Citation Nr: 18151033 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 16-14 983 DATE: November 16, 2018 ORDER The request to reopen a claim for service connection for a lung disability is denied. The request to reopen a previously denied claim for service connection for a left kidney disability is denied. The request to reopen a previously denied claim for service connection for left lower extremity peripheral neuropathy is denied. The request to reopen a previously denied claim for service connection for right lower extremity peripheral neuropathy is denied. Restoration of the 20 percent rating for hypertension from March 4, 2015 is granted. Restoration of the 30 percent rating for posttraumatic stress disorder (PTSD) from March 16, 2015 is granted. An initial rating higher than 20 percent for lumbosacral strain is denied. An initial rating higher than 10 percent for right lower extremity radiculopathy is denied. An initial rating higher than 10 percent for a right knee condition is denied. A compensable rating for bilateral hearing loss is denied. A rating higher than 10 percent for tinnitus is denied. A compensable rating for a deviated septum is denied. A rating higher than 50 percent for sleep apnea is denied. A rating higher than 20 percent for hypertension is denied. A rating higher than 20 percent for residuals of a right kidney ureteropelvic junction obstruction is denied. A separate 10 percent rating for vomiting and coughing up bile associated with residuals of a right kidney ureteropelvic junction obstruction is granted. A rating higher than 30 percent for PTSD is denied. A TDIU is granted. FINDINGS OF FACT 1. The Veteran did not appeal a February 2013 rating decision which denied service connection for a lung disability, and evidence received since that decision does not raise a reasonable possibility of substantiating the claim. 2. The Veteran did not appeal a November 2008 rating decision which denied service connection for a left kidney disability, and evidence received since that decision does not raise a reasonable possibility of substantiating the claim. 3. The Veteran did not appeal a February 2013 rating decision which denied service connection for left lower extremity peripheral neuropathy, and evidence received since that decision does not raise a reasonable possibility of substantiating the claim. 4. The Veteran did not appeal a February 2013 rating decision which denied service connection for right lower extremity peripheral neuropathy, and evidence received since that decision does not raise a reasonable possibility of substantiating the claim. 5. The reduction from 20 percent to 10 percent for hypertension from March 4, 2015 was not based on an adequate VA examination and was not based on sustained material improvement. 6. The reduction from 30 percent to 10 percent for PTSD from March 16, 2015 did not include a rating decision proposing the decrease or the required notice to the Veteran. 7. Lumbosacral strain is not manifested by forward flexion of 30 degrees or less, or by favorable ankylosis of the thoracolumbar spine. 8. Right lower extremity radiculopathy is manifested by mild incomplete paralysis of the sciatic nerve. 9. A right knee condition is not manifested by flexion of 30 degrees or less, extension of 10 degrees or less, instability, or recurrent effusions. 10. Bilateral hearing loss is manifested by level I hearing in the right ear and level III hearing in the left ear. 11. The Veteran is assigned the maximum schedular rating for tinnitus. 12. A deviated septum is not manifested by 50 percent obstruction of both nasal passages or a complete obstruction of a single nasal passage. 13. Sleep apnea is not manifested by chronic respiratory failure or treatment with a tracheostomy. 14. Hypertension is not manifested by diastolic pressure predominantly 120 or more. 15. Right kidney ureteropelvic junction obstruction is not manifested by infection or impaired kidney function. 16. Vomiting and coughing up bile associated with the right kidney ureteropelvic junction obstruction is manifested by epigastric distress with regurgitation not productive of considerable health impairment. 17. PTSD is manifested by chronic sleep impairment, avoidance and hyperarousal. 18. The Veteran’s service-connected disabilities likely preclude him from maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The February 2013 rating decision which denied service connection for a lung disability is final, and new and material evidence has not been received to reopen the claim. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.104(a), 3.156, 3.160(d), 20.200, 20.302, 20.1103. 2. The November 2008 rating decision which denied service connection for a left kidney disability is final, and new and material evidence has not been received to reopen the claim. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.104(a), 3.156, 3.160(d), 20.200, 20.302, 20.1103. 3. The February 2013 rating decision which denied service connection for left lower extremity peripheral neuropathy is final, and new and material evidence has not been received to reopen the claim. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.104(a), 3.156, 3.160(d), 20.200, 20.302, 20.1103. 4. The February 2013 rating decision which denied service connection for right lower extremity peripheral neuropathy is final, and new and material evidence has not been received to reopen the claim. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.104(a), 3.156, 3.160(d), 20.200, 20.302, 20.1103. 5. The criteria for restoration of the 20 percent rating for hypertension from March 4, 2015 have been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.105, 3.344. 6. The criteria for restoration of the 30 percent rating for PTSD from March 16, 2015 have been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.105, 3.344. 7. The criteria for an initial rating higher than 20 percent for lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5237. 8. The criteria for an initial rating higher than 10 percent for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.120, 4.124a, Diagnostic Code 8520. 9. The criteria for an initial rating higher than 10 percent for a right knee condition have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5260. 10. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.85, 4.86, Diagnostic Code 6100. 11. The criteria for a rating higher than 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.87, Diagnostic Code 6260. 12. The criteria for a compensable rating for a deviated septum have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.97, Diagnostic Code 6502. 13. The criteria for a rating higher than 50 percent for sleep apnea have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.97, Diagnostic Code 6847. 14. The criteria for a rating higher than 20 percent for hypertension have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.104, Diagnostic Code 7101. 15. The criteria for a rating higher than 20 percent for residuals of a right kidney ureteropelvic junction obstruction have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.115b, Diagnostic Code 7509. 16. The criteria for a separate 10 percent rating for vomiting and coughing up bile associated with residuals of a right kidney ureteropelvic junction obstruction have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.114, Diagnostic Code 7346. 17. The criteria for a rating higher than 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411. 18. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321, 4.1, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the U.S. Army from June 1989 to July 1989, from December 1990 to June 1991, and from March 1994 to October 2000. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from June 2015 and March 2016 rating decisions. In his July 2015 notice of disagreement, the Veteran referenced a left ankle disability which was not part of the June 2015 rating decision. VA sent him a letter in October 2015 asking that he clarify his intent with respect to that issue. He subsequently indicated that he sought to appeal a right ankle rating, but this clarification was not received until June 2017, well beyond the one-year period in which one can appeal an adverse VA determination. Therefore, it cannot be considered a timely notice of disagreement for the right ankle rating issue adjudicated in the June 2015 rating decision, and that issue will not be further addressed by the Board. Reopening Previously Denied Claims Generally, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131. Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A service connection claim that has been denied by an unappealed Regional Office decision or an unappealed Board decision may not thereafter be reopened. 38 U.S.C. §§ 7104(b), 7105(c). An exception to this rule exists for cases in which new and material evidence is presented with respect to a claim that had been denied, in which case the claim must be reopened and the former disposition reviewed. 38 U.S.C. § 5108. “New” evidence means evidence not previously submitted to agency decisionmakers, and “material” evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). This is a “low threshold” in which the phrase “raises a reasonable possibility” should be interpreted as “enabling rather than precluding reopening.” Shade v. Shinseki, 24 Vet. App. 110, 121 (2010). The credibility of the newly-submitted evidence is presumed, although not blindly accepted as true if patently incredible. Justus v. Principi, 3 Vet. App. 510 (1992). 1. Lung disability Service connection for a lung disability was denied in a February 2013 rating decision. The basis of that denial was that a lung disability was not shown to have been incurred in service and was not secondary to the Veteran’s service-connected sleep apnea. He did not appeal this decision and it became final. Since the February 2013 rating decision, additional evidence has been received. Specifically, a March 2015 pulmonary function test showed mild restrictive disease, and a May 2015 VA examiner diagnosed restrictive lung disease that was at least as likely as not due to the Veteran’s obesity. This evidence is not new. An August 2009 VA examination noted the same diagnosis and etiology. Similarly, recent statements from the Veteran that he has experienced breathing problems since service were also part of the record at the time of the prior final decision in February 2013. The treatment records generated since February 2013 do not contain any other information that might raise a reasonable possibility of substantiating a claim for service connection for a lung disability. As new and material evidence has not been received, the claim is not reopened. 2. Left kidney disability Service connection for left kidney disability was denied in a November 2008 rating decision. The basis of that denial was that a current left kidney disability had not been established. The Veteran did not appeal this decision and it became final. Since the November 2008 rating decision, no new evidence of any significance has been received regarding a left kidney disability. In fact, in an April 2017 statement, the Veteran questioned why VA kept including his left kidney as an issue. His statement is in line with a September 2012 VA examination in which he denied the presence of a left kidney condition. The treatment records generated since November 2008 do not contain any other information that might indicate the presence of a left kidney condition. As new and material evidence has not been received, the claim is not reopened. 3. Left lower extremity peripheral neuropathy Service connection for left lower extremity peripheral neuropathy was denied in a February 2013 rating decision. The basis of that denial was that the condition was not shown to have been incurred in service. He did not appeal this decision and it became final. Notably, a November 2009 rating decision denied this claim on the basis that there was no current disability, and the February 2013 rating decision did not specifically address whether a current diagnosis was established. Since the February 2013 rating decision, additional evidence has been received. VA examinations were conducted in March 2015, May 2016 and October 2016. Collectively, these examinations documented the absence of any symptoms of neurological impairment in left lower extremity, and no diagnoses were rendered. VA treatment records from February 2015 and March 2016 also show the Veteran denied the presence of any such symptoms. This evidence is not material because it does not relate to the previously unestablished element of a current disability and does not raise a reasonable possibility of substantiating a claim for service connection. As new and material evidence has not been received, the claim is not reopened. 4. Right lower extremity peripheral neuropathy Service connection for right lower extremity peripheral neuropathy was denied in a February 2013 rating decision. The basis of that denial was that the condition was not shown to have been incurred in service. He did not appeal this decision and it became final. Notably, a November 2009 rating decision denied this claim on the basis that there was no current disability, and the February 2013 rating decision did not specifically address whether a current diagnosis was established. Since the February 2013 rating decision, additional evidence has been received. A May 2015 VA examination specifically stated that the Veteran had numbness and other symptoms consistent with right lower extremity radiculopathy, and that peripheral neuropathy was not present. As discussed below, the Veteran is already service-connected for radiculopathy. None of the evidence generated since February 2013 establishes a diagnosis of peripheral neuropathy separate from radiculopathy. Collectively, this evidence is not material because it does not relate to any of the previously unestablished elements of service connection. As new and material evidence has not been received, the claim is not reopened. Reductions Rating reductions invoke specific due process considerations. Where a reduction in an evaluation of a service-connected disability is considered warranted, and the lower evaluation would result in a reduction or termination of compensation payments currently being made, a rating proposing the reduction or discontinuance must be prepared setting forth all material facts and reasons, and the Agency of Original Jurisdiction must notify the Veteran that he has 60 days to present additional evidence showing that compensation should be continued at the present level. The Veteran must also be informed that he may request a predetermination hearing, provided that the request is received by VA within 30 days from the date of the notice. 38 C.F.R. § 3.105(e), (i). For ratings that have been in effect for five years or more, reduction is warranted when reexamination discloses sustained material improvement. VA must find the following: (1) based on a review of the entire record, the examination forming the basis for the reduction is full and complete, and at least as full and complete as the examination upon which the rating was originally based; (2) the record clearly reflects a finding of material improvement; and (3) it is reasonably certain that the material improvement found will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a). See also Kitchens v. Brown, 7 Vet. App. 320 (1995). In considering the propriety of a reduction, the Board must focus on the evidence available to the RO when the reduction was effectuated, although post-reduction medical evidence may be considered for the limited purpose of determining whether the condition had demonstrated actual improvement. Dofflemeyer v. Derwinski, 2 Vet. App. 277 (1992). 5. Hypertension The June 2015 rating decision on appeal reduced the Veteran’s rating for hypertension from 20 percent to 10 percent effective November 10, 2014. In March 2016, this reduction was made effective only from March 4, 2015. This reduction from 20 percent to 10 percent did not reduce the Veteran’s overall level of compensation. Therefore, the due process requirements discussed above are not applicable. Under DC 7101, hypertension is rated at 20 percent when diastolic pressure is predominantly 110 or more, or systolic pressure is 200 or more. 38 C.F.R. § 4.104. The Veteran’s 20 percent rating for hypertension was in effect since October 2007, which was more than 5 years, and 38 C.F.R. § 3.344(a) is applicable. Under that regulation, the Board finds that restoration of the previously assigned 20 percent rating is warranted from March 4, 2015. First, the March 2015 VA examination which the reduction was partly based on was not adequate. The examiner did not record current blood pressure readings, but merely cited to previous readings from January 2014, January 2015 and February 2015. Second, the most recent reading from February 2015 cited by the examiner was 170/111, which is consistent with the criteria for the 20 percent rating. An additional reading from February 2015 not cited by the VA examiner but contained in the Veteran’s VA records was 155/123. These two readings do not support a finding of material improvement in the Veteran’s hypertension. Third, the post-reduction evidence does not show sustained improvement, with readings of 174/125 and 162/114 in March 2016 and a reading of 169/122 in October 2016. The Board acknowledges additional blood pressure readings from the appeal period which show diastolic pressure of less than 110, which would be consistent with the 10 percent rating. Nevertheless, because the VA examination upon which the reduction was initially based was inadequate, and because material improvement was not shown or maintained, restoration of the 20 percent rating is appropriate. 6. PTSD The June 2015 rating decision on appeal reduced the Veteran’s rating for PTSD from 30 percent to 0 percent effective November 10, 2014. In March 2016, the reduction was changed to 10 percent effective March 16, 2015. This reduction from 30 percent to 10 percent reduced the Veteran’s overall compensation from 90 percent to 80 percent. Therefore, the due process requirements discussed above are applicable. In that regard, there was no proposed rating decision setting forth all material facts and reasons, nor was the Veteran notified that he could submit additional evidence or request a predetermination hearing regarding the reduction. Rather, the June 2015 rating decision immediately reduced the assigned rating for PTSD in response to the Veteran’s claim for an increase. Therefore, the reduction is void and the 30 percent rating is restored. Hayes v. Brown, 9 Vet. App. 67, 73 (1996) (where VA reduces an appellant’s rating without observing applicable laws and regulations, the rating is void ab initio and will be set aside). Increased Ratings Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, present level of disability is the primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 7. Lumbosacral strain The Veteran is currently assigned a 20 percent rating for lumbosacral strain under Diagnostic Code (DC) 5237, which is part of the General Rating Formula for Diseases and Injuries of the Spine found in 38 C.F.R. § 4.71a. That formula provides that a higher 40 percent rating is warranted when forward flexion of the thoracolumbar spine is 30 degrees or less, or if there is favorable ankylosis of the spine. Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Note (5) of the General Rating Formula states that fixation of a spinal segment in a neutral position (0 degrees) always represents favorable ankylosis. VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). However, pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (holding that pain alone does not constitute function loss, but is just one fact to be considered when evaluating functional impairment). The Veteran underwent VA examinations in May 2015 and October 2016, which recorded similar findings. Forward flexion was at least 60 degrees, even when accounting for repetitive testing and the onset of pain. Ankylosis was not present. His treatment records do not include range of motion findings for the spine during the appeal period. Therefore, the criteria for a rating higher than 20 percent have not been met. The General Rating Formula provides for separate ratings for any neurologic abnormalities associated with a spinal condition. Here, the Veteran is already service-connected for right lower extremity radiculopathy, and that rating will be separately addressed. As discussed above, there are no neurologic symptoms or findings in the left lower extremity. The Veteran also denied any bladder or bowel incontinence during his VA examinations. Finally, a rating may also be assigned under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. However, these ratings require periods of bed rest prescribed by a physician, and the evidence does not reflect any such prescribed bed rest. Therefore, a rating under this formula is not warranted. 8. Right lower extremity radiculopathy The Veteran is currently assigned a 10 percent rating for right lower extremity radiculopathy under DC 8520, which addresses paralysis of the sciatic nerve. The 10 percent rating is assigned for mild incomplete paralysis. Higher ratings of 20 and 40 percent are assigned for moderate and moderately severe incomplete paralysis, respectively. A 60 percent rating is assigned when there is severe incomplete paralysis with marked muscular atrophy. 38 C.F.R. § 4.124a. Descriptive terms such as “mild” or “moderate” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence so that its decisions are “equitable and just” under 38 C.F.R. § 4.6. The use of such terms by examiners or other medical personnel are not dispositive, though they may be considered as evidence. In rating peripheral nerve injuries and their residuals, attention should be given to the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. The Board finds that a rating higher than 10 percent is not warranted. With respect to objective symptoms, a May 2015 VA examination documented normal strength, reflexes and sensation. An October 2016 VA examination recorded identical findings, except for a diminished ankle reflex. Subjectively, the May 2015 examiner noted mild constant pain, mild intermittent pain, mild paresthesias and mild numbness, and assessed an overall mild level of radiculopathy. The October 2016 examiner noted no constant pain, moderate intermittent pain, moderate paresthesias and mild numbness. He assessed an overall mild level of radiculopathy. The Veteran’s treatment records do not contain any significant findings except for a February 2015 entry noting the absence of any numbness, tingling or weakness. Collectively, this evidence is consistent with mild incomplete paralysis. The objective findings are limited to a diminished ankle reflex in October 2016, and both examiners diagnosed mild radiculopathy. Although the October 2016 examiner noted moderate intermittent pain and moderate paresthesias, no constant pain was present. Therefore, the currently assigned 10 percent rating is appropriate. 9. Right knee condition The Veteran is service-connected for a right knee condition without further specificity. His condition is currently assigned a 10 percent rating under DC 5003-5260. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. DC 5003 addresses degenerative arthritis, but a higher rating is not warranted unless the condition involves 2 or more major joints or joint groups. Here, the issue only relates to the Veteran’s right knee. DC 5260 addresses limitation of flexion of the leg. A higher 20 percent rating is assigned when flexion is limited to 30 degrees. During VA examinations in May 2015 and October 2016, flexion was at least 120 degrees, to include pain and repetitive testing. Therefore, a higher rating under DC 5260 is not warranted. DC 5261 addresses limitation of extension of the leg. A separate 10 percent rating may be assigned if extension is limited to 10 degrees. The May 2015 and October 2016 VA examinations both documented full extension, including after repetitive testing. Therefore, a separate rating under DC 5261 is not warranted. DC 5257 addresses subluxation or lateral instability of the knee. A separate 10 percent rating may be assigned if there is “slight” impairment due to subluxation or instability. As discussed earlier, terms such as “slight” are not defined. Nevertheless, both VA examinations documented a negative history of subluxation or instability with normal stability on objective testing. In addition, the Veteran did not describe any history of giving away or buckling. Therefore, a separate rating under DC 5257 is not warranted. DC 5258 provides a single 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain and effusion into the joint. However, the Veteran has not been diagnosed with dislocated semilunar cartilage, and both examinations documented the absence of any recurrent effusions. Therefore, a rating under DC 5258 is not warranted. Finally, DC 5259 provides a single 10 percent rating for symptomatic removal of semilunar cartilage. The VA examinations documented a positive history of a meniscectomy, and the Veteran reported symptoms of “catching” in the knee in October 2016. However, the pain and catching (a form of limited motion) otherwise experienced by the Veteran are contemplated within his current 10 percent rating for limitation of flexion. A separate 10 percent rating under DC 5259 would violate the rule against “pyramiding.” See 38 C.F.R. § 4.14 (the evaluation of the same manifestation under different diagnoses is to be avoided). 10. Bilateral hearing loss The Veteran is currently assigned a 0 percent (noncompensable) rating for bilateral hearing loss under DC 6100. Evaluations of defective hearing range from 0 to 100 percent. This is based on impairment of hearing acuity as measured by the results of controlled speech discrimination tests, together with the average hearing threshold level as measured by pure tone audiometric tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz. To evaluate the degree of disability from service-connected hearing loss, the rating schedule establishes eleven auditory acuity levels ranging from numeric level I for essentially normal acuity, through numeric level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII, Diagnostic Code 6100. Table VI in 38 C.F.R. § 4.85 is used to determine the numeric designation of hearing impairment based on the pure tone threshold average from the speech audiometry test and the results of the Maryland CNC speech discrimination test. The vertical lines in Table VI represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. The horizontal columns in Table VI represent nine categories of decibel loss based on the pure tone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row corresponding to the percentage of discrimination and the horizontal column corresponding to the pure tone decibel loss. 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 and the horizontal row corresponding to the numeric designation level for the ear having the poorer hearing acuity. The provisions of 38 C.F.R. § 4.86 govern exceptional patterns of hearing impairment. Exceptional patterns of hearing loss include pure tone thresholds 55 dB or above for all four of the specified frequencies. If such exceptional patterns are shown, then hearing loss is evaluated under either Table VI or Table VIA, whichever results in a higher Roman numeral. Table VIA is based solely on pure tone threshold average. The ratings for disability compensation for hearing loss are determined by the mechanical, meaning nondiscretionary, application of the above criteria. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The Veteran underwent a VA examination in March 2015. Pure tone thresholds, in   decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 20 45 50 50 39 LEFT 25 65 65 80 59 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 96 percent in the left ear. Utilizing Table VI, this corresponds to a hearing level of I in the right ear and II in the left ear. Under Table VII, this results in a 0 percent rating for hearing loss. An additional VA examination was conducted in October 2016. Pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 25 45 50 50 43 LEFT 35 65 75 75 63 Speech audiometry revealed speech recognition ability of 94 percent in the right ear and 88 in the left ear. Utilizing Table VI, this corresponds to a hearing level of I in the right ear and III in the left ear. Under Table VII, this results in a 0 percent rating for hearing loss. During his October 2016 VA examination, the Veteran reported difficulty hearing his daughter, nieces and sisters. While the Board acknowledges the Veteran’s statement, the schedular criteria for hearing loss contemplate the functional effects of difficulty hearing and understanding speech. Doucette v. Shulkin, 28 Vet. App. 366 (2017). 11. Tinnitus The Veteran is currently assigned a 10 percent rating for tinnitus under DC 6260. This code only provides for the 10 percent rating, and a higher percentage is not available anywhere else in the rating schedule for tinnitus. The Veteran has not asserted that an extraschedular rating is warranted, and no other bases for an extraschedular rating have been reasonably raised by the record. Therefore, no further discussion is required regarding tinnitus. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 12. Deviated septum The Veteran is currently assigned a 0 percent rating for his deviated septum under DC 6502, which provides a single 10 percent rating when there is a 50 percent obstruction of the nasal passage on both sides, or a complete obstruction on one side. 38 C.F.R. § 4.97. However, in every instance where the rating schedule does not provide a 0 percent rating, one shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. VA examinations from March 2015 and October 2016 both documented that the Veteran did not have 50 percent obstruction of both nasal passages, nor did he have a complete obstruction of one nasal passage. Neither examination documented any other pertinent signs or symptoms, and the Veteran’s outpatient treatment records do not include any significant findings pertaining to this disability. Therefore, the criteria for a 10 percent rating have not been met. 13. Sleep apnea The Veteran is currently assigned a 50 percent rating for his sleep apnea under DC 6847. This rating is assigned when sleep apnea requires use of a continuous airway pressure (CPAP) machine. The next higher 100 percent rating is assigned when sleep apnea results in chronic respiratory failure with carbon dioxide retention or cor pulmonale, or when sleep apnea requires a tracheostomy. VA examinations from March 2015 and October 2016 confirm the Veteran’s use of a CPAP machine. However, both exams confirmed that absence of any other pertinent findings or complications resulting from sleep apnea. In addition, no chronic respiratory failure was noted during a May 2015 VA lung examination, and there is no indication anywhere in the record that the Veteran underwent a tracheostomy to treat sleep apnea. Therefore, the criteria for a rating higher than 50 percent have not been met. 14. Hypertension In light of the restoration granted above, the Veteran is assigned a 20 percent rating for hypertension for the entire appeal period under DC 7101. A higher 40 percent rating is assigned when diastolic pressure is predominantly 120 or more. The evidence includes blood pressure readings from January 2015 through October 2016. This includes the following diastolic pressure readings of 120 or greater: February 2015 (123), March 2016 (125), October 2016 (122). However, most of readings during this period included diastolic pressure of less than 120: January 2015 (91, 94), February 2015 (111), March 2015 (99, 94), March 2015 (114), October 2016 (98, 78, 82, 79, 75). Because there are only 3 readings of 120 or more, with 11 readings of less than 120, the Board cannot find that the Veteran’s diastolic pressure is “predominantly” 120 or more, and a 40 percent rating is not warranted. 15. Residuals of a right kidney ureteropelvic junction obstruction The Veteran’s right kidney condition is currently assigned a 20 percent rating under DC 7509, which contemplates frequent attacks of colic requiring catheter drainage. A higher 30 percent rating is assigned for frequent attacks of colic with infection and impaired kidney function. In severe cases, the condition would be rated as renal dysfunction. “Colic” refers to acute abdominal pain. See Dorland’s Illustrated Medical Dictionary 389 (31st ed. 2007). During March 2015 and October 2016 VA examinations, laboratory testing showed normal kidney function, and his treatment records are negative for any positive findings of renal dysfunction. There is also no evidence of kidney infection. Therefore, a higher 30 percent rating is not warranted. 16. Vomiting and coughing up bile The Veteran’s service-connected kidney disability, discussed above, also includes “vomiting” and “coughing up bile.” VA records from March 2015 show he reported acid reflux and vomiting 2 to 5 times a day. During the March 2015 VA examination, the Veteran reported vomiting bile 2 to 4 times a day. During the October 2016 VA examination, he reported vomiting bile 3 times a week. The Veteran is service-connected for this symptomatology, but it is not contemplated by his 20 percent rating under DC 7509. Therefore, a separate rating is warranted. The Board finds that a 10 percent rating under DC 7346 contemplates recurrent epigastric distress, dysphagia and regurgitation consistent with the Veteran’s symptoms. See 38 C.F.R. § 4.114. A higher 30 percent rating is not warranted. Such a rating is assigned when symptoms are productive of considerable impairment of health, but the March 2015 VA records specifically noted that the Veteran had gained weight despite his vomiting, and there is no other indication of any unintended weight loss or other health impairment associated with the Veteran’s symptoms. 17. PTSD In light of the restoration discussed above, the Veteran is assigned a 30 percent rating for his PTSD throughout the entire appeal period. This rating is under DC 9411, which is part of the General Rating Formula for Mental Disorders found in 38 C.F.R. § 4.130. Under the General Rating Formula, a 30 percent evaluation contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, and recent events). A 50 percent evaluation is warranted where the disorder is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory for example, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A veteran “may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114 (Fed. Cir. 2013). Symptoms listed in the General Rating Formula serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. They are not intended to constitute an exhaustive list. Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). The Board finds that a rating higher than 30 percent is not warranted. During a March 2015 VA examination, the Veteran reported “rough” sleep with recurring bad dreams, but chronic sleep impairment is already contemplated under his current 30 percent rating. Otherwise, he reported having a girlfriend, meeting regularly with a group of fellow veterans, and spending his day learning new hobbies such as woodworking. He reported that he was typically in a good mood and tried to stay positive. The examiner stated that PTSD had been diagnosed but symptoms were not severe enough to interfere with functioning. VA records from October 2015 and February 2016 show that the Veteran avoided thoughts and situations which reminded him of his trauma, and that he experienced some emotional numbness and reliving of past experiences. Again, these symptoms are equivalent to the depressed mood covered by his 30 percent rating. He otherwise reported spending time with his girlfriend and dog and continuing his woodworking. On examination his mood was euthymic, and his affect and thought process were normal. His memory was intact and he denied any hallucinations. Notably, these records show the Veteran was incarcerated for two weeks for assault. He reported that he was acting in self-defense at the time. Given his statement, as well as the lack of any other assaultive or violent behavior during the appeal period, the Board finds that this incarceration, alone, does not warrant the assignment of a higher rating. An October 2016 VA examiner stated that, in addition to PTSD, the Veteran also had adjustment disorder due to several psychosocial stressors unrelated to PTSD, including deaths in the family and caring for his disabled daughter. Symptoms attributable to adjustment disorder included sleep impairment, subclinical anxiety and depressed mood. The Veteran reported that his difficulty sleeping was due to worry about things from the day before. The examiner further stated that avoidance, hyperarousal and re-experiencing were the symptoms associated with PTSD, and that PTSD was likely resulting in impairment due to only mild or transient symptoms. This assessment of PTSD is not consistent with a rating higher than 30 percent. Notably, the examiner assessed an overall level of impairment that resulted in an occasional decrease in work efficiency with generally satisfactory functioning. In other words, even when combining the impairment from PTSD and nonservice-connected adjustment disorder, the overall level of impairment is consistent with the 30 percent rating. In that regard, the Veteran reported that he continued to have a good relationship with his girlfriend, with support from his mother, sisters and brother. He also engaged in woodworking, antiquing and going for drives in the country. VA records from November 2016 show the Veteran experienced some difficulty following the death of his sister’s boyfriend, which would be associated with adjustment disorder based on the October 2016 VA opinion. He also reported sleeping difficulty as contemplated by his current 30 percent rating but was otherwise “doing OK.” In sum, the Veteran’s PTSD does not result in the symptoms found in the criteria for a 50 percent rating or an overall level of impairment consistent with such a rating. 18. A TDIU A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation due a single service-connected disability ratable at 60 percent or more, or due to two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). The Veteran is service-connected for sleep apnea, PTSD, lumbosacral strain, a right kidney disability with vomiting, hypertension, a right knee condition, a right ankle condition, right lower extremity radiculopathy, tinnitus, hearing loss and a deviated septum. Sleep apnea is rated at 50 percent and his combined evaluation is 90 percent, so he meets the schedular criteria for a TDIU. The central inquiry is determining whether a TDIU is warranted is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to a veteran’s level of education, special training, and previous work experience, but advancing age and the impairment caused by nonservice-connected disabilities are not for consideration in determining whether such a total disability rating is warranted. See 38 C.F.R. §§ 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran’s Social Security Administration (SSA) records, TDIU application, and VA treatment records and examination reports show that he has 4 years of college education. He has an employment history that includes delivering auto parts, stocking shelves and sweeping at a grocery store, construction, cooking, janitorial service, security, cleaning large industrial equipment, and working production at a jerky company. With regard to functional impairment, the Board places significant probative weight upon the findings of the SSA. In April 2010, it determined that the Veteran had the residual functional capacity to perform sedentary work at a slow pace for up to one-third of the day and have occasional contact with the public. It also found that the Veteran’s job skills did not transfer to other occupations within the limits of that residual functional capacity. Notably, these findings were based on impairment from his service-connected sleep apnea, PTSD, right knee condition and right ankle condition, as well as nonservice-connected obesity and cervical spine disc disease. It did not factor in impairment from the service-connected disabilities of lumbosacral strain, a right kidney condition with vomiting, hypertension, tinnitus, right lower extremity radiculopathy or hearing loss. VA examinations show the Veteran reported difficulty with prolonged standing or walking, and that he utilized a cane to assist with the limited mobility associated with his lumbar spine, right lower extremity radiculopathy, right knee condition and right ankle condition. Based on these findings, as well as the fact that the Veteran’s service-connected disabilities encompass physical, mental and sensory impairment, the Board finds it less likely than not that the Veteran would be able to maintain gainful employment   consistent with his education and prior experience due to those disabilities. Therefore, a TDIU is warranted. M. TENNER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Shamil Patel, Counsel