Citation Nr: 1754556 Decision Date: 11/29/17 Archive Date: 12/07/17 DOCKET NO. 12-09 686 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for ischemic heart disease prior to September 5, 2014, and in excess of 60 percent from September 5, 2014 to the present.. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for tinnitus. 4. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. O'Donnell, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from September 1966 to June 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from April 2011 and July 2011 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The April 2011 rating decision granted service connection for ischemic heart disease and assigned an initial 10 percent rating, effective August 31, 2010. The July 2011 rating decision, in pertinent part, denied service connection for bilateral hearing loss, and tinnitus. In October 2012, the Veteran testified before the undersigned at a travel Board hearing. A transcript of the hearing is associated with the claims file. The Board remanded the case for further development in April 2014. That development has been completed and the case has since been returned to the Board for appellate review. In a September 2014 rating decision, the RO assigned an increased rating from 10 percent to 60 percent for the Veteran's service-connected ischemic heart disease, effective September 5, 2014. Because the Veteran is presumed to seek the maximum available benefits, this issue remains on appeal, as reflected on the cover page of this decision. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. For the period on appeal prior to September 5, 2014, the Veteran's METs level due to solely to his cardiac condition is greater than 7 MET's but not greater than 10 METs. 2. As of September 5, 2014, the Veteran's METs level due to solely to his cardiac condition is greater than 3 METs. 3. The Veteran's current bilateral hearing loss was not permanently aggravated beyond its natural progression by service. 4. The Veteran's current tinnitus is at least as likely as not the result of an in-service event or injury. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for ischemic heart disease prior to September 5, 2014, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7005 (2016). 2. The criteria for an initial rating in excess of 60 percent for ischemic heart disease, as of September 5, 2014, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7005 (2016). 3. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1101, 1112, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.385 (2016). 4. Resolving reasonable doubt in favor of the Veteran, the criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C.A. §§ 1101, 1112, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Board has considered the Veteran's claim and decided entitlement based on the evidence or record. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claim. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Moreover, The Board finds there has been substantial compliance with its April 2014 remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268 (1998)) violation when the examiner made the ultimate determination required by the Board's remand.) II. Governing Law- Increased Rating Claims The Veteran is in receipt of a rating under diagnostic code 7005 for ischemic heart disease, rated as 10 percent disabling from the period between August 31, 2010 to September 5, 2014, and 60 percent thereafter. The Veteran contends that he is entitled to a higher evaluation for his service-connected ischemic heart disease for both periods on appeal. Under Diagnostic Code 7005, a 10 percent rating is warranted for coronary artery disease resulting in a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; requiring continuous medication. A 30 percent rating is warranted for coronary artery disease resulting in a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for coronary artery disease resulting in more than one episode of acute congestive heart failure in the past year, or; a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for coronary artery disease resulting in chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. For rating diseases of the heart, one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note 2. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but findings sufficient to identify the disease, the resulting disability, and above all, coordination of the rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The primary concern for an increased rating for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, VA has a duty to consider the possibility of assigning staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). III. Entitlement to an initial evaluation in excess of 10 percent for ischemic heart disease. A February 2011 treatment note indicates that the Veteran's ejection fraction was measured at 62 percent. Moreover, his resting 12 lead electrocardiography was within normal limits, and there was no evidence of myocardial ischemia. In March 2011, the Veteran had an echocardiogram, in which his estimated ejected fraction was measured at 55 percent. There was evidence of diastolic dysfunction, but no significant valvular regurgitation or stenosis was found. The Veteran's left and right ventricle were normal sized, and his left and right ventricular systolic function was normal. Moreover, his left ventricular ejection fraction was measured at 69.1 percent. A May 2011 VA treatment note indicates that the Veteran's ejection fraction was measured at approximately 60 percent, with no segmental wall motion abnormalities. The physician noted that the Veteran's stented LAD was normal and his left main, left circumflex, and right coronary arteries were normal. Also, a May 2011 cardiac report indicates that the Veteran's left ventriculography revealed normal sized chamber with good overall contractility. See May 2011 Medical Records. Moreover, his estimated ejection fraction was measured at 60 percent. A June 2011 VA examination reflects that the Veteran was taking continuous medication for his heart condition. The examiner noted that the Veteran did not have angina or syncope, and that there was no evidence of hypertrophy or dilation. Diagnostic exercise was conducted and the Veteran's ejection fraction was measured at 60 percent. METs testing based on the Veteran's responses indicated that the Veteran's METs level was consistent with 1-3 METs. The examiner noted that higher levels of activities caused symptoms of dyspnea and fatigue. However, the examiner opined that the estimated METs level was not more indicative of the Veteran's degree of cardiac disability than his ejection fraction because his exercise was limited by dyspnea and fatigue that are not of cardiac origin. Thus, the examiner found that the Veteran's ejection fraction was more indicative of his level of cardiac disability. In December 2011, the Veteran underwent a procedure in which a stent was placed in his left anterior descending artery. In a post-operative report, the Veteran indicated that he had no chest pain or discomfort, and he denied experiencing shortness of breath. The physician noted that palpation of the chest revealed no abnormalities, and all pulses were normal. An August 2013 treatment note indicates that the Veteran underwent a left heart catheterization procedure. The Veteran had ejection fraction measured at 65 percent. His wall motion was normal and there were no signs of mitral valve regurgitation. The Board has reviewed all of the evidence of record. Cf. Gonzalez v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). Based on the evidence of record, lay and medical, the Board finds that the Veteran's overall disability picture does not warrant an evaluation in excess of 10 percent under the applicable Rating Schedule. To that end, the aforementioned evidence does not show that during the period on appeal the Veteran had coronary artery disease resulting in a workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. As shown above, medical records have consistently shown that the Veteran's ejection fracture was above 50 percent. Moreover, the evidence reflects that at no point during the pendency of the appeal did the Veteran have any episodes of congestive heart failure. Additionally, there is no evidence during the period on appeal that the Veteran experienced hypertrophy or dilation. The Board acknowledges that the Veteran's estimated METs at the June 2011 VA examination showed that 1-3 METs would cause dyspnea and fatigue. However, the examiner explained that the estimated METs testing was not an accurate representation of the Veteran's symptomatology, in that his METs levels were a result of non-heart related disabilities. Additionally, the Board notes the various lay statements of record, however, the Board assigns significant probative weight to the medical evidence of record, as the Veteran's symptoms have been consistently identified his treating physicians. Symptoms of which the Board finds most closely approximate those contemplated by his current 10 percent evaluation, and do not warrant an increase under any alternative diagnostic code. The Board also finds that there are no other potentially applicable diagnostic codes. Indeed, Diagnostic Code 7005 specifically governs the evaluation of the Veteran's disability. Further, there has been no assertion that any other diagnostic code is applicable. The Board concludes that the preponderance of the evidence is against a finding that an evaluation in excess of 10 percent is appropriate for any period on appeal, and the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). IV. Entitlement to an evaluation in excess of 60 percent for ischemic heart disease, as of September 5, 2014. Under Diagnostic Code 7005, a 100 percent rating is warranted for coronary artery disease resulting in chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. In September 2014, the Veteran was afforded a VA examination with regard to his ischemic heart disease. The examiner indicated that the Veteran had never experienced a myocardial infarction or congestive heart failure. The Veteran's heart rhythm, pulse, and sounds were normal. There was no sign of hypertrophy or dilation. A coronary artery angiogram was conducted and the Veteran's ejection fraction was measured at 65 percent with normal wall motion, and no mitral regurgitation was reported. Interview based METs testing was performed, which indicated that experienced fatigue at a workload of greater than three but not more than 5 METs. Based on the evidence of record, lay and medical, the Board finds that the Veteran's ischemic heart disease does not warrant an evaluation in excess of 60 percent under the applicable Rating Schedule. To that end, the aforementioned evidence does not show that during the period on appeal the Veteran had chronic congestive heart failure, or a workload of 3 MET's or less resulting in dyspnea, fatigue, angina, dizziness, or syncope or; left ventricular dysfunction with an ejection fraction of less than 30 percent. Rather, the September 2014 VA examination indicates that the Veteran's ejection fraction was measured at 65 percent, and a workload of greater than 3 METs resulted in fatigue. Thus, the Board concludes that the preponderance of the evidence is against a finding that an evaluation in excess of 60 percent is appropriate for any period on appeal, and the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-56. V. Tinnitus The Veteran contends that his current tinnitus is related to his time in active service. Specifically, he asserts that he was exposed to noise from, among other things, being in close proximity to explosions from hand grenades, artillery and gunfire, as well as working in an engine room aboard patrol boats. The Veteran's DD Form 214 shows that his military specialty was as a diesel engine mechanic. The Board finds that the Veteran's statements are competent and credible and his reported noise exposure is consistent with the circumstances of his military service. The Veteran's October 2012 Board hearing transcript reflects that the Veteran reported his tinnitus had its onset while on active duty and that it has been continuous since that time. Thus, the Board finds that the Veteran has a current diagnosis of tinnitus. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) (noting that lay testimony may establish the presence of tinnitus because ringing in the ears is capable of lay observation). Moreover, the Veteran is competent to report that his symptoms of tinnitus have continued since his military service and the Board has no reason to doubt the credibility of his lay assertions. The Board acknowledges that the September 2014 VA examiner provided a negative nexus opinion in regard to the Veteran's tinnitus. However, the Board finds this opinion is of limited probative value, as the examiner did not consider the Veteran's statements regarding continuity of symptomatology. Rather, he found that tinnitus was not present at separation, which is inconsistent with the Veteran's competent and credible lay statements. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based on an inaccurate factual premise has no probative value). Nevertheless, the law is clear. Pursuant to the "benefit-of-the-doubt" rule, where there is "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. 38 U.S.C.A. § 5107 (West 2014). The Board finds that the Veteran's statement as to the onset of tinnitus during his October 2012 Board hearing to be competent and credible, and this lay evidence indicates a relationship between the current disability and the in-service noise exposure. The Board therefore concludes that, with the benefit of the doubt resolved in the Veteran's favor, a grant of service connection for tinnitus is warranted. See Gilbert, 1 Vet. App. 49, 55. VI. Bilateral Hearing Loss- Governing Law A. Service Connection The Veteran has claimed that his current bilateral hearing loss and tinnitus are due to noise exposure during his military service. The Veteran contends that his current bilateral hearing loss is related to his time in active service. Specifically, as stated above, he asserts that he was exposed to noise from, among other things, being in close proximity to explosions from hand grenades, artillery and gunfire, as well as working in an engine room aboard patrol boats. See October 2012 Board Hearing Transcript at 11-12. The Veteran's DD Form 214 shows that his military specialty was as a diesel engine mechanic. The Board finds that the Veteran's statements are competent and credible and his reported noise exposure is consistent with the circumstances of his military service. A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C.A. §§ 1110, 1131 (West 2016). To establish service connection, "the 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." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir.2004). The requirement that a current disability exist is satisfied if the claimant had a disability at the time his claim for VA disability compensation was filed or during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); but see Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (holding that the Board must address recent pre-claim evidence in assessing whether a current disability exists, for purposes of service connection, at the time the claim was filed or during its pendency). For the showing of a chronic disease in service, there is required to be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As organic diseases of the nervous system, tinnitus and sensorineural hearing loss are considered chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §3.303(b), 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also Fountain v. McDonald, 27 Vet. App. 25 (2015)(holding that the presumptive provisions of 38 C.F.R. § 3.309(a) include tinnitus as an organic disease of the nervous system where there is evidence of acoustic trauma). Additionally, veterans who served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including organic diseases of the nervous system (tinnitus and sensorineural hearing loss), are presumed to have been incurred in service if they manifested to a compensable degree within one year from the day of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2016); 38 C.F.R. §§ 3.307, 3.309 (2016). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate 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 (West 2016); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). B. Presumption of Soundness A veteran who served after December 31, 1946, is presumed to be in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). The presumption is rebutted where clear and unmistakable (obvious and manifest) evidence demonstrates that an injury or disease existed prior to service and was not aggravated by such service. 38 U.S.C.A. § 1111, 1137. The VA Office of General Counsel and the appellate courts have issued clarifying precedent decisions regarding application of the presumption of sound condition upon entry into service. Under this guidance, to rebut the presumption of sound condition under 38 U.S.C.A. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. A veteran is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 3-2003; see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). The law further provides that, if a preexisting disorder is noted upon entry into service, a veteran cannot bring a claim for service incurrence for that disorder, but a veteran may bring a claim for service-connected aggravation of that disorder. Paulson v. Brown, 7 Vet. App. 466, 468 (1995). In this type of case, the provisions of 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306 apply. Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If a presumption of aggravation under section 1153 arises, due to an increase in a disability in service, the burden shifts to the government to show a lack of aggravation by establishing by clear and unmistakable evidence "that the increase in disability is due to the natural progress of the disease." 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306; Jensen, 19 F.3d at 1417; Wagner, 370 F.3d at 1096. VA's General Counsel has held that the provisions of 38 C.F.R. § 3.306(b), providing that aggravation may not be conceded unless the pre-existing condition increased in severity during service, are not inconsistent with 38 U.S.C.A. § 1111. 38; C.F.R. § 3.306(b) properly implements 38 U.S.C.A. § 1153, which provides that a pre-existing injury or disease will be presumed to have been aggravated in service in cases where there was an increase in disability during service. The requirement of an increase in disability in 38 C.F.R. § 3.306(b) applies only to determinations concerning the presumption of aggravation under 38 U.S.C.A. § 1153 and does not apply to determinations concerning the presumption of sound condition under 38 U.S.C.A. § 1111, which requires VA to bear the burden of showing the absence of aggravation. VAOPGCPREC 3-2003; see also Wagner, 370 F.3d 1089. VII. Bilateral Hearing Loss- Analysis It is conceded that the Veteran had noise exposure while in service. However, the Veteran's service treatment records do not document any complaints or treatment for hearing loss. In fact, in the Veteran's May 1970 report of medical history, he indicated that he did not have any ear trouble. A clinical examination at that time also found his ears and drums to be normal. Following his separation from service, there is no indication in the record to suggest that the Veteran sought treatment for hearing loss, and there is no evidence of either disorder within one year of his military service. Indeed, the Veteran did not complain of hearing loss for many years following his separation from service. There is no other medical opinion indicating that the Veteran's hearing loss is related to his military service. Based on this evidence, the Board finds that right ear hearing loss, nor manifestations sufficient to identify the disease entity, was shown during service. Therefore, while sensorineural hearing loss is a chronic disease under 38 C.F.R. § 3.309(a), no notations of the diseases or any characteristic manifestations of hearing loss were shown in the service records. As such, service connection under 38 C.F.R. § 3.303(b) is not warranted, and right ear hearing loss may not be presumed to have been incurred in service. 38 U.S.C.A. § 1101; 38 C.F.R. §§ 3.307, 3.309. The remaining question is whether his current hearing loss is otherwise related to his military service, including his noise exposure therein. Here, the Veteran's February 1966 enlistment examination indicates decibel testing in his left ear revealed measurements of 0 for 500, 1,000, 2,000, and 3,000 Hertz. However, 35 decibels were measured at 4,000 Hertz and 50 decibels at 6,000 Hertz. Thus, the Veteran did not having hearing loss for VA purposed at enlistment. See 38 C.F.R. § 3.385. However, the Board notes that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Thus, the Board finds that the Veteran's hearing loss was noted at entry. See 38 C.F.R. § 3.304(b). In September 2014, the Veteran was afforded a VA examination for his diagnosed bilateral hearing loss. The examination report indicates that the Veteran reported his hearing loss had "come on slowly," and no specific onset was noted. The examiner commented that the Veteran's May 1970 separation examination revealed 15/15 bilateral hearing on whisper testing. The examiner indicated that there were no medical records indicating that the Veteran had complained of hearing loss or any ear conditions within a year of separation from service. With regard to his right ear, the examiner noted that the Veteran's enlistment and separation examinations showed normal hearing, and that the Veteran did not complain of hearing loss while in service. Rather, the examiner noted that the first documented complaints of hearing loss in the medical record occurred at a June 2011 VA examination, which was approximately 41 years following separation from service. The examiner indicated that hearing loss from noise exposure does not have a delayed onset, but rather the hearing loss would occur immediately following the noise exposure. To that end, the examiner indicated that most scientific evidence indicated that prior noise exposure ears are not more sensitive to future noise exposure and that hearing loss due to noise exposure does not progress once the exposure to noise is discontinued. Thus, the examiner found that the Veteran's right ear hearing loss was less likely than not related to his military service. As for the Veteran's left ear, the examiner reported that the Veteran's left ear hearing loss was noted on his enlistment examination. Similarly to the right ear, the examiner noted that file contained no documented evidence of hearing loss complaints during service, and that June 2011 was the first such incident of documented hearing loss. The examiner indicated that the Veteran separated from service with normal hearing per the whispered voice test. The examiner noted that such tests were thought to be insensitive to some high frequency hearing losses, but that they had a high degree of sensitivity for detecting mild hearing impairments. Taking the above mentioned evidence into account, the examiner opined that the Veteran's pre-existing left ear hearing loss was less likely than not aggravated beyond its normal progression by military service. At the Veteran's October 2012 Board hearing, he reported that, while on active duty in the Republic of Vietnam, he was consistently in proximity to artillery, grenade and gun fire. Additionally, the Veteran testified that he worked in loud engine rooms while aboard an aircraft carrier, as well as patrol boats. The Veteran indicated that after an eight hour shift in an engine room, there would be times when he was unable to hear well for two days following his shift. The Veteran also testified that he did not wear hearing protection while working in the various engine rooms. The Board has also considered the statements of the Veteran, asserting that his current hearing loss is related to his military service. However, although he is competent to report on what he has observed, such as his symptomatology, the Board finds that his not competent to provide an opinion regarding a nexus between his current hearing loss and his military service, as that involves a complex medical question. Nevertheless, the Board finds that the specific, reasoned opinion of the September 2014 VA examiner is of greater probative weight in this case as to whether the Veteran's right ear hearing loss is at least as likely as not related to his military noise exposure, and that the Veteran's left ear hearing loss was not permanently aggravated beyond its natural progression from service. The examiner reviewed the claims file and the Veteran's own reported history, and she has training, knowledge, and expertise on which she relied to form his opinion. She also provided a rationale for the conclusion reached. Given the record before it, the Board finds that evidence in this case does not reach the level of equipoise. See 38 U.S.C. § 5107 (a) ("[A] claimant has the responsibility to present and support a claim for benefits . . . ."); Fagan v. Shinseki, 573 F.3d 1282, 1286 (Fed. Cir. 2009) (stating that the claimant has the burden to "present and support a claim for benefits" and noting that the benefit of the doubt standard in section 5107(b) is not applicable based on pure speculation or remote possibility); Skoczen v. Shinseki, 564 F.3d 1319, 1323-29 (Fed. Cir. 2009) (interpreting section 5107(a) to obligate a claimant to provide an evidentiary basis for his or her benefits claim, consistent with VA's duty to assist, and recognizing that "[w]hether submitted by the claimant or VA . . . the evidence must rise to the requisite level set forth in section 5107(b)," requiring an approximate balance of positive and negative evidence regarding any issue material to the determination). ORDER Entitlement to an initial evaluation in excess of 10 percent for ischemic heart disease is denied. Entitlement to an evaluation in excess of 60 percent for ischemic heart disease, as of September 5, 2014, is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is granted. REMAND All veterans who are shown to be unable to secure and follow substantially gainful occupation by reason of service-connected disability shall be rated totally disabled. A total disability rating for compensation may be assigned, where the schedular rating is less than total, when a veteran is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Nevertheless, even when the percentage requirements are not met, entitlement to TDIU on an extraschedular basis may be granted in exceptional cases when the veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to secure or follow substantially gainful employment. See 38 C.F.R. § 4.16. An award of TDIU does not require a showing of 100% unemployability. See Roberson v. Principi, 251 F.3d 1378, 1385 (2001). However, an award of TDIU requires that the claimant show an inability to undertake substantially gainful employment as a result of a service-connected disability or disabilities. 38 C.F.R. § 4.16(b) ("[A]ll veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled."). In determining whether a claimant is unable to secure or follow substantially gainful employment, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term "unemployability" is synonymous with inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91, 57 Fed. Reg. 2317 (1992). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, entitlement to TDIU is based on an individual's particular circumstances. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, when the Board conducts a TDIU analysis, it must take into account the individual's education, special training, and previous work experience, but not his or her age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. See id. If a Veteran does not meet the applicable percentage standards enunciated in 38 C.F.R. § 4.16(a), an extra-schedular rating is for consideration where the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). Thus, the Board must evaluate whether there are circumstances, apart from any non-service-connected conditions and advancing age, which would justify a total rating based on unemployability. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Regarding potential entitlement to TDIU under 38 C.F.R. § 4.16(b), the Board has no authority to award TDIU under § 4.16(b) in the first instance. Rather, the rating board must submit to the Director of Compensation Service for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in § 4.16(a). Bowling v. Principi, 15 Vet. App. 1, 10 (2001). The Board notes that prior to September 5, 2014, the Veteran does not meet the schedular requirements for entitlement to a TDIU but the Board finds that there is evidence of entitlement to such prior to the date in which the Veteran's meets the schedular requirements. The Board notes that, as of September 5, 2014, the Veteran is service-connected for ischemic heart disease, evaluated as 60 percent disabling. Thus, the Veteran meets the schedular requirements for a TDIU due to service-connected disabilities under 38 C.F.R. § 4.16(a). Throughout the appeal period, the Veteran has alleged that his service-connected ischemic heart disease has precluded him from obtaining and maintaining employment. See December 2014 VA Form 21-8940 Veteran's Application for Increased Compensation Based on Unemployability. To that end, the Veteran reported that he has been unemployed since 2011. The June 2011 VA examiner reported that the Veteran's service-connected ischemic heart disease caused him dyspnea and fatigue, and to these symptoms he had to quit his job in maintenance. The examiner indicated that, as a result of his symptoms, the Veteran had difficulty walking and was unable to work in his farm. The September 2014 VA examiner indicated that symptoms associated with the Veteran's ischemic heart disease impacted his ability to work. To that end, the examiner reported that the Veteran had to quit his last job, which was in construction, because his ischemic heart disease caused a lack of endurance that made it too difficult for him to perform physical labor. The ultimate question of whether a Veteran is capable of securing or following substantially gainful employment is an adjudicatory determination, not a medical one. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) ("[A]pplicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner."). Likewise, it is within the Board's discretion to determine the need for additional development when dealing with the combined effects of multiple service-connected conditions. See Floore v. Shinseki, 26 Vet. App. 376, 381 (2013) (holding that "the need for a combined-effects medical examination report or opinion with regard to multiple-disability TDIU entitlement decisions is to be determined on a case-by-case basis, and depends on the evidence of record at the time of decision by the regional office (RO) or the Board."). In this case, in light of the lack of sufficient evidence on record regarding the functional effects of the Veteran's service-connected disabilities with regard to his ability to secure or follow substantially gainful employment, the Board finds that a remand is warranted prior to adjudication on the issue of the Veteran's entitlement to a TDIU. Moreover, to date, the issue of entitlement to a TDIU prior to September 5, 2014 has not been considered on an extraschedular basis under 38 C.F.R. § 4.16(b). Thus, because there is evidence that the Veteran may have been unemployable during the appeal period, due to service-connected disabilities, the issue of entitlement to a TDIU is referred to the Director of the Compensation Service for adjudication in the first instance. Accordingly, the case is REMANDED for the following action: 1. Prepare a full statement as to the Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue of entitlement to a TDIU. 2. Schedule the Veteran for a VA examination to address the functional impact of the Veteran's service-connected ischemic heart disease and tinnitus on his ability to work. The claims file should be made available to the examiner for review. Based on the examination and review of the complete record, the examiner is requested to address the functional impact of the Veteran's service-connected ischemic heart disease and tinnitus on his ability to secure or follow a substantially gainful occupation, consistent with his educational and occupational experience. When addressing the functional effect, the examiner must not consider the Veteran's age or any non-service connected disabilities. 2. Refer the issue of entitlement to a TDIU to the Director of Compensation Service for consideration of assignment of an extraschedular rating for a TDIU pursuant to 38 C.F.R. § 4.16(b), prior to September 5, 2014. 3. Readjudicate the claim. If any benefit sought on appeal remains denied, then a fully responsive SSOC should be furnished to the Veteran and his representative, and they should be afforded a reasonable opportunity for response. The Veteran has the right to submit additional evidence and argument on the matter or 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). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs