Citation Nr: 18145017 Decision Date: 10/26/18 Archive Date: 10/25/18 DOCKET NO. 15-03 932A DATE: October 26, 2018 ORDER Entitlement to a disability rating higher than 20 percent for lumbar strain with degenerative disc (“low back disability”) is denied. A disability rating of 20 percent for right lower extremity lumbar radiculopathy affecting the sciatic nerve is granted, but no higher. A disability rating of 20 percent for left lower extremity lumbar radiculopathy affecting the sciatic nerve is granted, but no higher. A disability rating of 20 percent for right lower extremity lumbar radiculopathy affecting the femoral nerve is granted, but no higher. A disability rating of 20 percent for left lower extremity lumbar radiculopathy affecting the femoral nerve is granted, but no higher. Entitlement to a disability rating higher than 10 percent for post-traumatic scar, status-post injury of left orbital area (“eye scar disability”) is denied; a separate, 10 percent rating for eye scar disability is granted. The petition to reopen the claim of entitlement to service connection for bilateral hearing loss is granted. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to a disability rating higher than 10 percent for neck strain with degenerative disc and joint disease cervical spine (“neck disability”) is remanded. Entitlement to a disability rating higher than 10 percent for left knee strain (“left knee disability”) is remanded. Entitlement to service connection for bilateral hearing loss is remanded. FINDINGS OF FACT 1. For the entire appeal period, the Veteran’s low back disability was manifested by painful limitation of motion with forward flexion, at worst, to 50 degrees, but without ankylosis of the entire thoracolumbar spine or intervertebral disc syndrome (IVDS). 2. The Veteran’s radiculopathy affecting the sciatic nerves of the bilateral lower extremities was manifested by moderate incomplete paralysis, but not moderately severe incomplete paralysis. 3. The Veteran’s radiculopathy affecting the femoral nerves of the bilateral lower extremities was manifested by moderate incomplete paralysis, but not severe incomplete paralysis. 4. For the entire appeal period, the Veteran’s eye scar disability manifested as one characteristic of disfigurement and as one painful scar, but not unstable or having any disabling effect. 5. The February 2006 rating decision that denied service connection for bilateral hearing loss was final. 6. The evidence received since February 2006 is not cumulative or redundant and raises a reasonable possibility of substantiating the claim denied in the February 2006 rating decision. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 20 percent for degenerative joint disease of the lumbar spine have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.71a, Diagnostic Codes 5242-5237 (2017). 2. Throughout the period on appeal, the criteria for a disability rating of 20 percent, but no higher, for radiculopathy affecting the sciatic nerves of the left lower extremity have been met. 38 U.S.C. 1155, 5107(b); 38 C.F.R. 4.1, 4.2, 4.3, 4.7, 4.10, 4.124(a), DC 8720. 3. Throughout the period on appeal, the criteria for a disability rating of 20 percent, but no higher, for radiculopathy affecting the sciatic nerves of the right lower extremity have been met. 38 U.S.C. 1155, 5107(b); 38 C.F.R. 4.1, 4.2, 4.3, 4.7, 4.10, 4.124(a), DC 8720. 4. Throughout the period on appeal, the criteria for a disability rating of 20 percent, but no higher, for radiculopathy affecting the femoral nerves of the left lower extremity have been met. 38 U.S.C. 1155, 5107(b); 38 C.F.R. 4.1, 4.2, 4.3, 4.7, 4.10, 4.124(a), DC 8726. 5. Throughout the period on appeal, the criteria for a disability rating of 20 percent, but no higher, for radiculopathy affecting the femoral nerves of the right lower extremity have been met. 38 U.S.C. 1155, 5107(b); 38 C.F.R. 4.1, 4.2, 4.3, 4.7, 4.10, 4.124(a), DC 8726. 6. The criteria for a disability rating higher than 10 percent for status-post injury of left orbital area have not been met. 38 U.S.C. §§ 1155, 5103, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.118, Diagnostic Codes 7800, 7805 (2017). 7. The criteria for a separate, 10 percent rating for status-post injury of left orbital area have been met. 38 U.S.C. §§ 1155, 5103, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.118, Diagnostic Codes 7804, 7805 (2017). 8. New and material evidence has been received to reopen the claim for service connection for bilateral hearing loss. 38 U.S.C. 5108, 7105 (2012); 38 C.F.R. 3.156 (2017). 9. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran testified before the undersigned Veterans Law Judge in a May 2018 video conference hearing. A transcript of that hearing has been associated with the file. The Board notes that during the hearing it was clarified that the burning and drooping symptoms the Veteran testified about are claims that have been deferred in a March 2018 rating decision and are not presently before the Board. The issues of increased disability evaluations for radiculopathy of the bilateral lower extremities affecting the sciatic nerves and lower extremities affecting the femoral nerves has been raised by the record. In a February 2018 rating decision, the RO granted service connection for lumbar radiculopathy of the left and right lower extremities, affecting the sciatic nerves and the femoral nerves, assigning a 10 percent evaluation for each. The Veteran filed a notice of disagreement in March 2018. As the Board retains jurisdiction over such issues as part and parcel of the Veteran’s higher rating claim for a low back disability, these have been listed on the title page of this decision. 38 C.F.R. § 4.71a, Diagnostic Code 5237, Note (1). The issue of service connection for a disability related to speech has been raised by the record in a February 2015 VA Form 9, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for any appropriate action, and any additional development deemed necessary. 38 C.F.R. § 19.9(b) (2017). New and Material The RO denied service connection for bilateral hearing loss in a February 2006 rating decision. This decision became final in February 2007. The evidence submitted after February 2006, including a February 2018 VA Disability Benefits Questionnaire and a May 2018 Board hearing transcript, relates to unestablished facts necessary to substantiate this service connection claim. Therefore, the Board finds that this claim should be reopened. Increased Rating Disability evaluations (ratings) are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2017). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40 (2017). Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Id.; see also 38 C.F.R. § 4.59 (2017) (discussing facial expressions such as wincing, muscle spasm, crepitation, etc.). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Excess fatigability and incoordination should be taken into account in addition to more movement than normal, less movement than normal, and weakened movement. 38 C.F.R. § 4.45 (2017). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. §§ 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Low back disability The Veteran’s has been assigned a 20 percent disability rating for his service-connected lumbar spine disability under Diagnostic Codes 5242-5237. Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Under this formula, a 10 percent rating is assigned for forward flexion greater than 60 degrees but not greater than 85 degrees; or combined range of motion (ROM) of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding or localized tenderness not resulting in abnormal gait or abnormal spinal contour or vertebral body fracture with loss of 50 percent or more of the height. The criteria provides for a 20 percent disability rating for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5242 through 5237. Note (1): to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Intervertebral disc syndrome (IVDS) may be evaluated under either the General Rating Formula or under the IVDS Formula, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table). Note (1) provides that an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Additionally, Diagnostic Code 5003 provides that evaluation of degenerative arthritis shall be on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. If this results in a noncompensable evaluation, a 10 percent evaluation is assigned for each major joint or group of minor joints affected. In the absence of any limitation of motion, involvement of two or more major joints or two or more minor joint groups warrants a 10 percent evaluation, and the same with occasional incapacitating exacerbations warrants a 20 percent evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2017). The Veteran contends that his low back disability warrants a rating higher than 20 percent. For the reasons explained below, the Board finds that a rating higher than 20 percent is not warranted at any time during the appeal period. The Veteran filed his initial claim for service connection in 2005. The RO denied this claim in February 2006. This decision was not appealed and became final. The Veteran filed another claim for service connection in November 2011. As such, the appeal period commences November 2011. A June 2013 VA examination shows the Veteran’s reports of flare-ups. He described the flare-ups as straining pain that occur one to two times a week, lasting about an hour. He claimed that he experiences a 10 percent reduction in function during a flare-up. Upon physical examination, the June 2013 examiner noted the Veteran’s lumbar range of motion as follows: forward flexion at 70 degrees with 90 degrees being normal, no objective evidence of painful motion; extension at 30 degrees or greater with 30 degrees being normal, no objective evidence of painful motion; right lateral flexion at 30 degrees or more with 30 degrees being normal, no objective evidence of painful motion; left lateral flexion at 30 degrees or more with 30 degrees being normal, no objective evidence of painful motion; right lateral rotation at 15 degrees with 30 degrees being normal, no objective evidence of painful motion; left lateral rotation at 15 degrees with 30 degrees being normal, no objective evidence of painful motion. With repeated performance of range of motion examination, there was additional limitation in ROM and functional loss and or functional impairment. After repetitive testing the Veteran had a change in ROM was as follows: flexion reduced 20 degrees, and left lateral rotation reduced 5 degrees. No localized tenderness or pain to palpation for joints and/or soft tissue of the thoracolumbar spine was noted. The examiner noted guarding and/ or muscle spasm of the thoracolumbar spine, noting that it did not result in abnormal gait or spinal contour. His motor examination showed 5/5 strength throughout his lower extremities. There was no radicular pain or any other signs or symptoms due to radiculopathy. There was no indication of muscle atrophy, or ankylosis of the spine or intervertebral disc syndrome (IVDS). No assistive devices as a normal mode of locomotion was noted. Results of imaging studies indicated arthritis. The Veteran’s low back disability impacted his ability to work. He could not lift more than 25 pounds, could not walk more than 1 mile at one time, could not walk more than 1.5 miles in an 8-hour day, could not stand more than 4 hours at one time, or sit more than 20 minutes, and could not stand more than 5 hours or sit more than 3 hours in an 8- hour day. The Veteran was afforded another VA examination in April 2015. He reported not taking any prescribed medications for his low back disability. He reported that his back had worsened with time. Upon physical examination in April 2015, the Veteran’s lumbar range of motion as follows: forward flexion at 70 degrees with 90 degrees being normal, no objective evidence of painful motion; extension at 20 degrees or greater with 30 degrees being normal, no objective evidence of painful motion; right lateral flexion at 25 degrees with 30 degrees being normal, no objective evidence of painful motion; left lateral flexion at 25 degrees with 30 degrees being normal, no objective evidence of painful motion; right lateral rotation at 30 degrees or more with 30 degrees being normal, no objective evidence of painful motion; left lateral rotation at 30 degrees or more with 30 degrees being normal, no objective evidence of painful motion. There was no additional limitation in ROM following repetitive-use testing. Functional loss and/ or functional impairment was noted. There was no localized tenderness or pain to palpation for joints and/or soft tissue of the thoracolumbar spine. His motor examination showed 5/5 strength throughout his lower extremities. There was no radicular pain or any other signs or symptoms due to radiculopathy. There was no indication of muscle atrophy, or ankylosis of the spine or intervertebral disc syndrome (IVDS). No assistive devices as a normal mode of locomotion was noted. Imaging studies were not performed. His disability did impacted ability to work. The functional impairment was that he could not lift more than 40 pounds, he was not able to walk more than 0.5 miles at one time, he was unable to walk more than 1 mile in an 8-hour day, he was unable to stand more than 1 hour at one time, or sit more than 2 hours, and during an 8-hour day he would not be able to stand or sit more than 4 hours. The flare-ups included pain, which occurs 36 times a year, lasting 10 minutes and that limits movement and walking. The examiner concluded that he was unable to assess estimated degrees of additional ROM loss as the Veteran was not able to replicate the estimated limitation at the time of examination. The Veteran was afforded another VA examination in February 2018. He described his pain as worse since its onset, describing the symptoms as back pain, swelling, aching, and sharp pain all the way up to his neck down to his toes. He reported flare-ups, describing it as occurring during cold weather, when he stands for long periods, when he lifts heavy things, and when he runs or walks for too long. He described the functional loss or functional impairment as being unable to do any lifting, walking, or running for long periods of time, or being unable to work out or do recreational activities. Upon physical examination in February 2018 the Veteran’s lumbar range of motion was as follows: forward flexion at 85 degrees with 90 degrees being normal, extension at 25 degrees or greater with 30 degrees being normal, right lateral flexion at 30 degrees with 30 degrees being normal, left lateral flexion at 30 degrees with 30 degrees being normal, right lateral rotation at 30 degrees with 30 degrees being normal, left lateral rotation at 30 degrees with 30 degrees being normal. There was no guarding or muscle spasm noted. The examiner stated that he was unable to describe flare-ups in terms of ROM, as loss of ROM was not anticipated. However, the examiner noted that functional loss was present due to increased pain, weakness, fatigue, and decreased movement during flare-ups. Pain, weakness, fatigability or incoordination would significantly limit functional ability with flare-ups. With repetitive-use testing after three repetitions additional limitation in ROM was noted. Pain that causes functional loss was noted on examination with respect to ROM on forward flexion and extension. ROM after 3 repetitions was recorded as: forward flexion to 75, extension to 20, right lateral flexion to 25, left lateral flexion to 25, right lateral rotation to 30, and left lateral rotation to 30. No localized tenderness or pain to palpation for joints and/or soft tissue of the thoracolumbar spine was noted. Evidence of pain with weight bearing was noted. His motor examination showed 4/5 strength throughout his lower extremities. Radicular pain or any other signs or symptoms due to radiculopathy was noted. Moderate intermittent pain, paresthesias/and or dysesthesias, and numbness in the bilateral lower extremities were noted. Femoral and sciatic nerves on both sides were the nerve roots involved with his radiculopathy. There was no indication of muscle atrophy, or ankylosis of the spine or intervertebral disc syndrome (IVDS). No use of assistive devices as a normal mode of locomotion was noted. Imaging studies were not performed. Objective evidence of pain when the back is used in non-weight bearing was noted. Passive ROM was noted as the same as active ROM. The Veteran’s low back disability impacted his ability to work. As part of his duties as a kinesiology student he would shadow health care providers and has had to take frequent breaks to alternate sitting and standing positions. He was unable to walk or stand for extended periods of time and had trouble walking extended distances across campus. After review of the evidence, the Board finds that for the entire appellate period a 20 percent rating is warranted because the evidence of record shows forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees—even when considering the evidence of flare-ups, painful motion, and functional loss. The preponderance of the evidence is against a finding supporting a higher rating under applicable diagnostic criteria under the General Rating Formula and Diagnostic Codes 5242 and 5237. There was muscle spasm or guarding, but at no time during the appeal period was it severe enough to result in abnormal gait or abnormal spinal contour. In addition, there was no indication of favorable ankylosis of the entire thoracolumbar spine. Therefore, a 40 percent disability rating could not be assigned. The Veteran reported flare-ups and functional loss was noted. The functional loss was due to increased pain, weakness, and fatigue, but there was no decreased movement during flare-ups. The 20 percent disability rating assigned accounts for these symptoms. The Board notes that the Veteran’s flexion appears to have improved throughout the pendency of the appeal. However, accounting for the functional loss, flare-ups and in the light most favorable to the Veteran, the Board finds that a 20 percent disability rating is warranted for the entire period on appeal. A 40 percent rating is warranted if forward flexion is 30 degrees or less or favorable ankylosis of the entire spine. Again, the Veteran is not entitled to a higher disability rating because he does not have forward flexion of the thoracolumbar spine 30 degrees or less or, favorable ankylosis of the entire thoracolumbar spine. Lastly, there is no probative evidence of record to indicate IVDS, so the Veteran would not warrant a higher rating under IVDS. In arriving at this conclusion, the Board has carefully considered the Veteran’s lay assertions. The Board understands his belief that his symptoms warrant a disability rating higher than 20 percent. However, the Board finds that the VA examinations outweigh the Veteran’s contentions. Notably, although the Veteran reported flare-ups, it is observed that even when pain that causes functional loss was noted during the February 2018 examination, he could forward flex to 85 degrees. Thus, it is considered that the rating assigned reasonably contemplates any flare-ups as may occur and is consistent with the spirit of Mitchell, supra. Even with the ROM being reduced, as noted in the June 2013 VA and February 2018 examinations, after repetitive testing—forward flexion did not go below 50 degrees, with the most recent forward flexion after repetitive testing recorded at 75 degrees. The Board notes that the February 2018 VA examiner noted radiculopathy affecting the sciatic nerves and femoral nerves. These claims will be discussed below. In sum, the most probative evidence of record does not support a rating higher than 20 percent for the Veteran’s low back disability. Radiculopathy affecting the sciatic nerves of the bilateral lower extremities and radiculopathy affecting the femoral nerves of the bilateral lower extremities The Veteran is service connected for radiculopathy affecting the sciatic nerves and radiculopathy affecting the femoral nerves. His radiculopathy affecting the sciatic nerves of the left and right lower extremities is rated as 10 percent disabling under Diagnostic Code 8720, which governs paralysis of the sciatic nerve. The effective date assigned was January 10, 2018—the date the VA 21-0966 intent to file was submitted. Note (1) to the General Rating Formula for the Spine directs any associated objective neurologic abnormalities to be evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a. Here, the evidence shows radiculopathy in the lower extremities but no bowel or bladder disturbance. Diseases affecting the sciatic nerves are rated on the basis of degree of paralysis, neuritis, or neuralgia under 38 C.F.R. § 4.124a. Under Diagnostic Code 8720, a 10 percent rating is warranted for mild incomplete paralysis and a 20 percent rating is warranted for moderate incomplete paralysis of the sciatic nerve. A 40 percent evaluation is warranted for moderately severe incomplete paralysis of the sciatic nerve, and a 60 percent rating is applicable if the incomplete paralysis is severe with marked muscle atrophy. Id. An 80 percent rating is available for complete paralysis evidenced by the foot dangling and dropping, no possible active movement below the knee, and weakened or lost flexion of the knee. Id. The Veteran’s radiculopathy affecting the femoral nerves of the left and right lower extremities is rated as 10 percent disabling under Diagnostic Code 8726, which governs paralysis of the femoral nerve. The effective date assigned is also January 10, 2018. Diagnostic Code 8726 rates neuralgia associated with the anterior crural (femoral) nerve. A 10 percent evaluation is warranted for mild incomplete paralysis of the anterior crural (femoral) nerve. A 20 percent rating requires evidence of moderate incomplete paralysis of anterior crural (femoral) nerve. A 30 percent rating requires evidence of severe incomplete paralysis of anterior crural (femoral) nerve. A 40 percent rating requires evidence of complete paralysis. When there is complete paralysis, there is paralysis of the quadriceps extensor muscles. Id. Neuralgia is characterized usually by a dull and intermittent pain. The maximum rating for neuralgia is equal to moderate incomplete paralysis of the involved nerve. 38 C.F.R. § 4.124 (2017). The term “incomplete paralysis” indicates a degree of lost or impaired function that is substantially less than that which is described in the criteria for an evaluation for complete paralysis of this nerve, whether the less than total paralysis is due to the varied level of the nerve lesion or to partial nerve regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. 4.124a. The Board notes that words such as mild, moderate and severe, as used in the various diagnostic codes are not defined in the rating schedule. The use of these terms by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. 38 C.F.R. 4.2, 4.6. Rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. 4.6. For the reasons explained below, the Board finds that a 20 percent rating, but no higher, for each impacted nerve (sciatic and femoral) in each lower extremity is warranted. The Veteran underwent examinations for his service-connected low back disability in June 2013 and April 2015. Upon physical examination, neither VA examiner noted any radicular symptoms or radiculopathy. The Veteran did not report any radicular symptoms during either examination. The Veteran submitted an intent to file in January 2018. During the February 2018 VA examination, the VA examiner noted radicular pain and or symptoms due to radiculopathy. He noted that it affects the Veteran’s left and right lower extremities, describing the intermittent pain as moderate on both sides and the paresthesia and or dysesthesias as moderate on both sides. Numbness on both sides was noted as moderate with no other signs of or symptoms of radiculopathy. The nerve roots involved were listed as L2/L3/L4 (femoral nerves) and L4/L5/S1/S2/S3 (sciatic nerves). The severity for both sides was described as moderate. After review of the evidence, the Board finds that as of January 2018, a 20 percent rating is warranted, but no higher, for each lower extremity. The Board finds, however, that the most probative evidence of record does not show moderately severe incomplete paralysis of the sciatic nerves or severe incomplete paralysis of the femoral nerves, and a rating higher than 20 percent is not warranted. The preponderance of the evidence is against a finding supporting a higher rating under applicable diagnostic criteria under the Diseases of the Peripheral Nerves and Diagnostic Codes 8720 and 8726. The Veteran presented with moderate pain on the left and right lower extremities affecting the sciatic nerves and the femoral nerves, moderate paresthesias and/or dysesthesias in both lower extremities affecting the sciatic nerves and the femoral nerves, and moderate numbness in both lower extremities affecting the sciatic nerves and the femoral nerves. At no time during the appeal period has he had moderately severe paralysis of the sciatic nerves or severe incomplete paralysis of the femoral nerves, and this is consistent with the lay and medical evidence of record. Therefore, a 40 percent disability for sciatic nerves or 30 percent disability rating for femoral nerves is not warranted. In arriving at this conclusion, the Board has carefully considered the lay assertion of the Veteran, requesting the maximum allowed. See March 2018 Notice of Disagreement. The Board understands his belief that his symptoms warrant disability ratings higher than 20 percent, but finds the Veteran is not competent to determine whether his radiculopathy meets the criteria for a higher rating. Moreover, the Board finds that the VA examination outweighs the Veteran’s contentions that his symptoms of radiculopathy of his bilateral lower extremities warrant a rating higher than 20 percent. A 20 percent rating, but no higher, for radiculopathy in each lower extremity affecting the sciatic nerves and in each lower extremity affecting the femoral nerves, is warranted. Eye scar disability The Veteran’s eye scar disability is rated as 10 percent disabling under Diagnostic Code 7800, which pertains to burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. 38 C.F.R. § 4.118, Diagnostic Code 7800. Under Diagnostic Code 7800, a 10 percent rating is warranted for scars that are located on the head, face, or neck when there is one characteristic of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. A 30 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, or lips), or; with two or three characteristics of disfigurement. Id. A 50 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. Id. An 80 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. Id. For purposes of evaluation of under 38 C.F.R. § 4.118, the eight characteristics of disfigurement are: a scar that is five or more inches, or thirteen centimeters, in length; a scar that is at least one-quarter of an inch, or 0.6 centimeters, wide at the widest part; surface contour of the scar that is elevated or depressed on palpation; a scar that is adherent to underlying tissue; skin that is hypo- or hyper-pigmented in an area exceeding six square inches, or 39 square centimeters; skin texture that is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches, or 39 square centimeters; underlying soft tissue that is missing in an area exceeding six square inches, or 39 square centimeters; and skin that is indurated and inflexible in an area exceeding six square inches, or 39 square centimeters. 38 C.F.R. § 4.118, Diagnostic Code 7800, Note 1. VA is to consider unretouched color photographs when evaluating under these criteria. Id. at Note 3. Additionally, VA is to separately evaluate disabling effects other than disfigurement that are associated with individual scars of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s) and apply 38 C.F.R. § 4.25 to combine the evaluation(s) with the evaluation assigned under Diagnostic Code 7800. Id. at Note 4. Finally, the characteristics of disfigurement may be caused by one scar or by multiple scars; the characteristics that are required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. Id. at Note 5. The Board notes that during the pendency of the appeal, the criteria for evaluating certain disabilities of the skin were revised, effective August 13, 2018. See 38 C.F.R. § 4.118, (Diagnostic Codes 7801, 7802, 7805, and 7806) (2017). The amended regulations are only applicable to claims received on or after August 13, 2018, or where a claimant requests readjudication under the new criteria. See 83 Fed. Reg. 32592 (August 13, 2018) (codified at 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7805, 7806 (2017)). Even though the amended regulations are not substantially different from the prior versions and would not result in a different outcome, the Board will consider both versions. As the Veteran’s scar is on his face, Diagnostic Codes 7801 and 7802 are not for application. Diagnostic Code 7806 is also not for application, as the disability is not a skin rash (dermatitis or eczema). As such, with respect to the revised diagnostic codes, the Board will only address Diagnostic Code 7805. Diagnostic Code 7804 has not been revised during the pendency of this claim. Under Diagnostic Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful, with a maximum 30 percent rating warranted for five or more scars that are unstable or painful. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1). If one or more scars are both unstable and painful, 10 percent is added to the evaluation that is based on the total number of unstable or painful scars. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (2). Scars can receive separate evaluations under Diagnostic Codes 7800, 7801, 7802, and 7805, despite also being rated under Diagnostic Code 7804. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (3). As stated above, Diagnostic Code 7805 has been revised. However, a review of the codes indicates that there is no substantive change in the language. Criteria effective prior to the August 13, 2018 revision Under Diagnostic Code 7805, any other scars, including linear scars, are to be rated based on any disabling effects not considered in a rating provided under Diagnostic Codes 7800-7804 under an appropriate diagnostic code for such effects. This instruction essentially directs that scars may be rated for the functional impairment caused by the scar. Criteria effective from August 13, 2018 Under Diagnostic Code 7805, any other scars, and other effects of scars are to be rated based on any disabling effects not considered under Diagnostic Codes 7800 through 7804. Diagnostic Code 7805 directs that any disabling effect(s) not considered in Diagnostic Codes 7800 through 7804 should be evaluated under the appropriate diagnostic code. This instruction essentially directs that scars may be rated for the functional impairment caused by the scar. In a February 2006 rating decision, the RO granted service connection for eye scar disability, assigning a noncompensable rating under Diagnostic Code 7800, with an effective date of June 2, 2005. In an October 2014 rating decision, the RO assigned a 10 percent disability rating under Diagnostic Code 7800 based on one characteristic of disfigurement (scar at least one-quarter inch wide at widest part), with an effective date of November 14, 2011. As the Veteran’s claim for increased disability rating was filed in November 2011—that is the date the appeal period commences. A May 2012 VA Disability Benefits Questionnaire (DBQ) for eye conditions lists the diagnosis as post traumatic scar left orbital area. During this examination, it was noted that the Veteran has scarring or disfigurement. An attribute of the scar was visible or palpable tissue loss. In the notation the examiner described an indented scar around orbital rim in superior temporal area. A June 2013 VA DBQ for scars/disfigurement lists the diagnosis as left eye scar. The scar was not painful or unstable. The scar was located in the left eye, and measured 0.1 centimeter by 4 centimeters. There was no visible or palpable tissue loss indicated. The examiner concluded that the scar did not result in limitation of function or impact the Veteran’s ability to work. A February 2018 VA DBQ for scars/disfigurement lists the diagnosis as post-traumatic scar, status-post injury of left orbital area. There were no scars on the trunk or extremities noted. The scar was not noted to be painful. However, in another section of the examination that appeared to be inapplicable to this scar, it was noted that the Veteran described the pain as a burning sensation, saggy skin, and irritation. The examiner noted there was no unstable scar. One scar was noted, located at the left eyebrow. The measurement was 4 centimeters by 0.8 centimeters. There was no visible or palpable tissue loss indicated. The examiner concluded that the Veteran’s scar did not impact his ability to work. During a February 2018 VA eye conditions examination, the examiner noted that the Veteran’s scar was at least one quarter inch wide at its widest part. During the May 2018 Board hearing the Veteran testified that his scar is painful. The most probative evidence shows that the Veteran’s eye scar disability warrants no more than a 10 percent disability rating under Diagnostic Code 7800, and a separate, compensable rating of 10 percent under Diagnostic Code 7804, for the entire period on appeal. As stated above, the Veteran’s eye scar has been rated as 10 percent disabling under Diagnostic Code 7800. A 10 percent rating is warranted when there is one characteristic of disfigurement. Here, the Veteran’s scar has been measured to be at least one quarter inch wide at its widest part. This has been contemplated by the 10 percent rating currently assigned. The Board notes that the May 2012 VA examiner indicated that the Veteran’s scar had visible or palpable tissue loss. However, as that examination was specifically for eye conditions and not scars, the Board views that indication as a clerical error. In addition, there are two VA DBQs of record, specifically for scars, that clearly state the Veteran’s eye scar does not result in visible or palpable tissue loss. Lastly, both DBQs were performed after the May 2012 VA examination and therefore assessed the Veteran’s then current level of severity more recently. Therefore, a higher rating of 30 percent is not warranted, as there is no probative evidence of record that the eye scar has visible or palpable tissue loss or has two or three characteristics of disfigurement. Under Diagnostic Code 7804, a 10 percent rating is warranted if there is a scar that is either unstable or painful. Here, the Veteran testified that his eye scar is painful. The Board finds his testimony to be credible and in the light most favorable to the Veteran finds that his scar has been painful during the entire period on appeal. As such, the Board finds that a separate, compensable disability rating of 10 percent is warranted. Therefore, resolving doubt in favor of the Veteran, the Board finds that the Veteran’s eye scar warrants a 10 percent rating for the entire appeal period. A 20 percent rating is warranted for three or four scars that are unstable or painful. Here, the Veteran has one scar. As such, a 20 percent rating is not warranted. An additional 10 percent evaluation is to be applied if there are any scars that are both unstable and painful. As noted above, the VA examiners clearly noted that the Veteran’s eye scar was not unstable with frequent loss of covering of skin over the scar. Absent any additional scars and in the absence of an unstable scar, a rating higher than 10 percent under this code is not warranted. As stated above, Diagnostic Code 7805 essentially directs that scars may be rated for the functional impairment caused by the scars when the disabling effects of the scars are not contemplated by Diagnostic Codes 7800 through 7804. Here, as the VA examiners agree—there is no functional impact or impact on the Veteran’s ability to work. The Board appreciates the Veteran’s contentions that his scar is painful. The 10 percent separate rating contemplates his painful scar. The medical evidence of record is considered more probative than the Veteran’s contentions, and the medical evidence indicates that the scar is not restrictive or disabling. As such, the evidence shows that there is no functional impairment or additional disabling effects as a result of the eye scar disability. Also, as the current criteria are substantially the same, the disability would not warrant a different or higher rating under the revised diagnostic code. The Board also finds that a compensable or separate rating is not warranted under any other Diagnostic Code as the Veteran’s scar is located on his face and does not warrant consideration under Diagnostic Codes 7801 and 7802. A disability rating higher than 10 percent under Diagnostic Code 7800 is not warranted and a disability rating higher than 10 percent under Diagnostic Code 7804 is not warranted for eye scar. TDIU Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that the Veteran meets the schedular requirements. If there is only one service-connected disability, this disability should be rated at 60 percent or more; if there are two or more disabilities, at least one should be rated at 40 percent or more with sufficient additional service-connected disability to bring the combination to 70 percent or more. 38 C.F.R. § 4.16(a). To meet the requirement of “one 60 percent disability” or “one 40 percent disability,” the following will be considered as one disability: (1) disability of one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from one common etiology; (3) disabilities affecting a single body system; (4) multiple injuries incurred in action; and (5) multiple disabilities incurred as a prisoner of war. Id. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran initially filed a claim for TDIU in February 2015. The RO denied the TDIU claim in a July 2014 statement of the case. The Veteran timely appealed this decision. He contends that he became too disabled to work in February 2015 due to his service connected disabilities—specifically his PTSD and low back disability. His service-connected disabilities include: PTSD rated as 70 percent; lumbar strain with degenerative disc disease lumbar spine rated at 20 percent; left knee strain associated with right patellofemoral pain syndrome rated at 10 percent; right patellofemoral pain syndrome rated at 10 percent; neck strain with degenerative disc and joint disease cervical spine rated at 10 percent; tinnitus rated at 10 percent; post traumatic scar, status post injury of left orbital area rated at 10 percent; right lower extremity lumbar radiculopathy affecting the sciatic nerve associated with lumbar strain with degenerative disc disease rated at 10 percent; left lower extremity lumbar radiculopathy affecting the sciatic nerve associated with lumbar strain with degenerative disc disease rated at 10 percent; right lower extremity lumbar radiculopathy affecting the femoral nerve associated with lumbar strain with degenerative disc disease rated at 10 percent; left lower extremity lumbar radiculopathy affecting the femoral nerve associated with lumbar strain with degenerative disc disease rated at 10 percent; diplopia rated at 0 percent; fracture, and left orbital floor rated at 0 percent. His combined rating is 90 percent. Therefore, the schedular threshold requirement for establishing entitlement to TDIU has been met. The Veteran has at least one disability ratable at 40 percent or more, and the additional service-connected disabilities bring the combined rating to 70 percent or more. As such, 38 C.F.R. § 4.16(a) is for application. Here, the Veteran’s service-connected disabilities meet the threshold percentage requirements to establish eligibility for TDIU pursuant to 38 C.F.R. § 4.16(a). It must still be determined whether he is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. In VA Form 21-8940 the Veteran indicated that his PTSD and low back disabilities are the disabilities that prevent him from securing employment. He indicated that he was employed full time as a sales manager from 2010 to 2015, stating that the last time he worked full-time was in February 2015. He stated he became too disabled to work in February 2015. According to his TDIU application, the Veteran completed one year of college. In VA Form 21-4192, the Veteran’s former employer indicated that the Veteran’s employment ended as a result of a reduction in labor. The Veteran was afforded a VA examination in relation to his service-connected PTSD in June 2013. During this examination, the reported working as a manager since February 2010, previously working for Verizon for 9 years. He reported that he loved his work. The examiner summarized the Veteran’s level of occupational and social impairment as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation. All the VA examinations related to the Veteran’s low back disability describe the impact his back has on his ability to work, noting the specific physical limitations involved. VA medical treatment records note the Veteran’s reports of difficulty working as a result of his PTSD symptoms. See April 2016 and January 2018 VA medical notes. The Veteran has provided competent testimony to show that his former full-time employment was severely impacted by his service-connected PTSD and it impacted his ability to perform his work duties. The Veteran meets schedular requirements for a TDIU, is service connected for many disabilities-including PTSD. The medical and lay evidence of record show that his service-connected disabilities cause a significant impact on his ability to work. The Board finds that the realistic chances of the Veteran obtaining and retaining employment must also be considered in light of his physical and educational capabilities. Although it is conceivable that there may be some occupations that that the Veteran could perform, the totality of the evidence supports a finding that his service-connected disabilities render him unable to obtain and maintain substantially gainful employment when his educational and work background are taken into consideration. Thus, the Board will resolve reasonable doubt in the Veteran’s favor and find that he has been unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. As such, a TDIU is granted. REASONS FOR REMAND Entitlement to an increased disability rating for neck disability, for a left knee disability and entitlement to service connection for bilateral hearing loss are remanded After a thorough review of the Veteran’s claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of the neck disability and left knee claims. The last VA examination of the neck disability occurred in June 2013. There are two cases from the United States Court of Appeals for Veterans’ Claims (Court) that were decided subsequent to the last VA examination that discusses what constitutes an adequate examination. The Court, in Correia v. McDonald, 28 Vet. App. 158 (2016) held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court’s holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. In addition, the Court, in Sharp v. Shulkin, 29 Vet. App. 26 (2017) held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. As such, a new VA examination is required to assess the Veteran’s current level of severity regarding his neck disability. The increased disability claim for the left knee disability must also be remanded, as the examinations fail to comply with Sharp v. Shulkin. First, the May 2012 VA examiner only focused on the Veteran’s service-connected right knee disability, despite the examiner specifically noting that there were some abnormalities related to the left knee, and the Veteran having an active claim for his left knee, as he filed in November 2011. Most relevant, is that the Veteran reported flare-ups of the left knee during the June 2013 VA examination and the February 2018 VA examination. The VA examiners failed to provide an estimate of motion loss in terms of degrees for the flare-ups. In addition, the wording of the examination report makes it unclear as to whether the Veteran’s ROM was assessed after repetitive motion. As such, a new examination is required. The Board notes that the Veteran recently underwent a VA examination in September 2018. Unfortunately, upon review of the examination report the Board finds that another VA examination is still required. The examiner who performed the February 2018 examination, also performed the September 2018 VA examination and the language of both reports are similar. The VA examiner identified his specialty as family medicine and identified himself as a doctor of osteopathy. In neither the February 2018 or September 2018 examination reports, did the VA examiner provide an estimate of motion loss in terms of degrees for the flare-ups. The examiner simply noted the same language the Veteran reportedly used when describing the flare-ups and stated that no loss of range of motion was anticipated. This, despite the examiner noting in the February 2018 examination, that there was additional ROM after repetitive use. In addition, the examiner noted that there was no additional ROM after repetitive use during the September 2018 VA examination, despite the Veteran reporting a worsening of symptoms. The record indicates that there is no current diagnosis of hearing loss under VA regulations. However, in-service noise exposure has been conceded and the Veteran is service connected for tinnitus. The Veteran’s hearing loss has not risen to the level required to be considered a hearing loss disability for VA purposes. However, the last VA examination the Veteran had with respect to his hearing loss occurred in February 2018. The Veteran testified that his hearing has continued to decline. As there is some indication that he may now have hearing loss thresholds that may be considered disabling for VA purposes, a new examination would be helpful. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination to determine the current severity of his neck disability. The Veteran’s electronic claims file should be made available to and reviewed by the examiner. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the neck disability alone and discuss the effect of the Veteran’s neck disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or whether it is due to the examiner not having the knowledge or training. 2. Schedule the Veteran for an examination of the current severity of his left knee disability—if possible, with someone other than the VA examiner that performed the February 2018 and September 2018 VA examinations. The Veteran’s electronic claims file should be made available to and reviewed by the examiner. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the left knee disability alone and discuss the effect of the Veteran’s left knee disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or whether it is due to the examiner not having the knowledge or training. 3. The AOJ should schedule the Veteran for a VA audiological examination with an appropriate examiner to determine the current nature and etiology of the claimed bilateral hearing loss disability. The claims file must be made available to the examiner for review, and the examiner should note that it has been reviewed in full. The examiner should elicit from the Veteran a complete history of his claimed hearing loss. Any tests or studies deemed necessary should be conducted. For any established hearing loss, the examiner is requested to provide an opinion as to whether it is at least as likely as not (i.e., at least a 50 percent probability or higher) that any such disability was either caused or aggravated by his military service, to include in-service noise exposure. For purposes of this opinion, the examiner is asked to presume that the Veteran had significant noise exposure during service. Offer an opinion as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran’s hearing loss is proximately due to or caused by the Veteran’s service-connected disabilities, to include his service-connected tinnitus. Offer an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s hearing loss, was aggravated (worsened in severity beyond a natural progression) by his service-connected disabilities, to include his service-connected tinnitus. A complete rationale for all opinions should be provided. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Talamantes, Associate Counsel