Citation Nr: 1752431 Decision Date: 11/15/17 Archive Date: 11/22/17 DOCKET NO. 11-27 566 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an evaluation greater than 50 percent prior to July 6, 2015, for posttraumatic stress disorder (PTSD). 2. Entitlement to higher evaluations for residuals of a shrapnel injury to the left buttock with left hip arthritis, status post total left hip replacement rated 10 percent prior to December 6, 2013; 30 percent from February 1, 2015; and 50 percent from July 6, 2015. 3. Entitlement to a compensable rating for bilateral hearing loss. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD D. Barrett, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1966 to July 1967. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Veteran was scheduled for a videoconference Board hearing in February 2014; he later withdrew the request for the hearing. These matters were previously before the Board in September 2014, at which time they were remanded for further development. In subsequent rating decisions from January 2015 and July 2016, the RO increased the rating for residuals of a shrapnel injury to the left buttock with left hip arthritis, status post total left hip replacement, to 100 percent from December 6, 2013 to February 1, 2015, 30 percent from February 1, 2015 to July 6, 2015, and 50 percent thereafter. The RO also increased the rating for PTSD to 50 percent effective from July 17, 2009, to July 6, 2015, and 100 percent thereafter. As these increases do not represent a complete grant of the benefits on appeal, the Veteran's claims for increased ratings for these disabilities remain in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). FINDINGS OF FACT 1. Prior to July 5, 2012, the Veteran's PTSD was productive of occupational and social impairment with reduced reliability and productivity, and difficulty in establishing and maintaining effective work and social relationships. 2. Resolving doubt in the Veteran's favor, from July 6, 2012, PTSD was productive of occupational and social impairment with deficiencies in most areas, but not total impairment. 3. Prior to December 6, 2013, left hip shrapnel injury residuals was manifested by pain and limited motion. 4. The Veteran underwent total left hip replacement surgery on December 6, 2013 and has a 100 percent disability rating from December 6, 2013, to February 1, 2015. 5. From February 1, 2015, to July 6, 2015, the Veteran's status post total left hip replacement resulted in moderate residuals of weakness, pain, and limitation of motion. 6. From July 6, 2015, the Veteran's status post left total hip replacement is productive of no more than moderately severe residuals of weakness, pain, and limitation of motion, without more severe residuals more nearly approximating markedly severe residuals or requiring crutches. CONCLUSIONS OF LAW 1. Beginning July 6, 2012, the criteria for a 70 percent rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2015); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 (2016). 2. The criteria for disability evaluations in excess of 20 percent prior to December 6, 2013; 30 percent from February 1, 2015; and 50 percent from July 6, 2015, have not been met. 38 U.S.C.A. § 1155 (West 2015); 38 C.F.R. § 4.71a, DC 5255-5010, 5054 (2016). 3. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2015); 38 C.F.R. §§ 4.7, 4.85-4.87, DC 6100 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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 (West 2015); 38 C.F.R. § 4.1 (2016). 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; 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 increased rating 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). When there is a proximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2015); 38 C.F.R. § 4.3 (2016). I. PTSD The criteria for evaluating psychiatric disorders (other than eating disorders) are set forth in a General Rating Formula. See 38 C.F.R. § 4.130. The Veteran has been assigned an initial 50 percent rating for PTSD under DC 9411. He maintains that his disability warrants a higher rating. The General Rating Formula for Mental Disorders provides that 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. 38 C.F.R. § 4.130, DC 9411. 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 work like setting); inability to establish and maintain effective relationships. Id. 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. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)(4th ed. 1994); 38 C.F.R. § 4.125. There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. Id.; see also Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). By regulation, the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (4th ed.) (DSM-IV) was applicable when the Veteran submitted the claim for service connection for PTSD at issue in this case. 38 C.F.R. § 4.130. VA regulations have been amended to make DSM-5, which was published by the American Psychiatric Association in 2013, applicable to VA claims effective in August 2014. As the claim at issue in this appeal was submitted many years prior to August 2014, DSM-IV remains applicable. See 79 Fed. Reg. 45,093 (August 4, 2014). A GAF score of 51 to 60 is defined as 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 score of 41 to 50 is defined as serious symptoms or serious impairment of social and occupational functioning. DSM-IV at 47. The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In a February 2010 rating decision, service connection was granted for PTSD and a 50 percent rating was assigned effective July 17, 2009. In a July 2016 rating decision, the RO awarded a 100 percent disability rating, effective July 6, 2015. Based on the review of the record, the Board finds that the criteria for a 70 percent rating are met, but only beginning July 6, 2012. Just prior to the submission of his claim in July 2009, the Veteran was seen at the Nashville VA Medical Center for primary care. A nursing note indicated a PTSD screening test was performed and the results were negative. The Veteran denied having any nightmares, was not constantly on guard, watchful, or easily startled, nor did he feel numb or detached from others, activities, or his surroundings. The Veteran was afforded a VA examination for PTSD in November 2009. The records indicate treatment had been limited to medication for the prior 18 months. The Veteran stated that with his medication, "some days are good, some days are not," and that he hoped to begin group therapy. He described his mood as happy and bored. The Veteran reported being married twice. He was first married from 1970 to 1978 and reported that marriage ended due to his wife's infidelity. They had one son, whom the Veteran raised alone after his wife left. The Veteran reported that he had a great relationship with his son. He reported being married to his current wife for 29 years as of this examination and reported that his relationship with his wife and his two stepchildren was very good. He also reported that his mother-in-law recently moved in with him and his wife and that he was her primary caregiver during the day. The Veteran stated that he enjoyed playing golf (although his medical conditions were making it tougher for him to play), fishing, and being outdoors in general, and that he and his wife also joined a bowling league. He also stated that he and his wife meet a lot of new people who seem friendly but they never become close friends; they were currently "working on developing closer friendships." The examiner opined that the Veteran's current psychosocial functioning was good. He had loving and supportive relationships with his wife and children. He had few friends since moving to Tennessee but was interested and working actively on developing new friendships. He had several hobbies and interests that he enjoyed and that involved social contact. On mental status examination, the examiner found that the Veteran appeared clean, neatly groomed, and casually dressed. His speech was clear and coherent and his attitude was cooperative, friendly, relaxed, and attentive. His affect was flat and his mood was anxious, happy, and good. The examiner also noted that the Veteran was easily distracted. The examiner noted that the Veteran's thought process and content were unremarkable. The Veteran did not suffer from memory problems, hallucinations, panic attacks, homicidal or suicidal thoughts, inappropriate behavior, or obsessive/ritualistic behaviors. He was able to interpret proverbs appropriately and was able to maintain minimum personal hygiene. His extent of impulse control was considered good and there were no episodes of violence. He was fully oriented. The examiner indicated that the Veteran's PTSD symptoms overall were no more than mild to moderate in severity. He did not find total occupational and social impairment or impairment with deficiencies in most areas (e.g. judgement, thinking, family relations, work or mood) to be present, but did find reduced reliability and productivity due to PTSD symptoms. This was manifest by a history of frequent job changes because the Veteran would get into "one of his moods," become angry, and leave the job. The Veteran's ability to concentrate would vary and his temper was out of control. This was evidenced by his incidences of road rage. The examiner assigned the Veteran a GAF score of 61, based on the Veteran's positive relationships with his family, his difficulty establishing new friendships (and attributing that to his recent move to Tennessee from Indiana), and his history of frequent job changes due to his anger problems. A December 2009 psychiatry follow-up note indicated the Veteran began treatment for his PTSD through the Nashville VA Medical Center. This note indicated the Veteran was doing fairly well but that his sleep continued to be fragmented because of sleep apnea and nightmares. The Veteran denied problems with appetite, was compliant with medications, and reported no side effects. He was assigned a GAF score of 50. Social Security Administration (SSA) documentation has also been obtained. The Veteran was denied disability benefits by the SSA in April 2010. On his application filed in November 2008, the Veteran noted that he was being treated for PTSD. A psychiatric review technique was completed by Dr. M.C. in December 2008, who found insufficient evidence to determine a medical disposition. Similarly, a psychiatric review technique completed by Dr. P.V. in February 2009 also concluded there was insufficient evidence to determine a medical disposition. The Veteran was afforded another VA examination for PTSD on July 6, 2015. At the VA examination in the Veteran reported that he had retired from his job at a nursery 3 years ago, because he could not deal his anxiety and also was unable to continue due to his inability to stand for a long time from chronic pain in hip. He noted that he had been a "home body" for the last 3 years due to declining health, increased anxiety, feelings of depression, and not being able to function physically. The Veteran denied having any hobbies; he used to enjoy fishing and playing golf but gave due to physical problems and increasing anxiety and depression. He also noted that in the last few years, he has avoided crowds and very rarely sees his golf buddies. The Veteran further indicated that over the last 3 to 4 years, he had felt depressed, anxious, had sleep problems, nightmares about his war experiences, and avoids crowds. He noted that he continues to have problems with anger, with little provocation and some time he loses his anger on the road and his wife gets scared that he may do some stupid things with other drivers. He has avoided confrontation with other drives and other people so far. He had not received any mental health care treatment in the last few years. On mental status examination, the following symptoms were noted by the examiner: depressed mood, anxiety, panic attacks that occur weekly or less often, near-continuous panic or depression affecting the ability to function, independently, appropriately and effectively; chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting; and an inability to establish and maintain effective relationships. Based on a review of the evidence and the Veteran's entire history, the Board finds that during this period the Veteran's PTSD has manifested with symptoms that more closely approximate the criteria for a 70 percent rating, but only from July 6, 2012. Prior to July 6, 2012, however, the cumulative evidence demonstrates that his symptoms resulted in no worse than moderate occupational and social impairment- consistent with a 50 percent rating. See 38 C.F.R. §§ 4.1, 4.130 (DC 9413); see Fenderson, 12 Vet. App. at 126. Prior to July 6, 2012 the Veteran's PTSD resulted in symptoms that included, but were not limited to: nightmares, social withdrawal, impaired judgment, and anger. The Veteran credibly reported frequent job changes due to his anger as well as experiences of road rage. The Veteran is competent to report his experiences and symptoms and his statements have been considered by the VA primary care clinicians and VA examiners. These symptoms are similar to many of those contemplated by the currently assigned 50 percent rating. In particular, the General Rating Formula lists, inter alia, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work among the types of symptoms associated with a 50 percent rating. 38 C.F.R. § 4.130. Although the 70 percent rating criteria also contemplates impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation, and difficulty in adapting to stressful circumstances (including in work or work-like settings), the Veteran's frequency of anger and inability to effectively maintain work is more closely analogous to that contemplated by his current 50 percent rating. Specifically, while the Veteran reported some anger and loss of concentration, these symptoms have not significantly interfered with occupational or social functioning. The Veteran has been able to maintain productive and meaningful relationships with family and friends. Notably, at the November 2009 VA examination the Veteran reported golfing with friends and that he was the primary caregiver for his mother-in-law during the day. He did not describe any significant impairment in social or occupational functioning due to panic attacks, depression, or similar symptoms. Although he was divorced once, he maintained a significant relationship with his current wife of over 29 years. In addition, he had a great relationship with his children. Moreover, there is little evidence of additional significant symptoms similar to those included in the criteria for 70 percent such as suicidal ideation, obsessional rituals which interfere with routine activities, or speech intermittently illogical, obscure, or irrelevant. For example, at the November 2009 examination his speech was clear and coherent and his personal appearance and hygiene were described as clean and neatly groomed. Throughout this time, the Veteran was also assigned numerous GAF scores, including a 61 at the November 2009 examination and a 50 in a VA psychiatrist note from December 2009. Although a medical professional's classification of the level of psychiatric impairment reflected in the assigned GAF score is probative evidence of the degree of disability, it is not determinative of the rating assigned by VA in evaluating a psychiatric disorder under the rating criteria. See VAOPGCPREC 10-95 (March 31, 1995). Rather, VA must consider all of the Veteran's symptoms and resulting functional impairment as shown by the evidence of record in assigning the appropriate rating, and will not rely solely on the examiner's assessment of the level of disability at the moment of examination. See 38 C.F.R. § 4.126. Here, the record contains two GAF scores from two consecutive months in 2009. An analysis of the entire record supports a rating of 50 percent, highlighted by the Veteran's overall disability picture spanning the entire appeal period while considering the medical professional's opinions and GAF scores. A 70 percent rating is assigned beginning July 6, 2012, and not earlier. This conclusion is primarily based upon the findings in the July 2015 VA examination report. At the VA examination in the Veteran reported that he had retired from his job 3 years ago, because he could not deal his anxiety. He also reported increased social withdrawal from friends and decreased participation in hobbies due to increased anxiety and feelings of depression. The examiner noted that the Veteran's PTSD was manifested with additional symptoms of near-continuous panic or depression affecting the ability to function, independently, appropriately and effectively; chronic sleep impairment, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, including work or a worklike setting; and an inability to establish and maintain effective relationships. Such findings are consistent with a 70 percent rating. The Veteran consistently reported that his symptoms had worsened about three years prior to the examination. Therefore, resolving all reasonable doubt in the Veteran, a 70 percent rating is assigned from July 6, 2012, and no earlier. A 100 percent rating is not assigned for this period as total impairment is not shown. The Veteran was still able to maintain a relationship with his wife and participate in hobbies, even though such was decreased. Total impairment is not shown. II. Left Hip Injury The service-connected left hip shrapnel injury, status post total left hip replacement is currently rated 10 percent prior to December 6, 2013; 30 percent from February 1, 2015, and 50 percent from July 6, 2015. The Veteran's claim for an increased rating of his left hip was received on August 18, 2009. The February 2010 rating decision currently on appeal denied an increased rating in excess of 10 percent. A January 2015 rating decision awarded a temporary 100 percent evaluation based on convalescence for a total left hip replacement from December 6, 2013 to February 1, 2015. From February 1, 2015, to July 6, 2015, the Veteran was assigned a 30 percent rating. A July 2016 rating decision increased the rating to 50 percent effective July 6, 2015. Therefore, there are three distinct periods on appeal. Prior to December 6, 2013, the Veteran's left hip disability was rated as 10 percent disabling under DC 5255-5010 for impairment of femur of the hip and thigh. A 10 percent evaluation was assigned for painful or limited motion of a major joint. Under DC 5010 (for rating traumatic arthritis) 10 percent evaluation is assigned for painful or limited motion of a major joint or group of minor joints and may also be applied once to multiple joints if there is no limited or painful motion A 20 percent evaluation is not warranted unless X ray evidence shows involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5010. The provisions of 38 C.F.R. § 4.71a, DC 5250 to 5255, provide the criteria for rating hip and thigh disabilities. Normal range of motion for the hip is to 125 degrees of flexion, to zero degrees of extension, and to 45 degrees of abduction. 38 C.F.R. § 4.71, Plate II (2016). DC 5250 provides ratings ranging from 60 percent to 90 percent for hip ankylosis and DC 5254 provides an 80 percent rating for flail joint of the hip. 38 C.F.R. § 4.71(a), DC 5250, 5254. However, the Veteran does not have ankylosis or flail joint of the hip, so DC 5250 and 5254 are not applicable in his case. Under DC 5255, for impairment of the femur, malunion of the femur with slight knee or hip disability warrants a 10 percent evaluation. Malunion of the femur with moderate knee or hip disability warrants a 20 percent evaluation. Malunion of the femur with marked knee or hip disability warrants a 30 percent evaluation. Fracture of surgical neck of the femur, with false joint or fracture of the shaft or anatomical neck of the femur with nonunion, without loose motion, weight bearing preserved with aid of brace warrants a 60 percent evaluation. Fracture of the shaft or anatomical neck of the femur with nonunion, with loose motion (spiral or oblique fracture) warrants an 80 percent evaluation. Id. The terms "moderate" and "marked" are not defined in the VA Schedule. Rather than applying a mechanical formula, it is incumbent upon the Board to arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6. Terminology such as "moderate" and "marked" used by VA examiners and others, although an element of evidence to be considered by the Board, are not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Under DC 5253, a 10 percent is warranted for limitation of rotation of the affected leg (with an inability to "toe-out" more than 15 degrees), or for limitation of adduction causing an inability to cross legs; and a 20 percent rating is warranted for limitation of abduction resulting in motion lost beyond 10 degrees. 38 C.F.R. § 4.71a, DC 5253. For limitation of extension of the thigh, where extension is limited to 5 degrees, a maximum 10 percent evaluation is assigned. 38 C.F.R. § 4.71a, DC 5251. For limitation of flexion of the thigh, where flexion is limited to 45 degrees, a 10 percent evaluation is assigned; where flexion is limited to 30 degrees, a 20 percent evaluation is assigned; where flexion is limited to 20 degrees, a 30 percent evaluation is assigned; and where flexion is limited to 10 degrees, a 40 percent evaluation is assigned. 38 C.F.R. § 4.71a, DC 5252. 1. Rating in excess of 10 percent prior to December 6, 2013. In a Statement in Support of Claim filed in August 2009, the Veteran asserted that over time the pain and use of his hip had gotten worse, to the point where a doctor had put him on pain medication. He asserted that he tried not to take too much, but on some days he had no choice. In a September 2009 Statement in Support of Claim, the Veteran reported that radiology reports and medical records from the Murfreesboro VA Medical Center would show an increase in severity of the residuals from his shrapnel injury to the left buttocks and the left hip arthritis. Records from the Murfreesboro VA Medical Center have been obtained. In September 2009 X-rays of the hip showed significant narrowing of the superior lateral hip joint space. A radiologist diagnosed moderately severe osteoarthritis in the left hip joint superiorly and that subchondral lucency in the femoral head was likely related to the osteoarthritis. An October 2009 medical record from the Nashville VA Medical Center indicates the Veteran had an orthopedic surgery consult with Dr. J.M. for his left hip. The pain was described as constant and bothersome. The Veteran's activities, such as bowling and golfing, were considerably limited. He was also bothered by the hip pain at night when he tried to sleep. The Veteran did not respond to the usual anti-inflammatories or pain medications. The physician noted that the Veteran had been in excellent health but with mild obesity. The orthopedic examination of the lower extremities revealed excellent function of all joints except to the left hip. There was an inability to cross the left leg over the right when he was sitting and there was a severe lack of motion in abduction and external rotation. Flexion was accomplished to 70 to 80 degrees in the left hip. The Veteran's right hip was normal. The Veteran was referred for consideration of total hip replacement. The Veteran was afforded a VA examination in November 2009. He reported pain with prolonged walking or standing. He reported that he was able to stand between 15 to 30 minutes and walk greater than 1/4 of a mile, but less than one mile. Objectively, his gait was observed to be normal without evidence of abnormal weight bearing. Hip range of motion showed left flexion was 0-115 degrees, left extension was 0-30 degrees, and left abduction was 0-45 degrees. The Veteran was able to cross his left leg over his right leg but he could not move his toes out to greater than 15 degrees. There was no objective evidence of pain with active motion and none following repetitive motion. There were subjective complaints of pain, but no joint ankylosis, deformity no giving way, instability, weakness, stiffness, incoordination, dislocation, subluxation, or effusion. X rays of the left hip demonstrated moderately severe osteoarthritis of the left hip joint. The diagnosis was degenerative joint disease in the left hip. Given the evidence of record, the Board finds that the Veteran's left hip disability does not warrant a higher rating prior to December 2013. For this appeal period, the evidence shows that the left hip osteoarthritis was manifested by limited motion with left hip flexion limited to no more than 115 degrees, extension limited to no more than 30 degrees, and left hip abduction limited to no more than 45 degrees. In October 2009, left hip adduction was limited such that the Veteran was unable to cross his legs. This is consistent with a 10 percent rating under DC 5253. Thus, under the regular rating schedule for a natural joint, Diagnostic Codes 5251-5253, the degree of functional limitation shown does not warrant a rating in excess of 10 percent. Although the Veteran he competently reported pain after prolonged walking or standing, he was able to perform repetitive testing without pain. The Board considered whether a higher rating is warranted based on functional impairment or due to pain, but finds that the current 10 percent rating already contemplates pain in the affected left hip joint. Accordingly, the criteria for a higher 20 percent rating based on limitation of flexion, even with consideration of pain, are not met. A rating in excess of 10 percent under DC 5255 for the left hip osteoarthritis is not warranted. The evidence shows no left hip ankylosis, flail joint, or any impairment of the femur was demonstrated. The Veteran is also not shown to have had a left hip replacement during this appeal period. See 38 C.F.R. § 4.71a, Diagnostic Codes 5250, 5254, 5255 and 5054. 2. Rating in Excess of 30 percent from February 1, 2015 to July 6, 2015. Medical records from the Cookeville Regional Medical Center show the Veteran underwent a total left hip replacement surgery on December 6, 2013. VA treatment records indicate the Veteran was seen on December 9, 2014, where it was noted that he was healed and fully recovered. As noted, a 100 percent evaluation was assigned from December 6, 2013, the date of the surgery, to January 31, 2015, the last day of the month following one-year after implantation of the prosthesis. A 30 percent evaluation was assigned for the Veteran's post-prosthetic replacement, effective February 1, 2015 under 38 C.F.R. § 4.71a, DC 5054 for hip replacement. As noted, under DC 5054, a 100 percent rating is assigned for hip replacement (prosthesis) with prosthetic replacement of the head of the femur or of the acetabulum for one year following implantation of prosthesis. After one year, the hip disability is rerated with the minimum rating assignable being 30 percent. A 50 percent rating is assigned when there are moderately severe residuals of weakness, pain, or limitation of motion. A 70 percent rating is assigned when there is markedly severe residual weakness, pain or limitation of motion following implantation of prosthesis. A 90 percent rating is assigned following implantation of prosthesis, when there is painful motion or weakness in the hip such as to require the use of crutches. 38 C.F.R. § 4.71a, DC 5054. The Veteran was afforded a VA examination for his hip in November 2014. Range of motion testing showed left flexion to 110 degrees, left extension to 30 degrees, and left abduction to 45 degrees. The Veteran was able to cross his legs. External rotation was limited to 40 degrees and internal rotation was limited to 30 degrees. There was no objective evidence of pain on the exam, including with weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional loss of function or range of motion after three repetitions. The Veteran was examined immediately after repetitive use over time. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time. The Veteran did not report any flare-ups. All muscle strength was normal (5/5) for flexion, extension, and abduction. The Veteran did not have malunion or nonunion of femur, flail hip joint, or leg length discrepancy. The examiner noted that the total hip replacement with residuals contributed to the mild decreased range of motion. No other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions were found. The Veteran regularly used a brace or cane to assist as a normal mode of locomotion. For this appeal period a rating in excess of 30 percent is not warranted for the left hip disability. At the November 2014 VA examination the Veteran had only minimal limitation in range of motion, full strength on flexion, extension, and abduction, and no pain. These findings are consistent with the 30 percent rating currently assigned under DC 5054. A rating in excess of 30 percent under DC 5054 is not warranted because the evidence does not show moderately severe residuals of weakness, pain, or limitation of motion. The Veteran's strength was 5/5 for flexion, extension, and abduction. His range of motion was only slightly limited on flexion to 110 degrees, but was normal on extension, abduction, and adduction. As noted, the Veteran had no pain or flare-ups. The Board has considered evaluating the Veteran's left hip disability under other pertinent diagnostic codes, but none are applicable because there is no objective evidence of ankylosis, flail joint, or impairment of the femur. See 38 C.F.R. § 4.71a, Diagnostic Codes 5250, 5254, 5255. 3. Rating in Excess of 50 percent from July 6, 2015. The Veteran was afforded a VA examination in July 2015. He denied flare-ups of the hip or thigh and having any functional loss or functional impairment of the hip joint. The Veteran reported occasional use of a cane when he left muscles become very sore. On objective examination, left hip range of motion was as follows: flexion to 105 degrees (125 being normal), extension to 30 degrees (normal), abduction to 30 degrees (45 being normal), and adduction to 20 degrees (normal). External rotation was limited to 40 degrees (60 being normal) and internal rotation was limited to 30 degrees (40 being normal). No pain was noted during the range of motion exercise; however, there was evidence of pain with weight bearing. The Veteran was examined immediately after repetitive use over time and no pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time. Left hip strength was found to normal 5/5 in flexion, extension, and abduction. There was no reduction in muscle strength and no muscle atrophy. The Veteran had no malunion or nonunion of femur, flail hip joint, or leg length discrepancy. He had scars but none were painful or unstable, or had a total area equal to or greater than 39 square cm (6 square inches). The examiner opined that the Veteran suffered moderately severe residuals of weakness, pain, or limitation of motion following his total hip joint replacement. A rating in excess of 50 percent under DC 5054 is not warranted because the evidence shows no markedly severe residual weakness, pain, or limitation of motion following implantation of prosthesis. The Veteran's strength was still normal at 5/5 for flexion, extension, and abduction. The Veteran had no pain during range of motion or flare-ups, although there was pain on weight bearing and pain on the lateral mid-thigh. His flexion was limited to 105 degrees, more than the last examination. Additional limitations were noted that were not on the prior examination, including limitation in abduction to 30 degrees, external rotation to 40 degrees, and internal rotation to 30 degrees. However, extension and adduction were still normal. None of the limitations were severe, as each was within 10 degrees of normal. For this period on appeal, the evidence shows that the left hip was manifested by no more than moderately severe residuals of weakness, pain, or limitation of motion. Therefore, a 50 percent rating, and no higher, is warranted from July 6, 2015. III. Hearing loss A July 2006 rating decision granted service connection for hearing loss and assigned a noncompsenable rating. In July 2009 the Veteran filed a claim for an increased rating. The Veteran was afforded VA examinations in August 2009, November 2009, and April 2016. At the August 2009 examination, the Veteran reported his hearing loss causes difficulty when he is trying to communicate, and specifically hearing women's voices. Puretone thresholds (in decibels) and speech discrimination scores were as follows: HERTZ CNC 1000 2000 3000 4000 Avg % RIGHT 10 25 45 65 36 96 LEFT 10 35 60 70 44 92 Under TABLE VI, the right ear is assigned a Level I and the left ear is assigned a Level I. Entering these numeric designations into TABLE VII yields a 0 percent rating. 38 C.F.R. § 4.85, DC 6100. At the November 2009 examination, puretone thresholds (in decibels) and speech discrimination scores were as follows: HERTZ CNC 1000 2000 3000 4000 Avg % RIGHT 15 25 50 65 39 96 LEFT 15 40 55 65 44 90 Under TABLE VI, the right ear is assigned a Level I and the left ear is assigned a Level II. Entering these numeric designations into TABLE VII yields a 0 percent rating. 38 C.F.R. § 4.85, DC 6100. At the April 2016 examination, the Veteran reported a decrease in hearing since his last VA examination. Puretone thresholds (in decibels) and speech discrimination scores were as follows: HERTZ CNC 1000 2000 3000 4000 Avg % RIGHT 25 35 55 70 46 98 LEFT 15 40 60 60 44 96 Under TABLE VI, the right ear is assigned a Level I and the left ear is assigned a Level I. Entering these numeric designations into TABLE VII yields a 0 percent rating. 38 C.F.R. § 4.85, DC 6100. Based on the audiological evaluations of record, the Veteran's hearing loss has not approximated the criteria for a rating in excess of 0 percent at any time during the appeal period. Though the Board does not discount the difficulties the Veteran has with his hearing acuity, schedular disability ratings for hearing loss are based on the results of the audiological studies of record. Lendenmann v. Principi, 3 Vet. App. 345, 349(1992) ("Assignment of 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."). Moreover, the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday social and work environment as these are the effects that VA's audiometric tests are designed to measure. Doucette v. Shulkin, 28 Vet. App. 366 (2017). As the preponderance of the evidence is against the Veteran's claim; the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. There are no additional expressly raised or reasonably raised issues raised on the record. ORDER From July 6, 2012, a 70 percent rating, and no higher, for PTSD is granted. Higher evaluations for residuals of a shrapnel injury to the left buttock with left hip arthritis, status post total left hip replacement rated 10 percent prior to December 6, 2013; 30 percent from February 1, 2015; and 50 percent from July 6, 2015 are denied. A compensable rating for bilateral hearing loss is denied. ____________________________________________ D. JOHNSON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs