Citation Nr: 1752564 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 13-02 454 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for sleep apnea. 2. Entitlement to service connection for lumbar sprain. 3. Entitlement to service connection for right hip condition. 4. Entitlement to service connection for left hip condition. 5. Entitlement to service connection for right ankle condition. 6. Entitlement to service connection for left ankle condition. 7. Entitlement to service connection for tracheostomy scar. 8. Entitlement to service connection for cervical spine condition. 9. Entitlement to a compensable initial rating for bilateral hearing loss. 10. Entitlement to service connection for right knee condition. 11. Entitlement to service connection for left knee condition. REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD Bridgid D. Houbeck, Counsel INTRODUCTION The Veteran served on active duty from August 1972 to August 1974 in the United States Army and from September 2003 to March 2004, from April 2005 to October 2005, and from December 2005 to May 2006 in the United States Air Force. This included service in Southwest Asia (Kuwait) from May 2005 to September 2005. He also had additional service in the Air National Guard of Puerto Rico. This matter comes to the Board of Veterans' Appeals (Board) on appeal from June 2011 and February 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. The June 2011 rating decision granted service connection for bilateral hearing loss and denied service connection for lumbar sprain and sleep apnea. The Veteran filed a notice of disagreement in July 2011. In August 2014 the RO issued a statement of the case. The Veteran perfected his appeal with an August 2014 VA Form 9. The February 2012 rating decision denied service connection for right knee condition, left knee condition, tracheostomy scar, right hip condition, left hip condition, right ankle condition, left ankle condition, and multilevel degenerative changes of the cervical spine associated with left neural foramina narrowing at C3-C4, C4-C5, and C5-C6 by x-rays, multilevel disc space narrowing with osteophytotic changes of the cervical spine, and muscle spasms of the cervical spine all claimed as cervical condition. The Veteran filed a notice of disagreement in March 2012. In December 2012 the RO issued a statement of the case. The Veteran perfected his appeal with a January 2013 VA Form 9. The issues of service connection for bilateral knee conditions are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's current sleep apnea had onset during his active service. 2. The Veteran's lumbar sprain is the result of related to a lifting injury during service with the Air National Guard of Puerto Rico. 3. The Veteran has not had a right hip condition for VA purposes at any time from contemporaneous to when he filed his claim to the present 4. The Veteran has not had a left hip condition for VA purposes at any time from contemporaneous to when he filed his claim to the present 5. The Veteran's right ankle condition did not have onset during active service and was not caused by his active service. 6. The Veteran's left ankle condition did not have onset during active service and was not caused by his active service. 7. The Veteran's tracheostomy scar did not have onset during and is not the result of his active service. 8. The Veteran's cervical spine condition did not have onset during and is not the result of his active service; cervical spine arthritis did not manifest within one year of separation from active service. 9. The Veteran's bilateral hearing loss has been manifested by not worse than Level I hearing impairment in either ear. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea have all been met. 38 U.S.C. §§ 1110, 1131 (2014); 38 C.F.R. §§ 3.303 (2017). 2. The criteria for service connection for lumbar sprain have all been met. 38 U.S.C. §§ 1110, 1131 (2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 3. The criteria for service connection for right hip condition have not all been met. 38 U.S.C. §§ 1110, 1131 (2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 4. The criteria for service connection for left hip condition have not all been met. 38 U.S.C. §§ 1110, 1131 (2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 5. The criteria for service connection for right ankle condition have not all been met. 38 U.S.C. §§ 1110, 1131 (2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 6. The criteria for service connection for left ankle condition have not all been met. 38 U.S.C. §§ 1110, 1131 (2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 7. The criteria for service connection for tracheostomy scar have not all been met. 38 U.S.C. §§ 1110, 1131 (2014); 38 C.F.R. §§ 3.303 (2017). 8. The criteria for service connection for cervical spine condition have not all been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131 (2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 9. The criteria for a compensable initial rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.85, 4.86, Diagnostic Code 6100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection - Generally 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. §§ 1110, 1131 (2014); 38 C.F.R. § 3.303(a) (2017). "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). Active service includes active duty; any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty for training (IDT) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty; or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C. § 101 (24); 38 C.F.R. § 3.6. In the case of members of the National Guard or Air National Guard of any State, ACDUTRA means full-time duty under section 316 (details of members of Army National Guard for rifle instruction of civilians), 502, 503, 504, or 505 of title 32 [32 U.S.C. §§ 316, 502, 503, 504, or 505], or the prior corresponding provisions of law. 38 U.S.C. § 101 (22). Similarly, IDT means duty (other than full-time duty) under sections 316, 502, 503, 504, or 505 of title 32 [32 U.S.C. §§ 316, 502, 503, 504, or 505], or the prior corresponding provisions of law, but does not include (i) work or study performed in connection with correspondence courses, (ii) attendance at an educational institution in an inactive status, or (iii) duty performed as a temporary member of the Coast Guard Reserve. 38 U.S.C. § 101 (23). Certain chronic diseases, including arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112 (2014); 38 C.F.R. §§ 3.307, 3.309(a) (2017). This presumption only applies to periods of active duty and not to the Veteran's active duty training (ACDUTRA) or inactive duty training (IDT) because, by definition, the presumption of service connection applies where there is no evidence that a condition began in or was aggravated during the relevant period of service. With regard to a claimant whose claim is based solely on a period of ACDUTRA or IDT, however, there must be some evidence that the condition was incurred or aggravated during the relevant period of service. See Smith v. Shinseki, 24 Vet. App. 40, 45 (2010). A compensable (10 percent) degree of arthritis requires establishment of arthritis by x-ray findings and limitation of motion objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. §4.71a, Diagnostic Code 5003. With regard to these presumptive disabilities, service connection for may also be established by a continuity of symptomatology, not necessarily continuity of treatment, between a current disorder and service. Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991); see also 38 C.F.R. § 3.303; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran is a Persian Gulf Veteran within the definition of 38 C.F.R. § 3.317 as a result of his documented service in Southwest Asia. See 38 C.F.R. § 3.2 (i). As a Persian Gulf Veteran, the Veteran may be entitled to compensation if he "exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of [38 C.F.R. § 3.317]" which have manifested to a compensable degree either in service or no later than December 31, 2016, and such symptomatology "by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis." 38 C.F.R. § 3.317. Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving the skin, muscle or joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, and gastrointestinal signs or symptoms. 38 C.F.R. § 3.317 (a), (b). A qualifying chronic disability means a chronic disability resulting an undiagnosed illness; a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms (chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, or any other illness that the Secretary determines meets the criteria), or any diagnosed illness that the Secretary determines warrants a presumption of service-connection. 38 C.F.R. § 3.317 (a)(2)(i). A "medically unexplained chronic multisymptom illness" is a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). "Objective indications of chronic disability" include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period are considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(4). By definition, section 1117 only provides compensation for symptoms of a chronic disability that have not been attributed to a "known clinical diagnosis." 38 C.F.R. § 3.317 (a)(1)(ii). II. Service Connection - Sleep Apnea The Veteran was diagnosed with severe obstructive sleep apnea following a sleep study in February 2008. He was subsequently medically discharged from the Air National Guard of Puerto Rico due to this condition in December 2009. The Veteran was not serving on active duty, active duty for training (ACDUTRA), or inactive duty for training (IDT) at the time of this initial diagnosis. The Veteran has related this condition to exposure to environmental toxins and/or to heavy snoring in-service. Specifically, the Veteran reported exposure to chemical agents, asbestos, deplete uranium, and the anthrax vaccine. The record shows that the Veteran served in Southwest Asia. With regard to his reported in-service snoring, the Veteran reported episodes of snoring and hypersomnolence beginning in 2006. In his September 2005 post-deployment health assessment, the Veteran reported that during this deployment he developed the symptom of still feeling tired after sleeping (hypersomnolence). This confusion regarding the date of his deployment during which these symptoms started does not impact the credibility of his underlying assertion that these symptoms began during a deployment. In his October 2010 Gulf War Guidelines examination, the Veteran stated that his sleep apnea began while in service in 2001 and manifested as heavy snoring and daytime hypersomnolence. He attributed a car accident six years earlier to this hypersomnolence. This examiner offered a confusingly circular opinion, stating that "if the medical condition has been associated to exposure to environmental hazards experienced during military service in Southwest Asia then as likely as not can be related to his Gulf War period of service." The initial "if" is in essence the crux of the question posed. Therefore, this statement is of no probative value. The Veteran underwent another Gulf War Guidelines examination in March 2011. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation, then offered an opinion as to the nature of the claimed disability, accompanied by a rationale. Therefore, this examination is adequate for VA purposes. This examiner noted that sleep apnea was a diagnosable chronic multi symptom illness with a partially explained etiology. Thus, this is not an undiagnosed illness or medically unexplained chronic multisymptom illness subject to 38 C.F.R. § 3.317. This examiner further state that there was no conclusive evidence in the medical literature that sleep apnea had a possible etiological relationship with specific exposure event experienced by the veteran during his service in Southwest Asia. Ultimately, this examiner found that it was not likely that the Veteran's sleep apnea was caused by or the result of a specific exposure event experienced by veteran during his service in Southwest Asia. In February 2012 the Veteran underwent a VA sleep apnea examination. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation, then offered an opinion as to the nature of the claimed disability, accompanied by a rationale. Therefore, this examination is adequate for VA purposes. This examiner found that the Veteran's sleep apnea was at least as likely as not related to complaints noted in military service. This examiner noted that sleep apnea caused poor sleep and daytime tiredness, making it difficult to concentrate, work, or drive. As all three elements of service connection have been met, service connection is warranted for sleep apnea and the appeal as to this issue must be granted. III. Service Connection - Lumbar Spine The March 2011 VA examiner diagnosed the Veteran with lumbar sprain and L5-S1 bulging disc. During his annual training with the Air National Guard of Puerto Rico in April 1986, the Veteran injured his back while performing heavy lifting work. He complained of back pain radiating down his left leg. A line of duty determination found that this injury was occurred in the line of duty. As this injury was found to be in the line of duty, it can form the basis for service connection. Ultimately the March 2011 VA examiner found that the Veteran's current lumbar sprain and L5-S1 bulging disc was at least as likely as not the result of his heavy lifting injury during service, noting the line of duty determination and stating that heavy lifting injuries are known to cause lumbar sprain and bulging discs. Similarly, in a June 2011 letter, the Veteran's private doctor stated that it was more probable than not that his back problems were due to his in-service heavy lifting accident. She stated that this accident caused chronic inflammatory problems with subsequent degenerative changes. Problems of bad posture loss of correct alignment and loss of curvature of cervical thoracic and lumbar lordosis were also present putting more weight on one side of the vertebra than the other causing disc bulging and herniation and problems of radiculopathy or neuropathy. As all three elements of service connection have been met, service connection for lumbar sprain and L5-S1 bulging disc is warranted. Hence, the appeal as to this issue must be granted. IV. Service Connection - Bilateral Hips The Veteran is also seeking service connection for a bilateral hip condition. The dispositive matter as to this claim is whether the Veteran has had the claimed disability during the course of the claim and appeal. "In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Further, the requirement of a current disability is satisfied if the disability existed at the time a claim of filing of VA disability compensation or during the pendency of that claim, even if the disability resolved prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). A diagnosis dated prior to the filing of a claim is relevant evidence in determining whether a current disability existed at the time the claim was filed or while the claim was pending, and it may support the existence of a current disability at the time of claim filing if it was close enough in time under the circumstances of the case. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). Here, the Veteran reported that his back pain radiated down his hips. The record, however, does not contain a medical diagnosis of a right or left hip condition. Instead, the February 2012 VA examiner found normal hips on clinical examination and x-rays. No hip pathology was found. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation. Therefore, this examination is adequate for VA purposes. Ultimately, the record shows that the Veteran does not currently have a right and/or left hip condition. The February 2012 examiner noted the Veteran's report of bilateral hip pain that he referred to as sciatica. He denied any history of hip trauma and had no sick call visits due to hip pain. Clinical examination was normal. X-rays revealed no bone pathology in either hip. Range of motion testing showed full range with no objective evidence of painful motion. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation, then offered an opinion as to the nature of the claimed disability, accompanied by a rationale. Therefore, this examination is adequate for VA purposes. The record does not contain a medical diagnosis of a right and/or left hip condition. Likewise, while the Veteran is competent to report hip pain, the record does not suggest that the Veteran has the requisite knowledge or skill to render his reports of hip pain more probative than the February 2012 VA examiner's findings. As such, the weight of the evidence is against a finding of a current right and/or left hip condition. While joint pain may be a symptom of undiagnosed illness, the record does not confirm joint pain in the hips. By his own account, the Veteran has stated that any hip pain experienced radiates from his back pain. Thus, the record does not establish a finding of an undiagnosed condition for which the Veteran could be entitled to service connection based on his service in Southwest Asia. In the absence of evidence that the Veteran currently has a right and/or left hip condition, there can be no award of service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer, 3 Vet. App. 223, 225 (1992). In this case, the preponderance of evidence is against a finding that the Veteran has had a disability of either hip at any time from contemporaneous to when he filed his claim to the present. Consequently, service connection for neither a right nor left hip condition is warranted. V. Service Connection - Bilateral Ankles The Veteran alleges bilateral ankle conditions and claims the conditions are due to service. During the pendency of this appeal, the Veteran has been diagnosed with bilateral arthritic changes ankle mortise and calcaneal enthesopathy. See February 2012 VA examination. Nevertheless, the record does not include any x-ray evidence of ankle arthritis from within one year of the Veteran's separation from active duty service in August 1974. Instead, the first record of this diagnosis of arthritis was several decades later. As such, service connection on a presumptive basis is not warranted. See 38 C.F.R. § 3.307 (a)(3). Thus, the Board will now address whether service connection on a direct basis is warranted. The Veteran's service treatment records are silent with regard to any ankle injury. Although he had a documented low back injury with complaints of pain radiating to his left leg, this record does not suggest any concurrent ankle injury. The Veteran underwent a VA examination in conjunction with this claim in February 2012. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation, then offered an opinion as to the nature of the claimed disability, accompanied by a rationale. Therefore, this examination is adequate for VA purposes. This examiner found that the Veteran's claimed bilateral ankle conditions were not at least as likely as not etiologically related to the Veteran's active military service, noting that his service treatment records were silent with regard to any ankle complaints and there were no complaints of any such condition within a year after his separation. Any in-service ankle condition was acute and transitory. The record does not include a positive medical nexus opinion. Again, although the Veteran has linked his ankle conditions to service, he has described this as sciatica radiating from his lumbar spine disability. This etiology does not account for the current diagnoses of arthritis and the medical records do not show bilateral ankle symptoms attributable to lumbar radiculopathy. Thus, there is no competent evidence to refute the February 2012 VA examiner's findings. The preponderance of evidence is against service connection for a right and/or left ankle condition and the appeal must be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. VI. Service Connection - Scar The Veteran is also seeking service connection for a neck scar. Records during the appeals period confirm that the Veteran has such a scar. The record includes an operation report from April 20, 2002 for a tracheotomy. This was performed due to airway obstruction and deep neck infection. The April 2002 surgery was not during a period of active duty, ACDUTRA, or IDT. Likewise, his service treatment records do not show complaints of or treatment for a deep neck infection during active service. The Veteran underwent a February 2012 VA examination in connection with this claim. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation, then offered an opinion as to the nature of the claimed disability, accompanied by a rationale. Therefore, this examination is adequate for VA purposes. The February 2012 VA examiner found that the Veteran's neck scar was not at least as likely as not etiologically related to the Veteran's active military service, noting that this scar was produced by a tracheostomy done on April 20, 2002 due to a neck abscess. Based on the above, the Veteran's current neck scar has been related to the April 2002 surgery, but that surgery has not been related to the Veteran's active service. Thus, the preponderance of evidence is against service connection for a neck scar. Thus, the appeal must be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. VII. Service Connection - Cervical Spine The Veteran is also seeking service connection for a cervical spine condition. During the pendency of this appeal, the Veteran has been diagnosed with multiple cervical spine conditions, including multilevel degenerative changes associated with left neural foramina narrowing at C3-C4, C4-C5, and C5-C6, multilevel disc space narrowing with osteophytosis changes, and muscle spasm. See February 2012 VA examination. Although this includes a diagnosis of arthritis, the record does not include any x-ray evidence from within one year of the Veteran's separation from active duty service in August 1974. Instead, the first record of this diagnosis of arthritis was several decades later. As such, service connection on a presumptive basis is not warranted. See 38 C.F.R. § 3.307 (a)(3). Thus, the Board will now address whether service connection on a direct basis is warranted. The Veteran's service treatment records are silent with regard to any cervical spine injury. Although he had a documented low back injury with complaints of pain radiating to his left leg, this record does not suggest any concurrent neck or cervical spine injury. The Veteran underwent a VA examination in conjunction with this claim in February 2012. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation, then offered an opinion as to the nature of the claimed disability, accompanied by a rationale. Therefore, this examination is adequate for VA purposes. This examiner found that the Veteran's claimed cervical spine condition was not at least as likely as not etiologically related to the Veteran's active military service, noting that his service treatment records were silent with regard to a cervical spine condition. There was documentation of a heavy lifting injury to his back (lumbar spine) during an annual training in April 1986, but there was no mention of a neck or cervical spine condition at that time. There was no evidence of treatments or complaints due to cervical spine condition until several years after service, which pointed to any in-service neck symptoms as acute and transitory. The current cervical or neck condition was due to the natural process of aging. The record does not include a positive medical nexus opinion. To the extent that the Veteran associates his current cervical spine condition to his in-service lumbar spine injury, the Veteran himself, at the time of his February 2012 VA examination, reported an onset of cervical pain one to one and a half years after his documented low back injury. This is not the type of immediately lay observable cause-and-effect relationship that would render the Veteran's lay etiological opinion competent. Thus, there is no competent evidence to refute the February 2012 VA examiner's findings. The preponderance of evidence is against service connection for a cervical spine condition and the appeal must be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. VIII. Increased Initial Rating - Bilateral Hearing Loss The Veteran was originally granted service connection for bilateral hearing loss in the June 2011 rating decision on appeal. At that time this disability was rated noncompensable (0 percent) effective February 1, 2010. In an August 2014 rating decision, the RO granted an earlier effective date of December 31, 2009, but did not alter the rating assigned. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Ratings for hearing loss disability are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level, in decibels (dB) as measured by pure tone audiometric tests in the frequencies 1,000, 2,000, 3,000 and 4,000 Hertz (Hz). 38 C.F.R. § 4.85, Diagnostic Code 6100. An examination for hearing impairment for VA purposes must include a controlled speech discrimination test (Maryland CNC). Id. To evaluate the degree of disability from defective hearing, the rating schedule requires assignment of a Roman numeral designation, ranging from I to XI. Other than exceptional cases, VA arrives at the proper designation by mechanical application of Table VI, which determines the designation based on results of standard test parameters. Id. Table VII is then applied to arrive at a rating based upon the respective Roman numeral designations for each ear. Id. Exceptional patterns of hearing impairment allow for assignment of the Roman numeral designation through the use of Table VI or an alternate table, Table VIA, whichever is more beneficial to the Veteran. 38 C.F.R. § 4.86. This applies to two patterns. In both patterns each ear will be evaluated separately. Id. The first pattern is where the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hz) is 55 dB or more. 38 C.F.R. § 4.86(a). The second pattern is where the pure tone threshold is 30 decibels or less at 1000 Hz and 70 dB or more at 2000 Hz. Id. If the second pattern exists, the Roman numeral will be elevated to the next higher numeral. Id. As the evidence described below shows, neither of the patterns are present in this case. In describing the evidence the Board refers to the frequencies of 1000 Hz, 2000 Hz, 3000 Hz, and 4000 Hz, as the frequencies of interest. A July 2009 audiogram shows puretone thresholds in the right ear at 500, 1000, 2000, 3000, and 4000 Hz were 10, 5, 0, 35, and 45 dB respectively. Puretone thresholds in the left ear at 500, 1000, 2000, 3000, and 4000 Hz were 10, 5, 5, 40, and 45 dB respectively. This is a puretone threshold average of 21 (21.25) dB in the right ear and 24 (23.75) dB in the left ear. In March 2011 the Veteran underwent a VA audio examination. This examiner reviewed the objective evidence of record, documented the Veteran's current complaints, and performed a thorough clinical evaluation. Therefore it is adequate for VA purposes. This report includes audiometric test results for both ears. Puretone thresholds in the right ear at 500, 1000, 2000, 3000, and 4000 Hz were 15, 10, 5, 35, and 45 dB respectively. Puretone thresholds in the left ear at 500, 1000, 2000, 3000, and 4000 Hz were 5, 10, 5, 25, and 40 dB respectively. This is a puretone threshold average of 20 dB in the right ear and 24 (23.75) dB in the left ear. Speech recognition scores obtained using the Maryland CNC Test were 100 percent for the both ears. The Veteran described his resulting functional impact as hearing difficulty that was worse in crowded environments. Based on the above, the Veteran's right ear hearing loss corresponds to no worse than Level I and his left ear hearing loss corresponds to no worse than Level I. See 38 C.F.R. § 4.85, Table VI. Applying these measurements to Table VII, the Veteran's hearing loss for this period warrants the current noncompensable (0 percent) rating. The Board is bound in its decisions by the VA regulations for the rating of hearing loss. 38 U.S.C. § 7104 (c). Rating hearing loss requires the use of the Maryland CNC speech discrimination test and the pure tone threshold average determined by an audiometry test. Application of the schedule to the facts of this case shows that a rating higher than 10 percent is not warranted. Therefore, the Board finds that the preponderance of the evidence is against a higher schedular rating for bilateral hearing loss. Hence the appeal as to a higher rating for this disability must be denied. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. The Board has considered whether referral for an extraschedular rating under 38 C.F.R. § 3.321(b)(1) is warranted in this case. The Board finds that the Veteran's symptoms of bilateral hearing loss are contemplated by the schedular rating criteria. Neither the facts of the case nor the Veteran's allegations raise the issue of extraschedular consideration. Thus, no analysis is required. See Yancy v. McDonald, 27 Vet. App. 484, 494 (2016) (holding that an extraschedular analysis is not warranted where it is not "specifically sought by the claimant nor reasonably raised by the facts found by the Board") (citing Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007). See also Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (explaining that the Board had no obligation to analyze whether referral is warranted for extraschedular consideration if an extraschedular rating is not specifically sought by the claimant or reasonably raised by the facts found by the Board). Similarly, the Board recognizes that a claim for a total rating based on individual unemployability (TDIU) may be raised as a separate claim, or in the context of an initial rating or a claim for an increase. See Rice v. Shinseki, 22 Vet. App. 447, 452-53 (2009). In this case neither the claimant nor the record has raised the question of unemployability due to service-connected disability. Therefore no further discussion of a TDIU is necessary. ORDER Service connection for sleep apnea is granted. Service connection for lumbar sprain is granted. Service connection for right hip condition is denied. Service connection for left hip condition is denied. Service connection for right ankle condition is denied. Service connection for left ankle condition is denied. Service connection for tracheostomy scar is denied. Service connection for cervical spine condition is denied. A compensable initial rating for bilateral hearing loss is denied. REMAND The Veteran has claimed bilateral knee conditions described as radiating pain from his lumbar spine disability. The August 2011 and February 2012 VA examinations found arthritis of the right and left knees, respectively, and found that these conditions were not causally related to the Veteran's military service. In a June 2011 letter, the Veteran's private doctor stated that loss of alignment of the spine and weight bearing problems caused degenerative changes of the knee. As the Veteran has been service connected for a lumbar spine disability in this decision, a new examination is necessary to determine whether the Veteran's reported radiating pain to the bilateral lower extremities is related to his service connected lumbar spine disability. Accordingly, the case is REMANDED for the following action: 1. Ensure that the Veteran is scheduled for a VA examination to determine the nature and etiology of any right and/or left knee condition. The claims file must be reviewed by the examiner and the examiner must note whether the claims file was reviewed. All indicated studies should be conducted, and all findings reported in detail. a. The examiner is asked to identify all knee conditions present. b. Then the examiner is asked to provide opinions as to whether it is at least as likely as not (a 50 percent or greater probability) that any of the diagnosed knee conditions are caused by his service connected lumbar spine disability. c. If the examiner determines that one or more of the knee conditions were not caused by the service-connected lumbar spine disability, then the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any of the diagnosed knee conditions have been aggravated (chronically worsened) by the service-connected lumbar spine disability. Each opinion must be accompanied by a clear rationale consistent with the evidence of record. If the examiner cannot respond without resorting to speculation, he or she should explain why a response would be speculative. 2. Thereafter, readjudicate the claims of service connection for right and left knee conditions. If any of the benefits sought are not granted, furnish to the Veteran and his representative a supplemental statement of the case and allow an appropriate opportunity to respond before returning the case to the Board. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ JAMES G. REINHART Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs