Citation Nr: 1754599 Decision Date: 11/29/17 Archive Date: 12/07/17 DOCKET NO. 13-18 397 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to an increased rating for service connected left ear hearing loss, currently evaluated as noncompensable prior to April 4, 2016, and 20 percent disabling beginning April 4, 2016. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD L. Hoover, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1967 to May 1969 as a combat infantryman in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in July 2010 by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The RO granted an increased rating for the Veteran's left ear hearing loss at 20 percent. However, this was not a full grant of the benefits sought and therefore both claims remain on appeal. Notice of Disagreements were received in March 2011 and May 2011. In May 2013 and August 2013, Statements of the Case were issued, and, in June 2013 and August 2014 the Veteran filed his substantive appeals (via a VA Form 9). In March 2015, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge via videoconference. A transcript of the hearing is of record. In May 2015, the Board remanded the claims on appeal for additional development and the case now returns for further appellate review. This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. Therefore, any future consideration of the Veteran's claim should take into account the existence of the electronic record. FINDINGS OF FACT 1. Right ear hearing loss is not attributable to service. 2. The Veteran at worst demonstrated Level VI hearing acuity in his service-connected left ear. CONCLUSIONS OF LAW 1. Right ear hearing loss was not incurred in or aggravated by active service and right ear sensorineural hearing loss may not be presumed to have been incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.385 (2017). 2. The criteria for a rating in excess of 20 percent for left ear hearing loss is not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.85, Part 4, Diagnostic Code 6100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claims and what the evidence in the claims file shows, or fails to show, with respect to those claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). I. VA'S DUTY TO NOTIFY AND ASSIST With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). II. LEGAL CRITERIA Service connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. In the case of a veteran who engaged in combat with the enemy in active service, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions, or hardships of such service, even though there is no official record of such incurrence or aggravation, and to that end, every reasonable doubt shall be resolved in favor of the veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Satisfactory lay or other evidence under section 1154(b) has been defined as "credible evidence." See Collette v. Brown, 82 F.3d 389, 393 (Fed. Cir.1996). However, these provisions deal with the question of whether a particular disease or injury occurred in service; that is, what happened then, and not the question of either current disability or nexus to service, for both of which competent evidence is generally required. In other words, these provisions do not presumptively establish service connection for a combat veteran; rather, they relax the evidentiary requirements for noting what happened in service. See Brock v. Brown, 10 Vet. App. 155, 162 (1997); Libertine v. Brown, 6 Vet. App. 521, 524 (1996). Organic disease of the nervous system such as sensorineural hearing loss will be presumed to have been incurred in or aggravated by service if it had become manifest to a degree of 10 percent or more within one year of the Veteran's separation from service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With chronic diseases shown as such in service or within the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear-cut clinical entity, at some later date. Continuity of symptomatology is required only where the condition noted during service or the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after service is required to support the claim. 38 C.F.R. § 3.303(b). This regulation pertains to "chronic diseases" enumerated in 38 C.F.R. § 3.309(a) (listing named chronic diseases). Walker v. Shinseki, 708 F.3d 1331, 1336-37 (Fed. Cir. 2013). The United States Court of Appeals for the Federal Circuit (Federal Circuit) noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a Veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, supra. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation"). Hearing loss disability is defined by regulation. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran had in-service audiological evaluations during service in October 1966 and April 1969 at which time auditory thresholds were recorded. It is unclear whether such thresholds were recorded using American Standards Association (ASA) units or International Standards Organization-American National Standards Institute (ISO-ANSI) units. For service audiological evaluations conducted prior to January 1, 1967, VA protocol is to assume the ASA standard was used. For service audiological evaluations conducted between January 1, 1967 and December 31, 1970, VA protocol is to consider the data under both ASA and ISO-ANSI standards, which ever is more beneficial to the Veteran. For service audiological evaluations conducted after December 31, 1970, VA protocol is to presume the ISO-ANSI standard was used. As such, audiometric data originally recorded using ASA standards will be converted to ISO-ANSI standard by adding between 5 and 15 decibels to the recorded data as follows: Hertz 250 500 1000 2000 3000 4000 6000 8000 add 15 15 10 10 10 5 10 10 Ratings Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, a Veteran appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). In evaluating service connected hearing impairment, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Acevedo-Escobar v. West, 12 Vet. App. 9, 10 (1998); Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The schedule provides a table (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment. Testing for hearing loss is conducted by a state-licensed audiologist, including a controlled speech discrimination test (Maryland CNC). The evaluation is based upon a combination of the percent of speech discrimination and the puretone threshold average which is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four. See 38 C.F.R. § 4.85. Table VII in the schedule is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear, the horizontal rows representing the ear having better hearing and the vertical columns representing the ear having the poorer hearing. The percentage evaluation is indicated where the row and column intersect. Table VIa is used when the examiner certifies that the use of speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of 38 C.F.R. § 4.86. See 38 C.F.R. § 4.85(c). When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. See 38 C.F.R. § 4.86(a). When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. See 38 C.F.R. § 4.86(b). According to the application regulations, if impaired hearing is service-connected in only one ear, in order to determine the percentage evaluation, from Table VII, the nonservice-connected ear will be assigned a Roman numeral designation of I, subject to the provisions of 38 U.S.C.A. § 3.383; 38 C.F.R. § 4.85(f). In this regard, compensation is payable for the combination of service-connected and nonservice-connected disabilities as if both disabilities were service-connected, provided the nonservice-connected disability is not the result of the Veteran's own willful misconduct. 38 C.F.R. § 3.383(a). If hearing impairment in one ear is compensable to a degree of 10 percent or more as a result of service-connected disability, and there is hearing impairment in the other ear as a result of nonservice-connected disability that meets the provisions of 38 C.F.R. § 3.385, compensation is payable as if both disabilities were service-connected. 38 C.F.R. § 3.383(a)(3)). Background On the Veteran's October 1966 pre-induction examination, audiological evaluation revealed that puretone thresholds, in decibels, were as follows (conversion added): HERTZ 500 1000 2000 3000 4000 RIGHT (0)15 (0)10 (0)10 (0)10 (5)10 LEFT (0)15 (0)10 (0)10 (25)35 (25)30 No frequency is 40 decibels or greater and at least three of the frequencies do not exceed 26 decibels, therefore, the pre-induction examination does not show a hearing loss disability. On the Report of Medical History, no relevant complaints were noted. No additional defects were noted on physical inspection in May 1967; the Veteran was found fit for duty. On the April 1969 separation examination, audiological evaluation revealed that puretone thresholds, in decibels, were as follows (conversion added): HERTZ 500 1000 2000 3000 4000 RIGHT (0)15 (0)10 (0)10 - (0)5 LEFT (0)15 (0)10 (15)25 - (50)55 No frequency in the right ear is 40 decibels or greater, and at least three of the frequencies do not exceed 26 decibels, therefore, the separation examination does not show a right ear hearing loss disability. On the Report of Medical History, the Veteran reported a positive response to the question of whether he experienced "ear, nose, or throat trouble" in service. This audiogram shows hearing loss in the left ear, which is already service connected. On the April 1979 VA examination, audiological evaluation revealed that puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 35 - - LEFT 10 10 60 - - No speech recognition scores are of record for this examination. No frequency in the right ear is 40 decibels or greater and at least three of the frequencies do not exceed 26 decibels, therefore, the audiogram does not show a right ear hearing loss disability. On an April 1988 audiogram conducted by the VA for a hearing aid fitting, audiological evaluation revealed that puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 35 50 45 LEFT 10 30 60 - 70 The puretone threshold average was 33.75 in the right ear and incomplete in the left ear. Initial Maryland CNC testing revealed speech recognition scores of 92 percent for the right ear and 76 percent for the left ear. The Veteran shows hearing loss for VA purposes in both the left and right ear in this audiogram as both ears show frequencies in excess of 40 decibels. On a June 1988 audiogram conducted by the VA for a hearing aid fitting, audiological evaluation revealed that puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 30 60 50 LEFT 15 35 60 70 The puretone threshold average was 36.25 in the right ear and incomplete in the left ear. Initial Maryland CNC testing revealed speech recognition scores of 96 percent for the right ear and 80 percent for the left ear. The Veteran shows hearing loss for VA purposes in both the left and right ear in this audiogram as both ears show frequencies in excess of 40 decibels. During a November 1989 VA examination, audiological evaluation revealed that puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT - 10 40 55 50 LEFT - 35 60 65 70 The puretone threshold average was 38.75 decibels in the right ear and 57.5 decibels in the left ear. Initial Maryland CNC testing revealed speech recognition scores of 92 percent for the right ear and 92 percent for the left ear. The Veteran shows hearing loss for VA purposes in both the left and right ear in this audiogram as both ears show frequencies in excess of 40 decibels. During an August 1992 VA examination, audiological evaluation revealed that puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 25 45 55 60 LEFT 20 35 65 70 80 The puretone threshold average was 46.25 decibels in the right ear and 62.5 decibels in the left ear. Initial Maryland CNC testing revealed speech recognition scores of 92 percent for the right ear and 76 percent for the left ear. The Veteran shows hearing loss for VA purposes in both the left and right ear in this audiogram as both ears show frequencies in excess of 40 decibels. During an April 2010 VA examination, audiological evaluation revealed that puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 40 50 65 70 70 LEFT 40 55 70 80 80 The puretone threshold average was 63.75 decibels in the right ear and 71.25 decibels in the left ear. Initial Maryland CNC testing revealed speech recognition scores of 78 percent for the right ear and 68 percent for the left ear. The Veteran shows hearing loss for VA purposes in both the left and right ear in this audiogram as both ears show frequencies in excess of 40 decibels. These results correspond to a level IV acuity in the right ear, and a level VI acuity in the left ear under Table VI. The Veteran also showed an exceptional pattern of hearing loss in his left ear, as each frequency is above 55 decibels, which corresponds to level VI under Table VIa. Thus, Table VI and Table VIa render the same result. According to the application regulations, if impaired hearing is service-connected in only one ear, in order to determine the percentage evaluation, from Table VII, the nonservice-connected ear (the Veteran's right ear) will be assigned a Roman numeral designation of I, subject to the provisions of 38 U.S.C.A. § 3.383; 38 C.F.R. § 4.85(f). Applying these results to Table VII, this corresponds to a 0 percent or noncompensable disability rating. Thus, hearing impairment in one ear is not compensable to a degree of 10 percent or more as a result of service-connected disability, so compensation is not payable as if both ear disabilities were service-connected. 38 C.F.R. § 3.383(a)(3). During a March 2011 VA audiology appointment, audiological evaluation revealed that puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 55 65 70 75 LEFT 35 50 75 80 80 The puretone threshold average was 66.25 decibels in the right ear and 71.25 decibels in the left ear. Initial Maryland CNC testing revealed speech recognition scores of 92 percent for the right ear and 88 percent for the left ear. The Veteran showed hearing loss for VA purposes in both the left and right ear in this audiogram as both ears show frequencies in excess of 40 decibels. These results correspond to a level V acuity in the right ear (under Table VIa, due to exceptional pattern), and a level III acuity in the left ear. 38 C.F.R. §§ 4.85, 4.86, Table VIa. However, according to the application regulations, if impaired hearing is service-connected in only one ear, in order to determine the percentage evaluation, from Table VII, the nonservice-connected ear (the Veteran's right ear) will be assigned a Roman numeral designation of I, subject to the provisions of 38 U.S.C.A. § 3.383; 38 C.F.R. § 4.85(f). Applying these results to Table VII, this again corresponds to a 0 percent or noncompensable disability rating. Thus, hearing impairment in one ear is not compensable to a degree of 10 percent or more as a result of service-connected disability, so compensation is not payable as if both ear disabilities were service-connected. 38 C.F.R. § 3.383(a)(3). The Veteran obtained a private audiology audiogram in April 2011 which did not use the Maryland CNC speech discrimination test, and therefore cannot be used to for rating purposes. The audiological evaluation revealed that puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 40 55 70 65 70 LEFT 45 50 80 80 85 The Veteran showed hearing loss for VA purposes in both the left and right ear in this audiogram as both ears show frequencies in excess of 40 decibels. During an August 2014 VA examination, audiological evaluation revealed that puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 55 65 70 75 LEFT 35 50 75 80 80 The puretone threshold average was 66.25 decibels in the right ear and 71.25 decibels in the left ear. Initial Maryland CNC testing revealed speech recognition scores of 76 percent for the right ear and 76 percent for the left ear. The Veteran showed hearing loss for VA purposes in both the left and right ear in this audiogram as both ears show frequencies in excess of 40 decibels. These results correspond to a level V acuity in the right ear (under Table VIa, due to exceptional pattern) and a level IV acuity in the left ear. However, according to the application regulations, if impaired hearing is service-connected in only one ear, in order to determine the percentage evaluation, from Table VII, the nonservice-connected ear (the Veteran's right ear) will be assigned a Roman numeral designation of I, subject to the provisions of 38 U.S.C.A. § 3.383; 38 C.F.R. § 4.85(f). Applying these results to Table VII, this corresponds to a 0 percent or noncompensable disability rating. Thus, hearing impairment in one ear is not compensable to a degree of 10 percent or more as a result of service-connected disability, so compensation is not payable as if both ear disabilities were service-connected. 38 C.F.R. § 3.383(a)(3). During an April 2016 VA examination, audiological evaluation revealed that puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 40 55 65 70 70 LEFT 45 55 75 80 80 The puretone threshold average was 65 decibels in the right ear and 72.5 decibels in the left ear. Initial Maryland CNC testing revealed speech recognition scores of 84 percent for the right ear and 80 percent for the left ear. The Veteran showed hearing loss for VA purposes in both the left and right ear in this audiogram as both ears show frequencies in excess of 40 decibels. The Veteran also showed an exceptional pattern of hearing loss in both ears, as each frequency in both ears is over 50 decibels. These results correspond to a level III acuity in the right ear under table VI and a level V acuity in the right ear under table VIa. The audiogram also showed a level IV acuity in the left ear under table VI and a level VI acuity in the left ear under table VIa. 38 C.F.R. §§ 4.85, 4.86, Table VI. However, according to the application regulations, if impaired hearing is service-connected in only one ear, in order to determine the percentage evaluation, from Table VII, the nonservice-connected ear (the Veteran's right ear) will be assigned a Roman numeral designation of I, subject to the provisions of 38 U.S.C.A. § 3.383; 38 C.F.R. § 4.85(f). Applying these results to Table VII, this corresponds to a 0 percent or noncompensable disability rating. Thus, hearing impairment in one ear is not compensable to a degree of 10 percent or more as a result of service-connected disability, so compensation is not payable as if both ear disabilities were service-connected. 38 C.F.R. § 3.383(a)(3). A negative medical nexus opinion regarding the Veteran's right ear hearing loss was rendered during the Veteran's April 2010 VA examination. An audiogram and physical evaluation of the Veteran were performed. The examiner conducted a thorough review of the Veteran's record. The examiner opined that because the audiometrics that are found in the military records suggest that the Veteran's hearing was within normal limits bilaterally at the time of discharge, military noise exposure did not cause or result in hearing loss. The Veteran also received a private nexus opinion from a private ENT in April 2011 who performed an audiogram, gathered a verbal history from the Veteran, and performed a physical examination. The ENT stated that the Veteran has a significant ongoing high frequency sensorineural hearing loss, and that even though his hearing loss was not evident at the time of his discharge, it is more likely than not that his current sensorineural hearing loss is related to his significant noise exposure during his military experience. The examiner listed no further rationale. A negative nexus opinion was submitted during the Veteran's September 2014 VA examination. The examiner reviewed the Veteran's claims file and performed an audiogram. The examiner stated that the Veteran's induction exam and separation exam both indicated normal hearing bilaterally, and that there was no significant shift in his hearing in the right ear from induction to separation. The VA examiner noted that the Veteran's private physician opined on the Veteran's hearing without review of evidence in the Veteran's service records. The VA examiner also noted that the Veteran also has a 3 year history of occupational noise exposure building houses and farming following separation from the army, and concluded that the Veteran's hearing loss was less likely than not related to his military service. A December 2014 addendum opinion was submitted, stating that the Veteran's hearing loss causes a functional impact for the Veteran because the Veteran used to work in construction, and can no longer perform the work because it became hazardous, as he could not hear commands. Service connection for right ear hearing loss The Veteran contends that his hearing loss is related to acoustic trauma in active duty when he served as an infantryman during the Vietnam War. The Board recognizes that the Veteran is a combat veteran, having received the Combat Infantryman Badge. In the case of any veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, campaign, or expedition, VA shall accept as sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service. 38 U.S.C.A. § 1154 (b) (West 2014). Service-connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. Id. In Reeves v. Shinseki, 682 F.3d 988, 999-1000 (2012), the Federal Circuit noted that in a case in which the Board only recognized that the Veteran sustained acoustic trauma, the Federal Circuit maintained that simply because the Board accepted the fact that the Veteran suffered acoustic trauma in service did not mean that it was not required to apply the section 1154(b) presumption to the separate issue of whether he suffered hearing loss while on active duty. Notwithstanding, the Federal Circuit explained that "[e]ven when the section 1154(b) combat presumption applies, a Veteran seeking compensation must still show the existence of a present disability and that there is a causal relationship between the present disability and the injury, disease, or aggravation of a preexisting injury or disease incurred during active duty.'" Id. at n. 9. Thus, the reduced evidentiary burden only applies to the question of service incurrence, and not to the remaining service-connection elements of current disability and nexus. See Collette v. Brown, 82 F.3d 389, 392 (Fed.Cir.1996) ("Section 1154(b) does not create a statutory presumption that a combat Veteran's alleged disease or injury is service-connected."). While the record clearly shows the Veteran had in-service combat noise exposure, there is clear and convincing evidence that the Veteran did not have hearing loss in his right ear during service. His official service treatment records show no hearing impairment on audiograms. Thus, the Veteran may not establish that there is a nexus between his military service and his current hearing loss by merely showing that "the [] disability he incurred in service was a chronic condition that persisted in the years following his active duty." Reeves, 682 F.3d at 999-1000. Rather, the Veteran must establish that his in-service exposure to combat noise led to a hearing disability following his service. Here, the VA medical opinion evidence shows that there is no such relationship. The Board notes that the Veteran submitted a private medical nexus opinion, however the opinion is of little probative value, as it does not contain a rationale for the examiner's opinion, and is based off of the Veteran's lay testimony and contains no indication that the examiner reviewed the Veteran's file and service treatment records. However, both the April 2010 and the September 2014 VA examiners reviewed the Veteran's claims file, performed an examination of the Veteran, and submitted rationales to support their opinions. As such, the Board finds that the negative nexus opinions submitted by the VA examiners outweigh the positive nexus opinion submitted by the Veteran's private physician. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). See also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (indicating most of the probative value of an opinion comes from its underlying reasoning, not just from mere review of the record, although that, too, has its importance if evidence in the file may affect the underlying basis of the opinion such as by revealing relevant facts). The Board has carefully considered the articles from the Veteran's representative providing information about delayed onset hearing loss. Medical treatise evidence can provide important support when combined with the pertinent opinion of a medical professional. Similarly, medical treatise evidence could "discuss [] generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible causality based upon objective facts." Mattern v. West, 12 Vet. App. 222, 229 (1999); Wallin v. West, 11 Vet. App. 509 (1998). Here, the aforementioned information is simply too general to make a causal link more than speculative in nature, or to outweigh the specific medical evidence in this case which is directly pertinent to the Veteran. Additionally, the Board acknowledges the Veteran's assertions that his bilateral hearing loss is related to his military service. The Board acknowledges that it is within the realm of common medical knowledge that exposure to loud noises may cause hearing loss. Therefore, the Veteran's lay opinion could possibly be sufficient to serve as the required nexus for his claim. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (explaining that lay evidence may be sufficient to establish the nexus element). However, determining the precise etiology of the Veteran's hearing loss is not a simple question, as there are conceivably multiple potential etiologies of the Veteran's sensorineural hearing loss. Ascertaining the etiology of hearing loss involves considering multiple factors and knowledge of how those factors interact with the mechanics of human hearing. In this case, the facts are complex enough that the Veteran's intuition about the cause of his hearing loss is not sufficient to outweigh the opinion of the VA expert that carefully considered the specific facts of this case. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (Lance, J., concurring) ("The question of whether a particular medical issue is beyond the competence of a layperson-including both claimants and Board members-must be determined on a case-by-case basis."). Thus, the Board finds that the Veteran's opinion is not entitled to significant weight as compared to the VA opinions, both of which determined that the Veteran's bilateral hearing loss is not related to his service. The Veteran is not entitled to service connection on a presumptive basis as his right ear hearing loss did not manifest in service, and there is no credible persuasive medical evidence or credible persuasive lay evidence that right ear hearing loss manifested to a compensable degree within one year after his departure from military service. 38 C.F.R. § 3.303(b). Thus, the Veteran's right ear hearing loss is not attributable to service. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The preponderance is against the Veteran's claim, and it must be denied. Increased rating in excess of 20 percent for left ear hearing loss. The Board acknowledges the Veteran's contentions regarding his difficulty hearing; however, the audiology examinations yielded results warranting a non-compensable rating throughout the appeal period notwithstanding the RO's erroneous treatment of both ears as service connected yielding a compensable rating in the April 2016 rating decision. This objective evidence is more persuasive with regard to the level of disability under the Rating Schedule as it specifically pertains to those rating criteria. Because all of the audiology examinations yielded non-compensable ratings, staged ratings are not appropriate for this claim. In Martinak v. Nicholson, 21 Vet. App. 447 (2007) the Court held that in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak, 21 Vet. App. at 455. The Court also noted, however, that even if an audiologist's description of the functional effects of the Veteran's hearing disability was somehow defective, the Veteran bears the burden of demonstrating any prejudice caused by a deficiency in the examination. In this case, the functional impact of the Veteran's hearing loss was that it created a safety hazard while working with electrical objects in construction. The Board in no way discounts the difficulties that the Veteran experiences as a result of his hearing loss. However, as was explained above, the assignment of disability ratings for hearing impairment is derived by a mechanical application of the rating schedule to the numeric designation assigned after audiometry results are obtained. Hence, the Board has no discretion in this matter and must predicate its determination on the basis of the results of the audiology results of record. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). In other words, the Board is bound by law to apply VA's rating schedule based on the Veteran's audiometry results. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In determining whether a higher rating is warranted for service-connected disability, VA must determine whether the evidence supports the Veteran's claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the preponderance of the evidence is against a compensable rating. In considering the claim for a higher rating, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). The Court has clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the C&P Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The symptoms associated with the Veteran's hearing loss disability are not shown to cause any impairment that is not already contemplated by the relevant diagnostic code, as cited above, and the Board finds that the rating criteria reasonably describe his disability. Therefore, referral for consideration of an extraschedular rating is not warranted. ORDER Entitlement to service connection for right ear hearing loss is denied. Entitlement to an increased rating for service connected left ear hearing loss, currently evaluated as noncompensable prior to April 4, 2016, and 20 percent disabling beginning April 4, 2016 is denied. ____________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs