bruce v. West, 11 Vet. App. 405, 409 (1998), quoting Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). In addition, exceptional patterns of hearing impairment exist for VA purposes when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 hertz) is 55 decibels or more. Then, the rating specialist must determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). The Veteran seeks entitlement to an initial compensable rating for hearing loss. The Veteran had a VA examination for hearing loss in October 2012. The pure tone thresholds, in decibels, were as follows: HERTZ A 500 B 1000 C 2000 D 3000 E 4000 B+C+D+E AVG. RIGHT 10 5 5 60 70 35 LEFT 15 5 15 55 70 36 The pure tone thresholds average was 35 decibels in the right ear and 36 decibels in the left ear. The Veteran's speech recognition was 94 percent in the right ear and 88 percent in the left ear. Applying the foregoing medical evidence to the rating criteria for hearing impairment, the Veteran's right ear is assigned a category I designation and the and left ear is assigned a category II designation under Table VI. 38 C.F.R. § 4.85. These categories correspond with a noncompensable disability rating under Table VII. 38 C.F.R. § 4.85. The claims file includes audiological findings dated in May 2014, however the examining audiologist found that the findings were not adequate for rating purposes and Maryland CNC testing was not employed. Thus these findings will not be considered. See 38 C.F.R. § 4.85. The Veteran had a audiological examination at in September 2015. The pure tone thresholds, in decibels, were as follows: HERTZ A 500 B 1000 C 2000 D 3000 E 4000 B+C+D+E AVG. RIGHT 15 5 5 55 75 35 LEFT 5 5 10 55 65 34 The pure tone thresholds average was 35 decibels in the right ear and 36 decibels in the left ear. The Veteran's speech recognition was 100 percent in the right ear and 100 percent in the left ear. Applying the foregoing medical evidence to the rating criteria for hearing impairment, the Veteran's right ear is assigned a category I designation and the and left ear is assigned a category I designation under Table VI. 38 C.F.R. § 4.85. These categories correspond with a noncompensable disability rating under Table VII. 38 C.F.R. § 4.85. During his examination the Veteran reported trouble hearing the television and some conversations. The Board has considered whether the Veteran's left and right ear hearing loss fell into one of the exceptional patterns that would allow for employment of a different Table under 38 C.F.R. § 4.86(a) or (b) but those criteria are not met. The Board has considered the Veteran's statements and is aware of his complaints about not being able to hear well. It must, however, be reiterated that disability ratings for hearing impairment are derived by a mechanical application of the numeric designations assigned after audiological evaluations are rendered. Lendenmann, 3 Vet. App. at 349. There was no indication that the audiological evaluation produced test results which were invalid. Additionally, the provisions of 38 C.F.R. § 4.86 pertaining to exceptional patterns of hearing loss are not for application as the requirements have not been met. In sum, the evidence shows that the Veteran's hearing loss has not risen to the level of a compensable rating since the award of service connection. As such, the preponderance of the evidence is against the claim for a higher initial schedular rating for bilateral hearing loss; there is no doubt to be resolved; and a higher initial rating is not warranted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102 , 4.3. Other considerations The Board has considered whether referral for extraschedular ratings are appropriate during any period of the appeal for either the Veteran's PTSD or hearing loss. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular ratings 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. See 38 C.F.R. § 3.321(b)(1) (2015); Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the rating 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 rating is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular rating 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." 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 Compensation 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. Here, the Board finds that the first Thun element is not satisfied for the Veteran's PTSD or for his hearing loss. During the pendency of the appeal, the Veteran's service-connected PTSD has been manifested by signs and symptoms such as sleep impairment and anxiety. Hearing loss is manifested by such functional effects as trouble hearing conversations and the television. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). These signs and symptoms, and their resulting impairment, are nevertheless fully consistent with the degree of symptomatology associated with the assigned ratings. The diagnostic codes in the rating schedule corresponding to mental disorders provide disability ratings on the basis of occupational and social impairment, and overall impairment. See, e.g. 38 C.F.R. §§ 4.130, Diagnostic Code 9411. Moreover, the rating criteria for hearing loss provide for higher schedular ratings had greater impairment been demonstrated by objective testing. The Board concludes that the schedular rating criteria reasonably describe the Veteran's disabilities and the Veteran's PTSD and hearing loss are not shown to demonstrate any impairment beyond that considered by the rating criteria. There is nothing exceptional or unusual about the Veteran's PTSD or hearing loss symptoms because the rating criteria reasonably describe his disability levels and symptomatology. Thun, 22 Vet. App. at 115. As the schedular rating criteria reasonably describe the severity and symptoms of the Veteran's PTSD and hearing loss, referral for extraschedular consideration is not required at any time during the pendency of the appeal. Furthermore, the disability picture is not so exceptional to warrant referral even when the Veteran's service-connected disabilities are considered in the aggregate. 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, there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Finally, as noted during his May 2013 VA examination, the Veteran is retired and has not asserted that his service-connected disabilities render him unemployable. This case thus does not raise a claim for a total disability rating based upon individual unemployability. ORDER Entitlement to service connection for a neck injury is denied. Entitlement to an initial rating higher than 50 percent for PTSD, to include entitlement to a temporary total rating under 38 C.F.R. § 4.29, for inpatient treatment is denied. Entitlement to a compensable rating for bilateral hearing loss is denied. REMAND The Board finds that further development is required before the Veteran's peripheral neuropathy claims can be considered by the Board. Specifically, the Veteran should be scheduled for a VA examination to determine the etiology of his peripheral neuropathy of the lower extremities and their relationship to his presumed exposure to Agent Orange in the Republic of Vietnam. The Veteran is not shown to have symptoms of neuropathy in service, however he is shown to have served in Vietnam and a December 2014 treatment note is shown to report a diagnosis of peripheral neuropathy and a notation: "? Agent Orange Exposure." As this may be an indication that neuropathy may be associated with herbicide exposure the Veteran should be afforded a VA examination to determine the nature and etiology of the Veteran's peripheral neuropathy of the bilateral lower extremities.. See McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 C.F.R. § 3.159(a)(1). Turning to the Veteran's claim for service connection for a head injury, in May 2015, the Board requested a VA medical examination in order to determine the etiology of his claimed head injury. In response, the Veteran was afforded multiple examinations. In September 2015, the Veteran was afforded a VA neuropsychiatric examination which included neuropsychological testing. Following a review of the Veteran's test results, a licensed clinical psychologist, J.M., found that the Veteran's testing was likely impacted by a host of factors such as post military head injury while working for the rail road, use of cocaine and narcotic pain medication post military, very serious emotional factors and pain. He noted that the Veteran's data may or may not suggest a diagnosis of mild neurocognitive disorder due to post military head injury, chronic history of cocaine use and narcotic pain medication. Dr. J.M. determined that the Veteran's neuropsychological testing did not relate to the prior history of the claim for TBI in service. The examiner stated that it did not make sense as to "how he functioned all those years and now has symptoms as he did." In an October 2015 VA examination, Dr. T.T. stated that there were no records of injuries to the head outside of the claimed in service injury and that there was no sustained functional impairment of a TBI supported by the evidence. In so finding, Dr. T.T. cited the findings of Dr. J.M. stating that the test results did not relate to the Veteran's service. The Board finds that clarification is necessary regarding the findings of Dr. T.T. Dr. T.T. is unclear as to whether the Veteran has a mild neurocognitive disorder due to post-service events. Further Dr. T.T.'s finding that it did not make sense as to how the Veteran "functioned all those years and now has symptoms as he did" without further explaining what the testing actually demonstrated or stating whether testing was compared with other findings. Given the lack of clarity in the medical findings, the Board would be forced to make a medical determination on these facts alone, which it is not warranted to do. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Thus, the claims file should be returned for clarification. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA neurological examination to determine the nature and etiology of his peripheral neuropathy of the right and left lower extremities. The claims file, including a copy of this remand, must be made available to the examiner, and the examiner should confirm that such records were reviewed. A complete history from the Veteran should be obtained and recorded. The examiner should opine as to the following: Is it at least as likely as not (i.e., a 50 percent or greater probability) that peripheral neuropathy of the right and left lower extremities was caused by or is otherwise related to the Veteran's active service, notably his conceded exposure to Agent Orange in the RVN. A comprehensive rationale must be provided for the opinions rendered. It is not sufficient to conclude that there is no causal nexus between a reported in-service injury and a current disability merely because there is no evidence of in-service medical treatment. 2. Return the claims file to Dr. T.T. in order to get an addendum to his findings explaining what the Veteran's neuropsychiatric testing demonstrated and whether a neurocognitive disorder is shown. If Dr. T.T. is no longer available, schedule the Veteran for an appropriate examination for an opinion on whether it is at least as likely as not (50 percent or greater probability) that he has a head injury or traumatic brain injury (TBI) that was caused by his service. The examiner is asked to review the claims file, and to provide an explanatory rationale for all opinions rendered that cites to evidence in the record and accepted medical knowledge. The examiner is first asked to clarify whether the Veteran has a head injury or TBI. A May 2003 MRI shows some abnormalities. All necessary diagnostic testing should be conducted to make this determination. The examiner is then asked whether any diagnosis is, at least as likely as not, related to service. Although the examiner is required to review the claims file in its entirety, the Board notes that the Veteran served on active duty from July 1968 to February 1971. He entered service with a normal clinical evaluation in May 1968; however, he did report having a history of a head injury. His STRs do not show any head injuries, but this is not dispositive of the inquiry. He has reported that he was hit in the head by a cannon recoil, and that he was also knocked down by an explosion. The examiner is asked to provide medical opinions regarding the etiology of all diagnoses under the assumption that these incidents occurred. Therefore, details of the incidents should be elicited from the Veteran. The Board notes that the Veteran also had an on-the-job injury in May 2003, wherein he hit his head on a train throttle. He reported feeling dazed but not losing consciousness. 3. Thereafter, the issues on appeal should be readjudicated. If any benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative should be provided with a Supplemental Statement of the Case (SSOC) which addresses all evidence submitted, and be afforded the appropriate opportunity to respond thereto. The Veteran has the right to submit additional evidence and argument on the 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 2014). ______________________________________________ A. C. MACKENZIE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs