Citation Nr: 18145820 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 15-32 029 DATE: October 30, 2018 ORDER An effective date prior to July 23, 2012 for the award of a 10 percent rating for lumbosacral strain is denied. An effective date prior to July 23, 2012 for the award of service connection for radiculopathy of the right lower extremity is denied. An effective date of July 23, 2012, but no earlier, for the award of a total disability rating based on individual unemployability (TDIU) is granted. A rating higher than 60 percent for right knee total arthroplasty, to include based on referral for extraschedular consideration, is denied. A rating higher than 0 percent for amputation of distal phalanx, right 5th digit, with scar, is denied. A rating higher than 0 percent for bilateral hearing loss is denied. REMANDED Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a left hip disability is remanded. The petition to reopen the service connection claim for tinnitus is remanded. Entitlement to a rating higher than 10 percent for lumbosacral strain is remanded. Entitlement to a rating higher than 10 percent for radiculopathy of the right lower extremity is remanded. Entitlement to an effective date earlier than July 23, 2012 for the award of a total disability rating based on individual unemployability (TDIU) is remanded. REFERRED Claims for service connection for psoriasis and left lower extremity radiculopathy were raised in the Veteran’ January 2014 notice of disagreement. They have not been addressed by the Agency of Original Jurisdiction (AOJ). Accordingly, they are referred to the AOJ) for appropriate action. See 38 C.F.R. § 19.9(b) (2017). FINDINGS OF FACT 1. The Veteran’s claim for an increased rating for his service-connected lumbosacral strain was received by VA on July 23, 2012. 2. Service connection for radiculopathy of the right lower extremity was granted based on the Veteran’s July 23, 2012 claim for an increased rating for lumbosacral strain as a manifestation of that disability. 3. The Veteran submitted an informal claim for a TDIU on July 23, 2012, followed by a formal application on August 15, 2012. 4. The 60 percent rating assigned the Veteran’s right knee total arthroplasty is the maximum available under the rating schedule for such disability, and it does not present such an exceptional or unusual disability picture as to render impractical application of the schedular criteria. 5. The rating schedule does not provide for a compensable rating for amputation of a single finger at the distal phalanx, and the scar is not painful or unstable. 6. The Veteran’s right ear hearing loss is manifested by a puretone threshold average of 44 decibels in the right ear and a speech discrimination score of 94 percent; his left ear hearing loss is manifested by a puretone threshold average of 68 decibels and a speech discrimination score of 96 percent. CONCLUSIONS OF LAW 1. The criteria for an effective date earlier than July 23, 2012 for the award of a 10 percent rating for service-connected lumbosacral strain are not met. 38 U.S.C. § 5110 (2017); 38 C.F.R. § 3.400 (2017). 2. The criteria for an effective date earlier than July 23, 2012 for the award of service connection for radiculopathy of the right lower extremity are not met. 38 U.S.C. § 5110 (2017); 38 C.F.R. § 3.400 (2017). 3. The criteria for an effective date of July 23, 2012 for the award of a TDIU are satisfied. 38 U.S.C. § 5110 (2017); 38 C.F.R. § 3.400 (2017). 4. A rating higher than 60 percent for right knee total arthroplasty may not be awarded as a matter of law, and the criteria for referral for extraschedular consideration are not satisfied. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.68, 4.71a Diagnostic Code 5055 (2017). 5. A compensable rating for amputation of distal phalanx, right 5th digit may not be awarded as a matter of law, and the criteria for a compensable rating for the scar are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.71a, Diagnostic Code 5199-5156, 5227 (2017); 38 C.F.R. § 4.118 (2012, 2018). 6. The criteria for a compensable rating for bilateral hearing loss are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, Diagnostic Code 6100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1960 to December 1963, and from September 1964 to October 1977. These matters come before the Board of Veterans’ Appeals (Board) on appeal from January 2013 and July 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). An appeal concerning entitlement to an automobile or other conveyance and adaptive equipment, or for adaptive equipment only, was recently certified to the Board. That appeal has not yet been docketed, and will be addressed by the Board in docket order. Effective Date Except as otherwise provided, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 5110(a); 38 C.F.R. § 3.400. The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if the application is received within one year from such date; otherwise, it is the date of receipt of the claim. 38 U.S.C. § 5110(a), (b)(2); 38 C.F.R. § 3.400(o). Thus, the effective date of an award of increased compensation may be assigned up to one year prior to the date of claim, if an ascertainable increase in disability is established during that period. Hazan v. Gober, 10 Vet. App. 511, 519 (1992). With respect to the date of claim, a specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid to any individual under VA law. 38 U.S.C.§§ 501, 5101 (2012); 38 C.F.R. § 3.151 (2017). Effective prior to March 2015, VA regulation provided that any communication or action, indicating an intent to apply for one or more VA benefits may be considered an informal claim. 38 C.F.R. § 3.155(a) (2017); Brannon v. West, 12 Vet. App. 32, 34-5 (1998). Such informal claims must identify the benefit sought. 38 C.F.R. § 3.155(a). Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. Id. If received within one year from the date it was sent to the claimant, it will be considered as filed as of the date of receipt of the informal claim. Id. Although this regulation is no longer extant, because it was in effect during the pendency of this appeal, it is applicable to the present case. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990) (when the evidence supports the claim or is in relative equipoise, the claim will be granted). 1. An effective date earlier than July 23, 2012 for the award of a 10 percent rating for service-connected lumbosacral strain is denied. The Veteran has not advanced any arguments in support of his appeal of the effective date assigned the award of the 10 percent rating for his service-connected lumbosacral strain. The RO found that the Veteran’s claim for an increased rating for this disability was received on July 23, 2012. The record does not show a formal or informal claim for an increased rating prior to that date following the August 2006 rating decision that awarded service connection. The VA treatment records do not show an ascertainable increase in disability within the one-year period preceding the date of claim. Accordingly, an earlier effective date is not warranted. Because an earlier effective date may not be assigned as a matter of law, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Sabonis v. West, 6 Vet. App. 426, 430 (1994). 2. An effective date earlier than July 23, 2012 for the award of service connection for radiculopathy of the right lower extremity is denied. Service connection for radiculopathy of the right lower extremity was awarded as secondary to the Veteran’s lumbosacral strain. In other words, in evaluating the Veteran’s lumbosacral strain for rating purposes, the RO awarded service connection and a separate 10 percent rating for radiculopathy as a manifestation of the lumbosacral strain. See 38 C.F.R. § 3.310 (2017) (providing for service connection on a secondary basis); see also 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (providing that associated neurologic abnormalities will be evaluated separately under an appropriate diagnostic code). The Veteran does not state, and the record does not show, that a claim for right lower extremity radiculopathy was submitted prior to July 23, 2012. Accordingly, the July 23, 2012 effective date is proper. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Sabonis v. West, 6 Vet. App. 426, 430 (1994). 3. An effective date of July 23, 2012, but no earlier, for the award of a TDIU is granted. The grant of a TDIU is an award of increased disability compensation for purposes of assigning an effective date. See Rice v. Shinseki, 22 Vet. App. 447, 454 (2009), Dalton v. Nicholson, 21, Vet. App. 23, 32-34 (2007); Wood v. Derwinski, 1 Vet. App. 367, 369 (1991).] The RO assigned an effective date of August 15, 2012 for the award of TDIU. The Board finds that this was error. The Veteran submitted an informal claim for a TDIU on July 23, 2012. This was followed by a formal application (VA Form 21-8940) received by VA on August 15, 2012. The issue of entitlement to TDIU is also part and parcel of the Veteran’s increased rating claims, which the RO found were submitted on July 23, 2012. See Rice v. Shinseki, 22 Vet. App. 447, 453, 455 (2009). Thus, based on the date of claim for TDIU and the date of the increased rating claims, which raised the issue of unemployability, an effective date of July 23, 2012 is warranted. See id.; 38 C.F.R. §§ 3.155(a), 3.400. Increased Rating VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2017). The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected disabilities in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Diagnostic codes in the rating schedule identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2017). Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see 38 C.F.R. § 3.102. Because the level of disability may have varied over the course of the claim, the rating may be “staged” higher or lower for segments of time during the period under review in accordance with such variations. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990) (when the evidence supports the claim or is in relative equipoise, the claim will be granted). 1. A rating higher than 60 percent for right knee total arthroplasty, to include based on referral for extraschedular consideration, is denied. The Veteran seeks a rating higher than 60 percent for his right knee total arthroplasty, including on an extraschedular basis. See January 2014 Notice of Disagreement Agreement. For the following reasons, the Board finds that a rating higher than 60 percent is not warranted. A. Schedular Criteria The Veteran’s right knee total arthroplasty is rated under Diagnostic Code (DC) 5055, which provides, in part, that a 100 percent rating is assigned for one year following implantation of prosthesis. 38 C.F.R. § 4.71a. Thereafter, the maximum rating available under DC 5055 is a 60 percent rating, which is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Id. As more than a year has passed since the Veteran’s right knee arthroplasty, a rating higher than 60 percent is not available under DC 5055. Further, a rating higher than 60 percent is not available under the other diagnostic codes pertaining to disability of the knee. 38 C.F.R. § 4.71a, DC’s 5256-5263. Finally, the “amputation rule” prohibits assignment of a rating higher than 60 percent for the Veteran’s right knee disability. 38 C.F.R. § 4.68 (2017). The amputation rule provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. Id. The rating criteria applicable to amputations of the lower extremities provide that a 60 percent rating is assigned for amputation of the thigh at the middle or lower third, or amputation of the leg with a defective stump. 38 C.F.R. § 4.71a, DC’s 5162 and 5163. The only higher ratings available for amputation of a lower extremity are amputation of the upper third of the thigh, one third of the distance from the perineum to the knee joint measured from the perineum, which is assigned an 80 percent rating, or amputation of the thigh with disarticulation and loss of extrinsic pelvic girdle muscles, which is assigned a 90 percent rating. 38 C.F.R. § 4.71a, DC’s 5161, 5160. The evidence does not indicate that the Veteran’s right knee disability would warrant amputation above the thigh at one of such levels, were amputation to be performed, and this issue is not reasonably raised by the record. Accordingly, a rating higher than 60 percent for the Veteran’s right knee arthroplasty may not be assigned as a matter of law under the schedular criteria. Therefore, the benefit-of-the-doubt rule does not apply. See Sabonis v. West, 6 Vet. App. 426, 430 (1994); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. B. Extraschedular Criteria Because the ratings provided in the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but nevertheless is still considered adequate to address the average impairment in earning capacity caused by the disability. 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111, 114 (2008); aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue presents such an exceptional or unusual disability picture with related factors such as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). These criteria involve distinct elements, each of which must be satisfied to warrant extraschedular referral. Chudy v. O’Rourke, 30 Vet. App. 34, 37-38 (2018); Anderson v. Shinseki, 22 Vet. App. 423, 427 (2009). The first element requires the Board to determine whether the evidence presents such an exceptional or unusual disability picture that the available schedular evaluations for the disability under consideration are inadequate. Thun, 22 Vet. App. at 115. This requires the Board to compare the Veteran’s symptoms and their severity with those contemplated by the rating schedule. King v. Shulkin, 29 Vet. App. 174, 178-79 (2017). If the Board determines that the Veteran’s symptoms or their severity is not contemplated by the rating schedule, the second element requires the Board to determine whether the exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Thun, 22 Vet. App. at 116. If the first two elements are met, then under the third element the Board must refer the claim to the Under Secretary for Benefits or the Director of Compensation Service for a determination as to whether an extraschedular rating is warranted. Id. If either of the first two elements is not satisfied, then referral is not warranted. Chudy, 30 Vet. App. at 37-38; Yancy v. McDonald, 27 Vet. App. 484, 494-95 (2016). Here, a comparison of the Veteran’s right knee total arthroplasty with the schedular criteria does not show an exceptional or unusual disability picture. His severe pain, weakness, and limited motion are contemplated by DC 5055 and the diagnostic codes applicable to limitation of motion of the knee. See 38 C.F.R. § 4.71a, DC’s 5260 and 5261. The July 2014 Notice of Disagreement (NOD) states that the Veteran’s right knee arthroplasty also causes significant disability to the surrounding weight-bearing joints and spine. The fact that a disability may affect other areas of the body causing additional disability does not in itself warrant extraschedular referral, as such “secondary” disability will be separately rated under appropriate diagnostic codes, provided that service connection is established for the additional disability. In this case, service connection has already been established for disability of the lumbosacral spine as secondary to the Veteran’s right knee arthroplasty, and a separate rating assigned. The issue of whether service connection is also warranted for disabilities of the bilateral hips is addressed in the REMAND section below. The July 2014 NOD also notes that the Veteran’s right knee disability affects his ability to drive. The functional effects of a disability in various contexts do not necessarily warrant extraschedular referral merely because they are not described in the rating schedule. Cf. Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (holding that “when a claimant’s hearing loss results in an inability to hear or understand speech or to hear other sounds in various contexts, those effects are contemplated by the schedular rating criteria”). Indeed, the basis of disability evaluations is the ability to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Driving is clearly a condition of ordinary life. The fact that a knee disability could potentially limit the ability to drive due to involvement of the knee in operating the gas and brake pedals is readily apparent to a lay person, and thus does not in itself show an exceptional or unusual disability picture vis-à-vis the schedular criteria. Moreover, VA law provides for adaptive equipment to operate an automobile in the case of anklylosis of one or both knees. 38 C.F.R. § 3.808(a)(6). Regardless of whether the criteria for such adaptive equipment are satisfied in a given case, this regulation shows that difficulty operating a vehicle due to certain disabilities is already contemplated. Finally, the December 2012 VA examination report reflects that the Veteran uses a cane for prolonged ambulation. The Board finds that his use of an assistive device such as a cane essentially serves as a “proxy” for symptoms such as his painful and limited motion and weakness of the right knee, which are contemplated by DC 5055. Cf. Spellers v. Wilkie, No. 16-4053, 2018 U.S. App. Vet. Claims LEXIS 1201 (September 7, 2018) (holding that in the context of evaluating a neurological condition, a cane or walker can serve as a proxy for symptoms contemplated by 38 C.F.R. § 4.120, and thus does not establish an exceptional or usual disability picture). Accordingly, the Veteran’s use of a cane does not establish an exceptional or unusual disability picture. Regarding the severity of the Veteran’s symptoms, the rating criteria under DC 5055 already contemplate severe painful motion or weakness. Moreover, a total disability rating has been assigned in part due to the Veteran’s right knee arthroplasty. See July 2015 Rating Decision. In sum, an exceptional or unusual disability picture is not established. Therefore, the first Thun element is not satisfied. Accordingly, the Board will not refer this case for extraschedular consideration. Thun, 22 Vet. App. at 116; Chudy, 30 Vet. App. at 37-38. 2. A rating higher than 0 percent for amputation of distal phalanx, right 5th digit, with scar, is denied. The Veteran’s right fifth finger disability is rated under DC 5156, which pertains to amputation of the little finger. 38 C.F.R. § 4.71a. Under DC 5156, a 20 percent rating is assigned for amputation of the little finger with metacarpal resection (more than one half of the bone lost). Id. A 10 percent rating is assigned without metacarpal resection, when the amputation is at the proximal interphalangeal joint or proximal to such joint. Id.; see id., Plate III. Because the amputation was at the distal joint of the fifth finger, a compensable rating under DC 5156 may not be assigned. See id. Further, because the Veteran does not have multiple service-connected finger amputations, the rating provisions governing multiple finger amputations do not apply. See 38 C.F.R. § 4.71a, DC’s 5126-5151, and notes (a) through (e). The Board also notes that amputations at distal joints, or through distal phalanges, other than negligible losses, will be rated as prescribed for favorable ankylosis of the fingers. See 38 C.F.R. § 4.71a, DC’s 5126-5151, note (c). Under DC 5224, favorable or unfavorable ankylosis of the ring or little finger is assigned a 0 percent rating. 38 C.F.R. § 4.71a. Accordingly, a compensable rating for the Veteran’s right fifth finger distal phalanx amputation is not available. Because a compensable rating may not be assigned the Veteran’s right fifth finger distal phalanx amputation as a matter of law, the benefit-of-the-doubt rule does not apply. See Sabonis v. West, 6 Vet. App. 426, 430 (1994); see also 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The evidence of record does not show that the associated right fifth finger scar is painful, unstable, or deep. In the December 2012 VA examination report, the examiner found that the scar was not painful or unstable, and did not comprise an area greater than 39 square centimeters (6 square inches). Accordingly, the preponderance of the evidence shows that the criteria for a compensable rating are not met or more nearly approximated under any applicable diagnostic code pertaining to scars, whether under the previous or current rating criteria. See 38 C.F.R. § 4.118 (2012, 2018). Thus, the benefit-of-the-doubt rule does not apply. See 38 C.F.R. §§ 3.102, 4.3. 3. A rating higher than 0 percent for bilateral hearing loss is denied. A. Rating Criteria Hearing loss is evaluated under 38 C.F.R. § 4.85, Diagnostic Code (DC) 6100. In evaluating hearing loss, disability ratings are derived from a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Hearing loss disability evaluations range from noncompensable to 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests using the Maryland CNC word list, in conjunction with the average hearing threshold, measured by puretone audiometric tests in the frequencies 1,000, 2,000, 3,000 and 4,000 cycles per second. 38 C.F.R. § 4.85, DC 6100. The rating schedule establishes eleven auditory acuity levels designated from Level I, for essentially normal hearing acuity, through Level XI for profound deafness. See id. VA audiometric examinations are generally conducted using a controlled speech discrimination test together with the results of a puretone audiometry test. Id. Table VI in 38 C.F.R. § 4.85 is then used to determine the numeric designation of hearing impairment based on the puretone threshold average derived from the audiometry test, and from the results of the speech discrimination test. The horizontal rows in Table VI represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. See id. The vertical columns in Table VI represent nine categories of decibel loss based on the puretone audiometry test. Id. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the horizontal row corresponding to the percentage of discrimination and the vertical column corresponding to the puretone decibel loss. Id. The percentage evaluation is derived from Table VII in 38 C.F.R. § 4.85 by intersecting the vertical column corresponding to the numeric designation for the ear having the better hearing acuity (as determined by Table VI) and the horizontal row corresponding to the numeric designation level for the ear having the poorer hearing acuity (as determined by Table VI). For example, if the better ear has a numeric designation Level of “V” and the poorer ear has a numeric designation Level of “VII,” the percentage evaluation is 30 percent. See id. There are alternative criteria for certain exceptional patterns of hearing loss. Specifically, if puretone thresholds in each of the specified frequencies of 1000, 2000, 3000, and 4000 Hertz are 55 decibels or more, an evaluation will be based either on Table VI or Table VIa in 38 C.F.R. § 4.85, whichever results in a higher evaluation. 38 C.F.R. § 4.86(a) (2017). Each ear will be evaluated separately. Id. When the puretone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, the Roman numeral designation for hearing impairment will be chosen from either Table VI or Table VIa under 38 C.F.R. § 4.85, whichever results in the higher Roman numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). B. Analysis The January 2013 VA examination report shows that on audiometric and speech discrimination testing, the Veteran’s right ear hearing loss was manifested by a puretone threshold average of 44 decibels, and a speech discrimination score of 94 percent. His left ear hearing loss was manifested by a puretone threshold average of 68 decibels and a speech discrimination score of 96 percent. Applying these values to Table VI yields a numeric designation of I for the right ear and II for the left ear. The point where designations I and II intersect on Table VII yields a 0 percent rating. Turning to the alternative criteria for exceptional patterns of hearing loss, the January 2013 VA examination report shows that the Veteran’s puretone thresholds were not 55dB or higher at each of the relevant frequencies, and that he did not have a puretone threshold of 70dB or higher at 2000 Hertz. Accordingly, the Veteran’s hearing impairment does not fit either pattern warranting application of the alternative rating criteria. See 38 C.F.R. § 4.86. In sum, the criteria for a rating higher than 0 percent for bilateral hearing loss are not satisfied. Regarding functional impairment associated with the Veteran’s hearing loss, when a claimant’s hearing loss results in an inability to hear or understand speech or to hear other sounds in various contexts, those effects are contemplated by the schedular rating criteria. Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017). The Veteran’s difficulty hearing and understanding speech is not shown to be more severe than what is contemplated by the rating criteria. Accordingly, his hearing loss does not constitute an exceptional or unusual disability picture. Thus, the Board will not refer the claim for extraschedular consideration. See 38 C.F.R. § 3.321(b); Thun, 22 Vet. App. at 116; Chudy, 30 Vet. App. at 37-38. Because the preponderance of the evidence weighs against a compensable rating for the Veteran’s bilateral hearing loss, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to a rating higher than 10 percent for lumbosacral strain is remanded. In his July 2014 NOD, the Veteran stated that the January 2013 VA examination did not accurately reflect the severity of his low back disability. The Board also notes that the examination was performed prior to Correia v. McDonald, and thus does not contain the findings required by that case. 28 Vet. App. 158 (2016). 2. Entitlement to a rating higher than 10 percent for radiculopathy of the right lower extremity is remanded Because the new examination of the Veteran’s low back will include findings regarding his associated radiculopathy, the Board will defer a decision on this claim. Cf. Harris v. Derwinski, 1 Vet. App 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on the resolution of the second issue). 3. Entitlement to service connection for right and left hip disabilities is remanded. A new examination and medical opinion are warranted. In the January 2012 VA examination report, the examiner only diagnosed “hip discomfort.” The report does not reflect that an x-ray study was performed. Moreover, pain that results in functional impairment may constitute a disability, even in the absence of an underlying diagnosis. Saunders v. Wilkie, 886 F.3d 1356, 1365-66 (Fed. Cir. 2018). The medical opinion is also not sufficient, as the examiner merely noted that the Veteran’s hip condition was not secondary to his knee and back disabilities, without separately discussing the issues of causation and aggravation, and limited the discussion to whether a hip condition manifested during active service, which is not relevant to the determination. See 38 C.F.R. § 3.310. The Veteran states that he has bilateral hip disabilities caused or aggravated by an abnormal gait and falling due to his service-connected right knee and low back disabilities. See July 2012 VA Form 21-4138; July 2014 Notice of Disagreement. The examiner did not address these issues. 4. The petition to reopen the claim for service connection for tinnitus is remanded. A new medical opinion is warranted. In the January 2013 VA examination report, the examiner opined that the Veteran’s tinnitus was less likely than not secondary to his service-connected bilateral hearing loss because the onset of hearing loss occurred prior to the onset of tinnitus. This explanation is not sufficient, as it seems a matter of logic that tinnitus secondary to hearing loss could occur after the onset of the latter, and need not necessarily have occurred in tandem with it. The Board also notes that a May 2000 VA examination report reflects a finding that the Veteran’s tinnitus had the same etiology as his hearing loss. 5. Entitlement to an effective date earlier than July 23, 2012 for the award of a total disability rating based on individual unemployability is remanded. The Veteran has appealed the effective date of TDIU. See July 2016 NOD. He has requested de novo review by a Decision Review Officer. Although the Board granted an effective date of July 23, 2012, it may not adjudicate the issue of whether an even earlier effective date is warranted without initial consideration of this issue by the AOJ (the Veteran has not specified the date he seeks). The matters are REMANDED for the following action: 1. Add to the file any VA treatment records dated since January 2013. 2. In a July 2012 statement (VA Form 21-4138), the Veteran stated that he went to the emergency room due to a fall, where he was diagnosed with a fractured bone in his hip. He should be requested to identify and authorize the release of the records pertaining to this treatment, so that VA may attempt to obtain them on his behalf. He should also be invited to submit the records himself. 3. Arrange for a VA examination of the Veteran’s lumbosacral spine and associated radiculopathy of the right lower extremity to assess the current severity of these disabilities. 4. Arrange for a VA examination of the Veteran’s hips, and medical opinion addressing secondary service connection, as specified below. The examiner should conduct any tests or studies deemed indicated, including an x-ray of the hips if warranted. The examiner is asked to provide an opinion as to whether it is at least as likely as not (50% probability or more) that any current right or left hip disability was caused or aggravated by his service-connected total right knee arthroplasty and/or low back disability, including due to an abnormal gait or falling. The examiner must provide a complete explanation in support of the conclusion reached. 5. Obtain a medical opinion as to whether it is at least as likely as not (50% probability or more) that the Veteran’s tinnitus is linked to his established in-service noise exposure, or is secondary to his service-connected hearing loss. The examiner must provide a complete explanation in support of the conclusion reached. (The opinion in the January 2013 VA examination report is not sufficient, as the examiner did not explain why the sole fact that hearing loss occurred prior to tinnitus weighed against a relationship between the two conditions.) 6. Send the Veteran written notice acknowledging his July 2016 NOD regarding an earlier effective date for the award of TDIU and Dependents’ Educational Assistance. He has elected de novo review by a Decision Review Officer (DRO). After such review, if the benefits sought are not granted, issue a Statement of the Case (SOC). Copies of the SOC must be sent to the Veteran and his representative, and he must be informed of the requirements for perfecting the appeal. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Rutkin, Counsel