Citation Nr: 18152900 Decision Date: 11/26/18 Archive Date: 11/26/18 DOCKET NO. 08-36 855 DATE: November 26, 2018 ORDER Service connection for amebiasis, to include as due to herbicide exposure, is denied. Service connection for peripheral neuropathy, to include as due to herbicide exposure, or as secondary to service connected posttraumatic stress disorder (PTSD), is denied. Service connection for right hip disability is denied. Service connection for arthritis (all joints) is denied. Service connection for periodontal disease, to include as due to herbicide exposure, is denied. An initial compensable rating for bilateral hearing loss prior to January 21, 2009, is denied. A rating in excess of 20 percent from January 21, 2009, to May 24, 2011, for bilateral hearing loss is denied. A rating in excess of 30 percent from May 24, 2011, to May 20, 2015, for bilateral hearing loss is denied. A rating in excess of 70 percent from May 20, 2015, for bilateral hearing loss is denied. REFERAL Issues of entitlement to service connection for osteoporosis and seizures have been raised during this appeal, but they have not been developed for appellate review. Accordingly, they are REFERRED to the RO for appropriate action. REMANDED Entitlement to service connection for diverticulitis, to include as due to herbicide exposure, is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for skin disability to include chloracne, porphyria cutanea tarda, myeloma, and cancer, is remanded. Entitlement to a rating in excess of 50 percent for PTSD from October 7, 2011, is remanded. FINDINGS OF FACT 1. The Veteran has not had a current disability of amebiasis during the appeal period. 2. The Veteran has not had a current disability of peripheral neuropathy during the appeal period. 3. The Veteran’s right hip disability is not related to service. 4. The Veteran’s diagnoses of arthritis and pain are not related to service. 5. The Veteran did not incur dental trauma during service. 6. Audiological testing conducted prior to January 20, 2009, shows the Veteran did not have an exceptional hearing loss pattern in either ear and had hearing loss no higher than Level III for the right ear and no higher than Level II for the left ear upon application of Table VI. 7. Audiological testing conducted on January 21, 2009, and May 22, 2009, shows the Veteran had an exceptional hearing loss pattern bilaterally with Level V hearing loss bilaterally upon application of Table VIA. 8. Audiological testing conducted on December 9, 2013, shows the Veteran had an exceptional hearing loss pattern bilaterally with Level VI hearing loss for the right ear and Level VII hearing loss for the left ear upon application of Table VIA. 9. Audiological testing conducted on April 5, 2017, shows the Veteran had an exceptional hearing loss pattern bilaterally with Level IX hearing loss for the right ear and Level X hearing loss for the left ear upon application of Table VI. CONCLUSIONS OF LAW 1. The criteria for service connection for amebiasis have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for peripheral neuropathy to include as due to herbicide exposure, or as secondary to service connected PTSD, have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for right hip disability have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for entitlement to service connection for arthritis (all joints) have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for periodontal disease have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 4.150. 6. The criteria for a compensable rating for bilateral hearing loss prior to January 20, 2009, are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.85, 4.86. 7. The criteria for a rating in excess of 20 percent for bilateral hearing loss from January 21, 2009, to May 24, 2011, are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.85, 4.86. 8. The criteria for a rating in excess of 30 percent for bilateral hearing loss from May 24, 2011, to May 20, 2015, are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.85, 4.86. 9. The criteria for a rating in excess of 70 percent for bilateral hearing loss from May 20, 2015, are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.85, 4.86. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1965 to August 1967. This appeal comes to the Board of Veterans’ Appeals (Board) from January 2007, September 2013, and August 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In November 2011, the Veteran testified before a Veterans Law Judge (VLJ) at a Travel Board hearing. The judge has subsequently left employment by VA. A letter dated in September 2018 informed the Veteran of this fact and of his right to request another hearing to be conducted by a Veterans Law Judge who would decide his claims. The Veteran was informed that the Board will assume he did not desire another hearing if he did not respond to the letter within thirty days. The Veteran has not responded to this correspondence. There is no indication that it was not delivered to him. The Board will assume he does not desire another hearing. The matter of the Veteran’s entitlement to an increased rating for bilateral hearing loss was previously before the Board in September 2011, May 2012, October 2013, November 2014, and February 2017. Further procedural history for this claim is discussed below. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2014) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Moreover, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and an organic disease of the nervous system such as neuropathy or arthritis, becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). The law provides that “a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service.” 38 U.S.C.§ 1116(f); 38 C.F.R. § 3.307. For purposes of applying the presumption of exposure to herbicides under 38 C.F.R. § 3.307(a)(6)(iii), “service in the Republic of Vietnam” means that a veteran must have been present within the land borders of Vietnam to obtain the benefit of the presumption of herbicide exposure. See Haas v. Peake, 525 F.3d 1168, 1197 (Fed. Cir. 2008). Section 3.307(d)(6) provides that the term “herbicide agent” means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307(d)(6)(i). As a preliminary matter, the Veteran served in Vietnam for one year from August 17, 1966 to August 16, 1967. The RO has conceded herbicide exposure. If a veteran was exposed to an herbicide agent during active military, naval, or air service, the diseases listed under 38 C.F.R. § 3.309(e) shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. The list of diseases associated with exposure to certain herbicide agents is as follows: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin’s disease; ischemic heart disease; all chronic B-cell leukemias; multiple myeloma; non-Hodgkin’s lymphoma; Parkinson’s disease; early-onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). For secondary service connection to be granted, generally there must be (1) medical evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When service connection is, thus, established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (2017); see Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.§ 5107(b). 1. Entitlement to service connection for amebiasis (also claimed as dysentery) is denied. The Veteran contends that he is entitled to service connection for dysentery and amebiasis. He contends that he had lingering effects of severe dysentery after his family physician treated him for the condition in September 1967. According to the Veteran, he had been exposed to parasites in the water and food while he was stationed in Vietnam. These parasites, according to him, have continued to live in his intestines for the rest of his life, and he treats the condition with yeast tablets. After careful review of the claims record, the Board finds there is no competent evidence demonstrating that the Veteran has a current disability of amebiasis or dysentery during the appeals period. The only evidence of record which indicates the Veteran has amebiasis and/or dysentery is the Veteran's own allegations. As a lay person, the Veteran is not competent to diagnose the presence of amebiasis and dysentery. These are complex medical determinations which require specialized medical knowledge which the Veteran does not possess. As such, this claim does not have the first required element of service connection, a current disability; so it fails as a matter of law. Brammer v. Derwinski, 3 Vet. App. 223 (1992). 2. Entitlement to service connection for peripheral neuropathy to include as due to herbicide exposure, or as secondary to service-connected posttraumatic stress disorder (PTSD) is denied. The Veteran contends that his peripheral neuropathy is “an extension of and is the manifestation” of his PTSD. The service treatment records are silent as to complaints of, diagnosis of or treatment for peripheral neuropathy. There is no evidence of the presence of peripheral neuropathy to a compensable degree within one year of the Veteran's service in Vietnam which would allow for the grant of service connection for early onset peripheral neuropathy on a presumptive basis due to the Veteran's herbicide exposure while stationed in Vietnam. In February 2016, the Veteran underwent a Diabetic Sensory-Motor Peripheral Neuropathy DBQ examination. It was concluded that the Veteran did not have a current disability of peripheral neuropathy, so no etiology opinion was given. Clinical records reference the presence of radiating hip pain and tingling in the feet. These records did not include a diagnosis of peripheral neuropathy. The radiating hip pain and tingling in the feet were not linked to active duty. The only evidence of record which indicates that the Veteran currently has peripheral neuropathy is his own allegations. The diagnosis of peripheral neuropathy is a complex medical determination which required specialized medical knowledge which the Veteran does not have. His opinion as to the existence and etiology of peripheral neuropathy is without probative value. The probative evidence of record does not demonstrate that the Veteran has a current disability of peripheral neuropathy. In the absence of proof of a present disability of peripheral neuropathy, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Accordingly, the claim is denied on a direct and secondary service connection basis. 3. Entitlement to service connection for right hip disability and arthritis (all joints) is denied. The Veteran asserts that he is entitled to service connection for arthritis (all joints). He reports that it is untreatable, and his pain comes and goes in severity. He, specifically, reported locking in his right knee and issues with his right knee since undergoing surgery. Moreover, he attributes pain in his right hip and right ankle to his right knee issues. The record indicates that the Veteran has complained of issues with his neck, shoulder, hips, ankles, right knee, and right trigger finger. He has a current diagnosis of arthritis in his right knee and right hip; and it is reported that he has a medical history of gout and osteoporosis. As such, the Board finds that the Veteran has a current disability. The Veteran’s STR’s demonstrate that the Veteran dislocated his right ankle before service, in February 1965. A medical history report from June 1965 indicates that the Veteran dislocated his right ankle “four months ago.” However, it also indicates that he had not had trouble with his legs since. The Veteran entered service in October 1965 and there are not any reports in his STR’s that indicate that his right ankle incurred trauma or was aggravated while in service. Nor does the Veteran assert that he incurred trauma to his right ankle during service. As such, service connection for his right ankle is not warranted because the claim lacks evidence of an inservice incurrence and nexus. While the record indicates that the Veteran has a current disability of arthritis in his right knee and right hip, the record does not demonstrate that these disabilities were incurred in service or are related to service. There is nothing in his STR’s that report any trauma to the right knee or right hip, and there are not any inservice medical diagnoses associated with his right knee or right hip. Nor is there any evidence that he incurred trauma to “all of his joints” while he was in service. Therefore, while the Board accepts that the medical record indicates a current disability of osteoporosis and gout, direct service connection is not warranted because there is no evidence of inservice incurrence. Accordingly, absent evidence of the required second element of service connection, direct service connection is not warranted for a right ankle, right hip disability, right knee arthritis, or arthritis of all of his joints. However, the Veteran does not allege an onset of symptoms related to his arthritis during service. Instead, he reports that his current arthritis is due to herbicide exposure, and that he is entitled to service connection on a presumptive basis. Yet, his current disabilities of arthritis are not subject to presumptive service connection for herbicide-exposed Veterans. 38 C.F.R. § 3.309(e). Also, the Veteran is not competent to provide an etiology opinion regarding his arthritis and exposure to herbicides. He lacks the requisite medical expertise, and the etiology is not susceptible to lay observation. See Jandreau v. Nicholson, 492 F.3d. 1372 (2007); see also, Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (although it is error to categorically reject a non-expert opinion as to etiology, or nexus, not all questions of nexus are subject to non-expert opinion; whether a layperson is competent to provide a nexus opinion depends on the facts of the particular case). As such, presumptive service connection is also not warranted. Accordingly, the claims for service connection for right hip disability and arthritis of all joints are denied. In reaching its determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 4. Entitlement to service connection for periodontal disease is denied. A claim for service connection for a compensable dental disorder is also considered to be a claim for VA outpatient dental treatment. Mays v. Brown, 5 Vet. App. 302, 306 (1993). Service connection for compensation purposes can only be established for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150 (2017), such as impairment of the mandible, loss of a portion of the ramus and loss of a portion of the maxilla, but not periodontal disease. Compensation is available for loss of teeth only if due to loss of substance of the body of the maxilla or mandible. Simmington v. West, 11 Vet. App. 41 (1998). For loss of teeth, bone loss through trauma or disease (i.e. osteomyelitis) must be shown for purposes of compensability. Specifically, under Diagnostic Code 9913 (“loss of teeth, due to loss of substance of body of maxilla or mandible without loss of continuity”), missing teeth may be compensable for disability rating purposes, but the Note immediately following Diagnostic Code criteria states that “these ratings apply only to bone loss through trauma or disease such as osteomyelitis, and not to the loss of the alveolar process as a result of periodontal disease, since such loss is not considered disabling.” 38 C.F.R. §4.150, Diagnostic Code 9913. There is no indication in the inservice medical records that the Veteran had any injury, or pertinent disease pertaining to his teeth, gums, or mouth in service. Post-service medical records show dental treatment and a current diagnosis of periodontal disease, but they do not show any of the dental conditions listed under 38 C.F.R. § 4.150, such as impairment of the mandible, loss of a portion of the ramus, or loss of a portion of the maxilla. Moreover, none of the dental records in the claims file contain a medical opinion that indicates the Veteran's current periodontal disease is due to service. The Veteran is not competent to provide an opinion as to the etiology of his dental problems. This is a complex medical determination. As previously discussed, service connection for loss of teeth can be established for compensation purposes only if the loss is due to the loss of the body of the maxilla or mandible due to trauma or disease such as osteomyelitis, which is not shown here. 38 C.F.R. § 4.150, Diagnostic Code 9913. The Veteran does not have any dental condition for which service connection for compensation purposes can be awarded. Additionally, to the extent that the Veteran alleges that his condition is the result of exposure to herbicides, the Board notes that periodontal disease is not a disorder that warrants service connection based on presumptive herbicide exposure. See 38 C.F.R. § 3.309(e). The Board has considered the Veteran’s lay statements and the private medical records submitted from Cape Regional Medical Center, Dr. M.B., and Dr. T.M. As mentioned, the dental records that were received from these entities did not include any nexus opinion that connected the Veteran’s periodontal disease or dental condition to service. As such, this medical evidence is not probative to the etiology of the Veteran’s periodontal disease claim. Accordingly, as the Veteran does not have loss of the substance of the body of the maxilla or the mandible due to trauma or disease during active duty, service connection for compensation purposes must be denied. In reaching its determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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 for that rating. 38 C.F.R. § 4.7. Where a Veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, as is the case here, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous... ” Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, “staged” ratings may be assigned for separate periods of time based on facts found. Id.; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (VA’s determination of the ‘present level’ of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the rating claim has been pending). 5. Entitlement to an initial compensable rating for bilateral hearing loss after September 18, 2006 but before January 21, 2009, a rating in excess of 20 percent from January 21, 2009 to May 24, 2011, a rating in excess of 30 percent from May 24, 2011 to May 20, 2015, and a rating in excess of 70 percent thereafter is denied. The matter of the Veteran’s entitlement to an increased rating for bilateral hearing loss was previously before the Board in September 2011, May 2012, October 2013, November 2014, and February 2017. The Veteran appealed the Board’s November 2014 decision on his bilateral hearing loss claim to the United States Court of Appeals for Veterans Claims (Court). In a March 2016 Memorandum Decision, the Court vacated the November 2014 Board decision, concluding that the Board failed to ensure substantial compliance with previous remand directives that instructed VA examiners to address and describe the functional effects of the Veteran’s hearing loss on his daily activities and occupational functioning. Stegall v. West, 11 Vet. App. 268 (1998) (a remand by the Board confers on the Veteran, as a matter of law, the right to substantial compliance with the remand). Thereafter, the matter of the Veteran’s entitlement to an increased rating for bilateral hearing loss was remanded to the Board for further development consistent with the Memorandum Decision. The most recent Board decision in February 2017, remanded the bilateral hearing loss claim for an additional VA examination consistent with the March 2016 Memorandum Decision. Increased Rating Law for Bilateral Hearing Loss When evaluating service-connected hearing impairment, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned in audiometric evaluations. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992) (defective hearing is rated on the basis of a mere mechanical, and therefore nondiscretionary, application of the rating criteria). The rating schedule provides rating tables for the evaluation of hearing impairment. Table VI assigns a Roman numeral designation (I through XI) for hearing impairment based on a combination of percent speech discrimination and the puretone threshold average (the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz , divided by four). 38 C.F.R. § 4.85. Table VII is used to determine the percentage evaluation by combining the Table VI Roman numeral designations for hearing impairment in each ear. 38 C.F.R. § 4.85. 38 C.F.R. § 4.86 provides for exceptional patterns of hearing impairment. When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. 38 C.F.R. § 4.86(a). When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation from either Table VI or Table VIA, whichever results in the higher numeral. 38 C.F.R. § 4.86(b). That numeral is then elevated to the next higher Roman numeral. Id. Each ear is evaluated separately. Id. A. Initial Compensable Rating (from September 18, 2006 to January 21, 2009) is denied. The Veteran was originally denied service connection in a December 21, 2004 decision. The Veteran filed an appeal to this, but it was not received until September 2006, so it was not timely. A January 19, 2007, rating decision granted service connection for bilateral hearing loss with a noncompensable rating effective his new date of claim, September 18, 2006. The Veteran filed for a claim for increase in February 2007, and requested an additional VA examination. In correspondence received March 8, 2008, the Veteran emphasized that he is a Vietnam combat veteran and that hearing aids are necessary for him to hear well. He stated that it was totally unacceptable that while he has been recognized for hearing loss and issued hearing aids, he has not been compensated. Moreover, according to him, his hearing, at this time was “severe.” In January 2007, the Veteran underwent a VA examination in connection with his claim for service connection. An audiogram yielded the following results with puretone thresholds, measured in decibels: 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 25 45 50 55 65 Left Ear 25 45 50 55 70 The puretone threshold average was 54 decibels in the right ear and 55 decibels in the left ear. Speech discrimination scores using the Maryland CNC test were 90 percent in the right ear and 92 percent in the left ear. Applying these results to Table VI, the Veteran had Level I hearing acuity in the left ear and Level II hearing acuity in the right ear. Applying Table VII, the Veteran had noncompensable hearing loss at the time of the January 2007 examination. At the Veteran’s behest, another VA examination was provided in August 2007. An audiogram yielded the following results with puretone thresholds, measured in decibels: 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 30 50 60 60 65 Left Ear 30 50 55 65 80 The puretone threshold average was 59 decibels in the right ear and 63 decibels in the left ear. Speech recognition scores using the Maryland CNC test were 92 percent in the right ear and 90 percent in the left ear. Based on Table VI, the Veteran had Level III hearing acuity in the right ear and Level II hearing acuity in the left ear. Although the audiogram results do show a worsening in the Veteran’s hearing relative to the January 2007 examination, when applying these results to Table VII, the Veteran still had noncompensable hearing loss at the time of the August 2007 examination. In September 2007, the Veteran was fitted for hearing aids. Notably, the use of hearing aids is evidence that a veteran has impaired hearing; however, such evidence alone does not establish that the hearing loss disability had risen to a compensable level nor does it provide automatic entitlement to an increased rating. A December 2008 psychiatry note indicated the Veteran was hard of hearing and he did not hear the doctors when he was called in the waiting room. The Veteran stated that he was unable to hear in spite of having hearing aids and felt frustrated with VA for refusing him compensation. The Board finds that a compensable rating is not warranted for the Veteran’s bilateral hearing loss before January 21, 2009. As discussed above, neither examination warranted an increase under 38 C.F.R. § 4.85. Also, none of the pure tone thresholds shown on the February 2007 or August 2007 audiological evaluations reflected an exceptional pattern of hearing loss as contemplated by 38 C.F.R. § 4.86(a) because the pure tone threshold at each of the four specified frequencies (1,000, 2,000, 3,000, and 4,000 Hertz) were not 55 decibels or more; as such, that provision is inapplicable. Additionally, an exceptional pattern of hearing loss as contemplated by 38 C.F.R. § 4.86(b) also was not shown as the two VA audiological evaluations reflect that pure tone thresholds for the Veteran were not 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz; and thus, neither Table VI or Table VIA was applicable to this period on appeal. B. A rating in excess of 20 percent from January 21, 2009 to May 24, 2011 is denied. On January 21, 2009, the Veteran was afforded another VA examination. The Veteran indicated difficulty understanding speech in the presence of noise, particularly women and children’s voices. An audiogram yielded the following results with puretone thresholds, measured in decibels: 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 50 55 60 60 75 Left Ear 60 55 60 70 85 The puretone threshold average was 62.5 decibels in the right ear and 67.5 decibels in the left ear. Speech discrimination scores using the Maryland CNC test were 34 percent bilaterally, and it was noted that such scores were “at limits of equipment.” Due to the fact that the speech discrimination scores could not be applied because of “the limitations of equipment” in the January 2009 examination, the Veteran was scheduled for a new examination. At the May 2009 VA examination, an audiogram yielded the following results with puretone thresholds, measured in decibels: 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 50 55 65 70 85 Left Ear 45 55 65 70 80 The puretone threshold average was 69 decibels in the right ear and 67 decibels in the left ear. Speech recognition scores using the Maryland CNC test were 90 percent for the right ear and 84 percent for the left ear. Thereafter, in May 2009, the Veteran submitted a statement from a friend who indicated she had known him for six years and had to look straight at him when she talked if he was not wearing his hearing aids. In addition, she indicated that if there was a lot of background noise, she had to speak directly into his ear even when he was wearing his hearing aids and that he went through hearing aid batteries on a weekly basis. The Board finds that a higher rating is not warranted for this period of appeal, from January 2009 to May 24, 2011. Upon review of both the January 2009 and May 2009 audiometric results, the Veteran had exceptional hearing loss as defined by 38 C.F.R. § 4.86(a) because the puretone thresholds at each of the four specified frequencies was 55 decibels or more. Since the speech discrimination scores from the January 2009 examination were at the limits of the equipment, Table VI was not used to interpret the results. Table VIA indicates a Level V hearing acuity bilaterally after the January 2009 examination. Also, after consulting Table VI and Table VIA, per 38 C.F.R. § 4.86(a), the Veteran still exhibited Level V hearing acuity bilaterally at the May 2009 examination. This equates to a 20 percent rating. Accordingly, a 20 percent rating, but no higher, was the appropriate rating for this period on appeal. As such, the Veteran’s claim for increase for this period on appeal is denied. C. A rating in excess of 30 percent from May 24, 2011 to May 20, 2015 is denied. In May 2012, the Board remanded the claim for another examination to assess the severity of the Veteran’s hearing loss. This examination was scheduled for September 2012. The Veteran failed to report to the examination. In October 2013, the Board found that the Veteran had shown good cause for his failure to report and remanded the claim again for a VA examination which was provided in December 2013. At the December 9, 2013 VA examination, the Veteran indicated he could not hear people when they talked to him; he could not hear the blinker in the car; and he could not hear someone across the room. He stated that without his hearing aids, he could not hear anything. An audiogram yielded the following results with puretone thresholds, measured in decibels: 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 60 65 70 80 90 Left Ear 60 70 70 85 105 The puretone threshold average was 76 decibels in the right ear and 83 decibels in the left ear. Speech recognition scores using the Maryland CNC test were 80 percent for the right ear and 72 percent for the left ear. The Board has considered that the claims record included a May 24, 2011 VAMC audiogram that was scanned into the file. Also, the Veteran’s audiogram from his private doctors dated December 28, 2012 and January 7, 2013 were considered. However, neither of these audiograms included speech discrimination testing using the VA-approved Maryland CNC word list, as required by 38 C.F.R. § 4.85. They are not appropriate for rating the hearing loss under the pertinent regulations. While the RO has attempted to get authentication and more information about the private examinations, as recent as May 2018, no response has been received to this date. Therefore, they are inadequate for rating purposes, and are not probative to his rating for his bilateral hearing loss during this period on appeal. The Veteran was increased to 30 percent in a December 2013 RO opinion. In a March 2018 opinion, the RO concluded that due to a clear and unmistakable error the Veteran’s bilateral hearing loss rating of 30 percent was effective May 24, 2011 because it was the earliest date of record that a 30 percent rating was ascertainable. While it was not adequate for rating purposes, the RO used the May 24, 2011 VAMC audiogram as the earliest evidence that the Veteran’s hearing loss disability warranted an increase. Again, audiometric results showed exceptional hearing loss under 38 C.F.R. § 4.86(a) and upon review of Table VI and Table VIA, the Board finds the use of puretone threshold average without consideration of the speech discrimination tests to be most favorable for the Veteran. Under Table VIA, the Veteran had Level VI hearing acuity in the right ear and Level VII hearing acuity in the left ear on December 9, 2013. Table VII indicates that a 30 percent rating, but no higher, was appropriate using these scores. Accordingly, the claim for a higher rating during this period is denied. D. A rating in excess of 70 percent after May 20, 2015 is denied. At the April 5, 2017, VA examination, the Veteran reported that he could not hear normal conversation and communicate without his hearing aids. An audiogram yielded the following results with puretone thresholds, measured in decibels: 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Right Ear 70 80 90 95 100 Left Ear 70 70 75 90 105+ The puretone threshold average was 91.25 decibels in the right ear and 85 decibels in the left ear. Speech recognition scores using the Maryland CNC test were 50 percent for the right ear and 38 percent for the left ear. Again, audiometric results showed exceptional hearing loss under 38 C.F.R. § 4.86(a) and upon review of Table VI and Table VIA, the Board finds the use of puretone threshold average with consideration of the speech discrimination tests to be most favorable for the Veteran. Under table VI the Veteran had Level X hearing acuity in the left ear and hearing acuity of Level IX in the right ear. Table VII indicates that a 70 percent rating, but no higher is warranted. In making its determination, the Board has considered the VA audiograms conducted on May 20, 2015 and March 8, 2017. However, they cannot be used for VA rating purposes because they do not indicate if a Maryland CNC speech discrimination test was used. Thus, they are inadequate, and are not probative to the Veteran’s hearing levels during this period of the appeal. E. Other considerations The Board has carefully considered the lay statements submitted by the Veteran and his representative regarding his inability to hear well. The Veteran is certainly competent to describe his hearing loss. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, the Veteran’s description of his hearing loss disability must be considered in conjunction with the clinical evidence of record. The Board emphasizes that hearing loss disability ratings are derived by a mechanical application of the rating schedule. Lendenmann, 3 Vet. App. 349. The Board has no discretion in this matter and must predicate its determination on the basis of the results of the audiology studies of record. The Board acknowledges the Veteran’s numerous statements regarding his opinion that the hearing tests conducted pursuant to the directives of VA regulations do not adequately reflect the impairment caused by his hearing disability in “real life” and his specific disagreement with the use of the speech discrimination test that is administered in a sound proof booth with a head set. However, as discussed below, the VA regulations take into account the Veteran’s symptoms associated with his hearing impairment. It is clear to the Board that the Veteran’s hearing has diminished through the years and the Board recognizes the Veteran’s frustration; however, higher evaluations under the schedular criteria cannot be granted in the absence of audiometric findings that indicate entitlement to a higher rating under the appropriate Tables. In this case, there are no audiometric findings of record indicating that higher ratings than those presently assigned are warranted. Thus, the Board cannot grant an increase in compensation for his hearing loss disability pursuant to the rating schedule. F. Extraschedular considerations In the Appellant’s September 2014 Post-Remand Brief, the Veteran’s representative argued that extraschedular consideration is warranted in this case based on the Veteran’ statements that hearing loss has “severely impaired his activities of daily living and that he is unable to hear anything unless he uses his hearing aids.” The representative contended that this lay testimony, when considered alongside the Veteran’s audiometric thresholds, indicated that the available schedular evaluation is inadequate to portray the severity of hearing loss experienced by the Veteran. In its March 2016 decision, the Court concluded that the Board, in its November 2014 decision, failed to discuss extraschedular consideration in terms of the effects of the Veteran’s hearing loss on his functional capacity. The Court also concluded that the duty to assist was violated when the Board relied on the December 2013 examination that did not include a description of the effects of the Veteran’s hearing loss on his occupational functioning and daily activities. At his April 2017 VA examination, the examiner reported that a severe to profound hearing loss will impact daily function in occupational as the hearing loss can cause a person to miss 100 percent of the presented speech. The examiner reported that the Veteran would benefit from assistive telephone communications due to his hearing loss. Additionally, the examiner recommended one on one communication with speakers, and noted that communication with unfamiliar persons would be difficult due to the Veteran’s level of hearing loss. The Board had considered whether an extraschedular rating is warranted for the service-connected bilateral hearing loss during the relevant period on appeal due to the Veteran’s profound hearing loss. However, the Board finds an extraschedular rating is not warranted. Ratings shall be based as far as practicable upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: a finding that the case presents such an exceptional or unusual disability picture with such related factors 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)(1) (2017). The United States Court of Appeals for Veterans Claims (Court) has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service connected disability are inadequate. See Yancy v. McDonald, 27 Vet. App. 484 (2016); Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances); Sowers v. McDonald, 27 Vet. App. 472, 478 (2016) (“[t]he rating schedule must be deemed inadequate before extraschedular consideration is warranted”). Second, if the schedular rating does not contemplate the veteran’s level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran’s disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 116. Third, if the first two Thun elements have been satisfied, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran’s disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. at 116. In other words, the first element of Thun compares a veteran’s symptoms to the rating criteria, while the second element considers the resulting effects of those symptoms; if either prong is not met, then referral for extraschedular consideration is not appropriate. Yancy, 27 Vet. App. at 494-95. With respect to the first prong of Thun, the evidence in the instant appeal does not establish such an exceptional disability picture as to render the schedular criteria inadequate. The schedular rating criteria for rating hearing loss provide for disability ratings based on audiometric evaluations, to include speech discrimination and pure tone testing. Here, all the Veteran’s hearing loss symptoms and described hearing impairments are contemplated by the schedular rating criteria. The Veteran’s hearing loss disability has manifested in difficulty understanding speech in the presence of noise or just understanding speech when people are talking to him. As reported by the April 2017 VA examiner, understanding speakers is difficult for the Veteran, and he is unlikely to hear anything. The Veteran also indicated he could not hear his blinker in his car or when people were across the room. Moreover, without his hearing aids, he reported that he could not hear anything. In his August 2016 sworn affidavit he further reported that his inability to hear people at work significantly affected his employment. However, the schedular rating criteria specifically provide for ratings based on all levels of hearing loss in various contexts, as measured by both audiometric testing and speech recognition testing. The ability of the Veteran to hear sounds and voices is measured and rated by an audiometric test, as this test measures different frequencies and captures high frequency hearing loss from sources including voices, music, sirens, and certain high pitched sounds. The ability of the Veteran to understand people and having to ask others to repeat themselves on a regular basis is rated by a speech recognition test, as this test measures conversation comprehension, words, and missed conversations. The schedular rating criteria specifically provide for ratings based on all levels of hearing loss, including exceptional hearing patterns which are demonstrated in this case since his January 2009 VA examination, and as measured by both audiometric testing and speech recognition testing. See Doucette, 28 Vet. App. 366 (holding “that the rating criteria for hearing loss contemplate the functional effects of difficulty hearing and understanding speech”). The decibel loss and speech discrimination ranges designated for each level of hearing impairment in Tables VI and VIa were chosen in relation to clinical findings of the impairment experienced by veterans with certain degrees and types of hearing disability. The regulatory history of 38 C.F.R. §§ 4.85 and 4.86 includes revisions, effective June 10, 1999. See 64 Fed. Reg. 25,202 (May 11, 1999). In forming these revisions, VA sought the assistance of the Veteran’s Health Administration (VHA) in developing criteria that contemplated situations in which a veteran’s hearing loss was of such a type that speech discrimination tests may not reflect the severity of communicative functioning these veterans experienced or that was otherwise an extreme handicap in the presence of any environmental noise, even with the use of hearing aids. VHA had found through clinical studies of veterans with hearing loss that, when certain patterns of impairment are present, a speech discrimination test conducted in a quiet room with amplification of the sounds does not always reflect the extent of impairment experienced in the ordinary environment. The decibel threshold requirements for application of Table VIa were based on the findings and recommendations of VHA. The intended effect of the revision was to fairly and accurately assess the hearing disabilities of veterans as reflected in a real life industrial setting. 59 Fed. Reg. 17,295 (Apr. 12, 1994). The inherent purpose of the schedular rating criteria is to determine, as far as practicable, the severity of functional impact resulting from a service connected disability, including any resultant occupational and social impairment, and therefore contemplates the Veteran’s difficulties functioning in a social environment due to hearing loss. Accordingly, the Board finds that the Veteran’s reported hearing related difficulties are factors contemplated in the regulations and schedular rating criteria. See also Doucette, 28 Vet. App. 366 (holding that “the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday work environment, as these are precisely the effects that VA’s audiometric tests are designed to measure... an inability to hear or understand speech or to hear other sounds in various contexts... are contemplated by the schedular rating criteria”). Accordingly, extraschedular consideration is not warranted in this claim. REASONS FOR REMAND 1. Entitlement to service connection for diverticulitis is remanded. This claim stems from the Veteran’s other claim of entitlement to service connection for amebiasis. As discussed above, the record does not indicate that the Veteran has ever had a diagnosis of amebiasis. However, an ambulatory care note from November 26, 2013 reveals that the Veteran was diagnosed with diverticulosis during a colonoscopy that was three years prior to this note. While, he has a current disability of diverticulosis, more evidence is needed to determine whether this disability is related to his active duty service. The November 2013 record reveals that the Veteran reported suffering with diarrhea every two to three weeks after having dysentery in Vietnam. The claims record also contains correspondence from the Veteran that says that he has had issues with his intestines since September 1967, but medical records from his family doctor are not available for review. The Veteran has not undergone a VA medical examination for this claim. Consistent with the VA’s duty to assist, under McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006), a VA medical examination must be provided when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. See 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159(c)(4)(i). The Veteran has reported consistent problems with digestion since he left Vietnam, and he recently was diagnosed with diverticulitis. However, there is not an etiology opinion on record that has determined whether his current diverticulitis is due to service, including his herbicide exposure. Accordingly, the Board finds that his claim meets the threshold to trigger the VA’s duty to assist and provide a VA examination. As such, a remand for a VA examination and etiology opinion is needed. 2. Entitlement to service connection for hypertension, as due to herbicide exposure is remanded. The Veteran contends that he is entitled service connection for hypertension as due to his exposure to herbicides in service. Although current VA regulations do not provide hypertension as a presumptive disability associated with herbicide exposure, the National Academy of Sciences (NAS), in 2006 and 2008 updates, concluded that there was “limited or suggestive evidence of an association” between hypertension and herbicide exposure. See 75 Fed. Reg. 32,540, 32,549 (June 8, 2010); 75 Fed. Reg. 81,332, 81,333 (December 27, 2010). As noted above, the Veteran is presumed to have been exposed to herbicides. As there is evidence indicating that there may be an association between hypertension and herbicide exposure, a VA opinion must be obtained. 3. Entitlement to service connection for porphyria cutanea tarda, chloracne, and multiple myeloma are remanded. While porphyria cutanea tarda, chloracne, and multiple myeloma are diseases subject to presumptive service connection under 3.309(e), there is not enough medical evidence in the record for the Board to make a determination on whether these disorders are linked to active duty service. Therefore, a remand for a VA examination is required. The Veteran contends that he is entitled to service connection for porphyria cutanea tarda, chloracne, and multiple myeloma. He reports that the blotches on his skin are indicative of porphyria cutanea tarda, and that he has a mild case. He also refers to these blotches as scarring and states that a dermatologist would find that he has chloracne. In September 2011, the Veteran was seen for a C&P examination to determine if he had multiple myeloma. He had recently had biopsies done in June 2011. However, the examiner concluded that the biopsies were benign, and that he did not have multiple myeloma. Yet, the Veteran was later seen for a dermatology consultation on May 31, 2018. The report assessed that the Veteran had small purplish pearly plaques, and it was recommended that he undergo a punch biopsy. A July 31, 2018, correspondence indicates that recent biopsy reported that the plaques were cancerous. Follow-up has not been done to determine what the “plaques” on his skin were at his May 31, 2018, consultation. Additionally, it is not clear what type of skin cancer the Veteran has. As there is not enough evidence for the Board to make a determination, the Veteran’s claim must be remanded for a VA examination that determines what are the current skin conditions the Veteran has and whether the diagnosed skin conditions are related to service. 4. Entitlement to rating in excess of 50 percent for PTSD from October 7, 2011 to present is remanded. A remand is needed for this claim because group therapy records for the Veteran’s PTSD need to be associated with the claims file. At his February 2017 C&P examination, the examiner indicated that the Veteran was presently undergoing mental health treatment through group therapy at the Melbourne, Florida VA Vet center, but the records associated with this therapy were not available for review. There is no explanation in the claims file why these records were not associated with the record, but these notes from his group therapy are needed because they are relevant to the current severity of the Veteran’s service-connected PTSD. See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). As such, these records need to be associated with the claims file. After the records have been associated with the record, an addendum opinion should be requested by the RO from the February 2017 examiner to determine if his opinion regarding the severity of the Veteran’s PTSD has changed after reviewing the group therapy records. These matters are REMANDED for the following action: 1. Obtain all outstanding VA and private medical records to the extent possible, including all records that pertain to the Veteran’s PTSD group therapy. 2. Schedule the Veteran for a VA examination for his diverticulitis. After reviewing the claims file, the examiner is asked to: a) Provide an opinion addressing whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s diverticulitis was due to his presumed in-service herbicide agent exposure. b) Provide an opinion addressing whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s diverticulitis was incurred in or aggravated by of active service. He examiner should address the Veteran’s reported in service gastrointestinal complaints. The examiner should assume the Veteran is competent to report on gastrointestinal symptomology he experiences. If the examiner has a reason to discount the Veteran's self-reported history, it should be stated and then a rationale should be provided to support the opinion that the history provided by the Veteran is not supported by the other evidence of record. 3. Schedule the Veteran for a VA examination for his hypertension. After reviewing the claims file, the examiner is asked to: a) a) Provide an opinion addressing whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension was due to his presumed in-service herbicide agent exposure. b) Provide an opinion addressing whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension was incurred in or aggravated by of active service. He examiner should address the Veteran’s reported in service gastrointestinal complaints. In providing the above opinion, the examiner should address the NAS 2006 and 2008 updates which concluded that there was “limited or suggestive evidence of an association” between hypertension and herbicide exposure. See 75 Fed. Reg. 32,540, 32,549 (June 8, 2010); 75 Fed. Reg. 81,332, 81,333 (Dec. 27, 2010). 4. Schedule the Veteran for a VA dermatology examination. After reviewing the claims file, the examiner is asked to: (a) Confirm whether the Veteran has a current diagnosis of porphyria cutanea tarda, chloracne, or multiple myeloma. (b) Provide an opinion addressing whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s skin cancer, or any confirmed diagnosis from (a) above, was due to his period of active service, to specifically to include his presumed in-service herbicide agent exposure. 5. After directive (1) is complete, obtain an addendum opinion from the February 2017 examiner, or another appropriately qualified VA examiner, to determine whether his or her opinion regarding the Veteran’s current severity of his PTSD has changed with the addition of the group therapy records which were not available at the time of the original examination. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Wade, Associate Counsel