Citation Nr: 18155185 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 15-35 107 DATE: December 4, 2018 ORDER A rating in excess of 20 percent for diabetes mellitus, type II, with erectile dysfunction, is denied. A rating in excess of 10 percent for peripheral neuropathy, left upper extremity is denied. A rating in excess of 10 percent for peripheral neuropathy, right upper extremity is denied. A rating in excess of 20 percent for peripheral neuropathy, left lower extremity is denied. A rating in excess of 20 percent for peripheral neuropathy, right lower extremity is denied. A compensable rating for mild non-proliferative diabetic retinopathy, right and left eyes is denied. A rating in excess of 10 percent for bilateral hearing loss is denied. A rating in excess of 10 percent for tinnitus is denied. REMANDED Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the rating period, the Veteran’s diabetes mellitus has been managed by oral hypoglycemic medication and insulin, but not by recommended regulation of activities; and, the erectile dysfunction associated with the diabetes is manifested by a loss of erectile power, but not by penile deformity. 2. Throughout the rating period, the Veteran’s peripheral neuropathy, left upper extremity, has been manifested by symptoms indicative of mild incomplete paralysis of the median nerve, but not by moderate or severe incomplete paralysis or by complete paralysis. 3. Throughout the rating period, the Veteran’s peripheral neuropathy, right upper extremity, has been manifested by symptoms indicative of mild incomplete paralysis of the median nerve, but not by moderate or severe incomplete paralysis or by complete paralysis. 4. Throughout the rating period, the Veteran’s peripheral neuropathy, left lower extremity, has been manifested by symptoms indicative of moderate incomplete paralysis of the sciatic nerve, but not by moderately severe or severe incomplete paralysis or by complete paralysis. 5. Throughout the rating period, the Veteran’s peripheral neuropathy, right lower extremity, has been manifested by symptoms indicative of moderate incomplete paralysis of the sciatic nerve, but not by moderately severe or severe incomplete paralysis or by complete paralysis. 6. Throughout the rating period, the Veteran’s corrected visual acuity is shown to be 20/40 or better in both eyes at all times and there is no noted visual field impairment and no indication of incapacitating episodes related to his eye disability. 7. Throughout the rating period, the Veteran’s hearing impairment has not reached the level for which assignment of a rating in excess of 10 percent is warranted with the application of the rating schedule to the numeric designations resulting from audiometric testing. 8. The Veteran’s service-connected bilateral tinnitus is assigned a 10 percent rating, the maximum rating authorized under Diagnostic Code 6260. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for diabetes mellitus, type II, with erectile dysfunction, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7913 (2017). 2. The criteria for a rating in excess of 10 percent for peripheral neuropathy, left upper extremity, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2017). 3. The criteria for a rating in excess of 10 percent for peripheral neuropathy, right upper extremity, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2017). 4. The criteria for a rating in excess of 10 percent for peripheral neuropathy, left lower extremity, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). 5. The criteria for a rating in excess of 10 percent for peripheral neuropathy, right lower extremity, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2017). 6. The criteria for a compensable rating for mild non-proliferative diabetic retinopathy, right and left eyes, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.79, Diagnostic Codes 6006, 6066 (2017). 7. The criteria for a rating in excess of 10 percent for bilateral hearing loss have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.85, Diagnostic Code 6100 (2017). 8. There is no legal basis for the assignment of a schedular evaluation in excess of 10 percent for bilateral tinnitus. 38 U.S.C. §1155 (2012); 38 C.F.R. § 4.87, Diagnostic Code 6260 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability evaluations are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2017). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321(a), 4.1 (2017). In increased rating claims, the Board must discuss whether “staged ratings” are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2017); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In accordance with 38 C.F.R. §§ 4.1, 4.2 (2017) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the diabetes and its complications under review. In November 2011, the Veteran filed a claim for a TDIU. The RO construed this as a claim for increased ratings for the service connected disabilities, each of which is discussed below. Diabetes Mellitus, Type II, with Erectile Dysfunction The RO granted service connection for diabetes mellitus associated with herbicide exposure by way of an April 2004 rating decision and an initial 20 percent rating was assigned. A 20 percent rating is warranted for diabetes mellitus that requires insulin and restricted diet; or oral hypoglycemic agent and restricted diet. For an increase to 40 percent, the evidence must show the required use of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities). A 60 percent rating is warranted in cases requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating requires more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 38 C.F.R. § 4.119, DC 7913. “Regulation of activities” has been defined as the situation where a veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining “regulation of activities” as used by VA in 7913). Medical evidence is required to show that occupational and recreational activities have been restricted. Camacho v. Nicholson, 21 Vet. App. 360 (2007). Note (1) following the rating criteria indicates that compensable complications from diabetes mellitus are evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are considered part of the diabetic process under DC 7913. Shortly following the Veteran’s claim, he was afforded a VA examination. The February 2012 examination report shows the Veteran’s diabetes as managed by prescribed insulin injection once per day. The examiner confirmed that the Veteran does not require regulation of his activities as a part of the medical management of his diabetes, although the Veteran suggested he has fatigue that limits his activities. There was no report of ketoacidosis and while there was a report of hypoglycemic episodes two to four times monthly, there were no hypoglycemic episodes requiring hospitalization or requiring twice a month visits to the diabetic care provider. Rather, the Veteran reported the episodes resolving with glucose or eating. The examiner also confirmed that there was no unintentional weight loss or loss of strength associated with the Veteran’s diabetes. Outside of the disorders separately discussed, below, the examiner reported the only other residual of the Veteran’s diabetes was erectile dysfunction. Physical examination revealed no deformity, although loss of erectile power was reported. There was no voiding dysfunction or other symptoms associated with the erectile dysfunction. There were no other noted residuals of diabetes, other than those discussed below. The Veteran confirmed that he takes Lisinopril for kidney protection only, but does not have hypertension and there is no indication of a kidney disorder. The Veteran was again examined in May 2015. This examination report showed the Veteran manages his diabetes with prescribed oral hypoglycemic agents and more than one injection of insulin per day, but without any regulation of activities. The frequency of care was noted as less than two times per month and he had no hospitalizations for episodes of ketoacidosis or hypoglycemic reactions, as well as no unintentional weight loss or loss of strength. The Veteran reported having hypoglycemic episodes approximately twice per month, usually at night and usually resolved with glucose or eating. He continued the use of Lisinopril for kidney protection and reported he does not have hypertension. The Veteran did report a myocardial infarction the prior year and that he was now on Metoprolol for the heart condition. The examiner noted the residuals of diabetes as including peripheral neuropathy and retinopathy, both of which are separately rated and discussed below, as well as erectile dysfunction and a cardiac condition. The Veteran underwent an examination for his erectile dysfunction and the findings were essentially the same as the prior examination. At this time, he did not allow physical examination as he himself reported he has normal anatomy with no penile deformity or abnormality. As to the cardiac condition noted by this examiner, the Veteran was awarded service connection for a heart condition in May 2015 and the Veteran has not challenged the rating assigned. This matter will not be further considered in association with the diabetes claim. The Board reviewed the Veteran’s VA outpatient records during the pendency of this appeal. There are no findings within these records that are outside of the scope of the symptoms, treatment and diabetes management noted in the VA examination reports. He has not issued any statements suggesting a worsening in the disability since the May 2015 examination. In sum, the Board finds that the preponderance of the evidence is against a rating in excess of the 20 percent presently assigned for diabetes mellitus throughout this appeal period. As explained in detail above, the Veterans diabetes is consistently shown to be managed by the use of oral medications and insulin. At no time, however, has there been need for regulation of activities. While the Board recognizes the Veteran’s fatigue associated with his diabetes, there is no indication in the medical evidence that he has been prescribed or advised to avoid strenuous occupational and recreational activities by a medical professional. Moreover, while there is notation of hypoglycemic episodes, there is no clinical indication of ketoacidosis or hypoglycemic episodes requiring hospitalization at any time or requiring twice a month visits to a physician. For these reasons, there is no basis upon which to assign a rating in excess of 20 percent for diabetes under Diagnostic Code 7913. Moreover, with regard to the Veteran’s erectile dysfunction, the Board notes it has been deemed as part of the diabetes process and special monthly compensation on account of the loss of use of a creative organ has already been assigned. Under 38 U.S.C. 4.115b, Diagnostic Code 7522, a compensable rating for erectile dysfunction requires a physical deformity of the penis with loss of erectile power. No such findings are present in this case. While the loss of erectile power is recognized, there is no indication of a physical deformity of the penis. As such a compensable rating is not warranted and the Veteran’s erectile dysfunction must be considered a part of the diabetic process under Diagnostic Code 7913. Peripheral neuropathy – Left and Right Upper Extremities The Veteran was initially awarded separate ratings for right and left upper extremity peripheral neuropathy associated with his diabetes mellitus by way of a June 2010 rating decision. 10 percent ratings were assigned for each upper extremity at that time. The Veteran’s diabetic peripheral neuropathy is rated under Diagnostic Code 8515 for evaluation of paralysis of the median nerve. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, combine with application of the bilateral factor. Id. Under Diagnostic Code 8515, complete paralysis of the median nerve warrants a 60 percent rating for the nondominant arm and 70 percent rating for the dominant arm. 38 C.F.R. § 4.124a. Complete paralysis is characterized as follows: hand inclined to the ulnar side, the index and the middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remained extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. Id. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. Id. Mild incomplete paralysis of the median nerve warrants a 10 percent rating. Moderate incomplete paralysis of the median nerve warrants a 20 percent rating for the nondominant arm and a 30 percent rating for the dominant arm. Severe incomplete paralysis of the median nerve warrants a 40 percent rating for the nondominant arm and a 50 percent rating for the dominant arm. 38 C.F.R. § 4.124a, Diagnostic Code 8515. Notably, the Veteran is left hand dominant. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The terms “mild,” “moderate” and “severe” are not defined in VA regulations, and the Board must arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6. Full wrist motion includes dorsiflexion (extension) from 0 to 70 degrees, wrist palmar flexion from 0 to 80 degrees, wrist ulnar deviation from 0 to 45 degrees and wrist radial deviation from 0 to 20 degrees. See 38 C.F.R. § 4.71, Plate I. In this case, following the November 2011 claim, the Veteran was afforded a VA examination. At the time of his February 2012 VA examination, the Veteran reported the numbness and tingling in his upper extremities having worsened over the past few years and involving his hands to elbows, which causes difficulty driving. He reported difficulty with fine motor skills with his hands. The examiner characterized the pain in his upper extremities as mild and intermediate, with moderate paresthesias and moderate numbness. Physical examination revealed less than normal strength on the right side, but normal strength on the left. There were decreased tendon reflexes in both upper extremities. There was decreased sensation in the hands and fingers of both upper extremities. Position sense (grasp of index finger) and vibration sensation was normal, bilaterally. Based upon these findings, the examiner characterized the Veteran has having mild incomplete paralysis of the right upper extremity median nerve, and normal radial and ulnar nerves. The examiner characterized the Veteran’s left radial, median and ulnar nerve all as normal. More recently, the Veteran was examined in May 2015. His symptoms were reported by him as essentially the same as in February 2012. The examiner again characterized the pain in his upper extremities as mild and intermediate, but this time also characterized his paresthesias and numbness as mild. Physical examination revealed strength and deep tendon reflexes within normal limits in both upper extremities at this time. Light touch/monofilament testing revealed decreased sensation in both forearms and both hands. Position sense and vibration sensation was normal in both upper extremities. The examiner at this time characterized the Veteran’s disability as mild incomplete paralysis of the median nerve, bilaterally. The Veteran has not asserted and the evidence does not suggest that his symptoms have worsened since his most recent examination. Thus, a new examination is not warranted. The Board finds that for the entire appeal period, the Veteran’s diabetic neuropathy of the bilateral upper extremities most closely approximates the criteria for the presently assigned 10 percent rating for each upper extremity. The evidence shows that the Veteran has consistently reported symptoms throughout the appeal period, and a VA examiner has likened these symptoms to mild incomplete paralysis of the median nerve. The examiner considered the symptoms and the functional impairment of his fine motor skills when making this assessment. The Board sees no symptoms described as moderate or severe in nature. Given these facts, there is simply no basis for awarding a rating in excess of 10 percent for either upper extremity. There is not moderate or severe incomplete paralysis, or complete paralysis of the median nerve. The appeal is denied. Peripheral neuropathy – Left and Right Lower Extremities The Veteran was initially awarded separate ratings for right and left lower extremity peripheral neuropathy associated with his diabetes mellitus by way of a February 2006 rating decision; 10 percent ratings were assigned for each lower extremity at that time. In June 2010, a rating decision was issued and the lower extremity ratings were each raised to 20 percent disabling. The Veteran’s diabetic peripheral neuropathy of the lower extremities is rated under Diagnostic Code 8520 for evaluation of paralysis of the sciatic nerve. The same principals apply to rating the peripheral nerves of the lower extremities as described in relation to the upper extremities, above. Under Diagnostic Code 8520, complete paralysis of the sciatic nerve warrants an 80 percent rating. Complete paralysis is characterized as follows: the foot dangles and drops, no active movement possible of the muscles below the knee, flexion of the knee weakened or (very rarely) lost. Mild incomplete paralysis of the sciatic nerve warrants a 10 percent rating. Moderate incomplete paralysis of the sciatic nerve warrants a 20 percent rating. Moderately severe incomplete paralysis of the sciatic nerve warrants a 40 percent rating. And, severe incomplete paralysis of the sciatic nerve, with marked muscular atrophy, warrants a 60 percent rating. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Following the November 2011 claim, the Veteran was afforded a VA examination. At the time of his February 2012 VA examination, the Veteran reported the numbness and tingling involving his feet to his knees, which causes difficulty driving, particularly because he is unable to adequately sense the location of his feet and pressure on the pedals. He reported standing for more than 15 minutes or walking for more than 30 minutes will increase the numbness, tingling, pain, and cold sensation. He also reported problems with balance and numbness in his feet and legs with increased sitting. The examiner characterized the pain in his lower extremities as constant and severe, as well as severe paresthesias and severe numbness. Physical examination revealed normal strength of both lower extremities. There was decreased tendon reflexes at the left knee and ankle and at the right knee. There was decreased sensation at the knee, thigh and foot for both lower extremities. Position sense and vibration sensation was noted as absent in both lower extremities. There was no indication of muscle atrophy. Based upon the foregoing, the examiner diagnosed right and left lower extremity peripheral neuropathy, but the report shows the sciatic nerve and femoral nerve to be normal, bilaterally. More recently, the Veteran was examined in May 2015. At this time, he continued reporting numbness and tingling in the lower extremities. He reported numbness of his entire right leg with activity, numbness and tingling from the knees to his feet, and numbness increasing with sitting. He again reported difficulty driving and problems with balance. At this time, he also indicated having problems with cold feet and being unable to walk without shoes, even at home, due to pain in his feet. The Veteran at this time reported constant mild pain in both lower extremities with intermittent severe pain, as well as moderate paresthesias and moderate numbness. Strength testing was normal. There were decreased deep tendon reflexes on the left at the knee, normal on the right. Deep tendon reflexes were absent at the ankle, bilaterally. There was decreased light touch at the ankle and lower leg, with light touch absent at the foot, bilaterally. Position sense was normal, but vibration sensation was decreased in both lower extremities. The examiner indicated there was no muscle atrophy. Based upon the foregoing, the examiner characterized the lower extremity disorder as moderate incomplete paralysis of the sciatic nerve. The Veteran has not asserted and the evidence does not suggest that his symptoms have worsened since his most recent examination. Thus, a new examination is not warranted. The Board finds that for the entire appeal period, the Veteran’s diabetic neuropathy of the bilateral lower extremities most closely approximates the criteria for the presently assigned 20 percent rating for each lower extremity. The evidence shows that the Veteran has consistently reported his symptoms throughout the appeal period, and a VA examiner has likened these symptoms to moderate incomplete paralysis of the sciatic nerve. The examiner considered the symptoms and the functional impairment, including some trouble with driving and an inability to walk without shoes on his feet. The Board’s examination of the medical evidence and consideration of the functional impact of the disabilities leads to a conclusion that the lower extremity peripheral neuropathy is moderate in nature. Severe impact has not been described. For instance, there is no indication of an interference with walking, but there are symptoms when walking and a need to wear shoes. This is not to say there is a need for interference with walking to show a severe level of disability; it is simply of an example of the severity of the Veteran’s disability compared to potentially increased symptoms more indicative of severe disability. The Board finds the VA examiner’s characterization of the disability to reasonably describe the severity given the symptoms reported. Given the determination that the Veteran’s lower extremity peripheral neuropathy is likened to moderate incomplete paralysis of the sciatic nerve, there is no basis for awarding a rating in excess of 20 percent for either lower extremity. The appeal is denied. Diabetic Retinopathy – Left and Right Eyes The RO recognizes the presence of diabetic retinopathy in the Veteran’s eyes, but has not assigned a compensable rating, a finding which the Veteran’s has specifically appealed. Impairment of vision under title 38 C.F.R. includes an examination of the visual acuity (§ 4.75), field of vision (§ 4.76) and muscle function (§ 4.77). The regulations direct that evaluation of visual impairment is to be rated based on the consideration of three factors: (1) impairment of visual acuity (excluding developmental errors of refraction), (2) visual field, and (3) muscle function. 38 C.F.R. § 4.75(a) (2017). However, examinations of visual fields or muscle function will be conducted only when there is a medical indication of disease or injury that may be associated with a visual field defect or impaired muscle function. 38 C.F.R. § 4.75(b). Retinopathy is rating under 38 C.F.R. § 4.79, Diagnostic Code 6006, which directs that eye disabilities are to be rated on the basis of either visual impairment or incapacitating episodes according to a General Rating Formula, whichever results in a higher rating. The Veteran was afforded a VA examination for his eyes in February 2012. Mild nonproliferative diabetic retinopathy was noted to be present in both eyes. Physical examination revealed corrected distance and near vision in both eyes to be 20/40 or greater. Pupils were described as round and reactive to light with no defect. There was no visual field defect and, therefore, no additional testing necessary to evaluate visual fields. There were no other abnormalities of the eye and no indication of incapacitating episodes related to the eye disorder. Thus, the Veteran’s retinopathy was manifested by a normal eye examination with visual acuity of 20/40 or greater in both eyes. More recently, the Veteran was examined in May 2015. He was again noted to have mild non-proliferative diabetic retinopathy in both eyes and this time also noted to have senile nuclear sclerosis cataracts in both eyes. The examiner noted the cataracts to be age related. Corrected near and distant visual acuity was again measured as 20/40 or better in both eyes, pupils were normal, as was the remainder of the eye examination aside from the non-service-connected cataracts. There was again no visual field defect and no indication of incapacitating episodes. The Veteran’s clinical records were also reviewed and do not show any visual impairment or other symptoms related to the Veteran’s retinopathy that are inconsistent with the findings in the examination reports. Further, the Veteran has not suggested that his retinopathy has worsened since the most recent examination, so there is no basis to remand this claim for a new examination. In sum, the evidence of record does not demonstrate that the Veteran’s service-connected right and left eye retinopathy warrants a compensable rating. The disability was not manifested by an impairment of central visual acuity or visual fields at any time during the pendency of this claim. The Veteran’s corrected visual acuity is shown to be 20/40 or better in both eyes at all times and there is no noted visual field impairment. Moreover, there is no suggestion in the record that he has ever had an incapacitating episode related to his eye disability. Impairment of central visual acuity and impairment of visual fields are evaluated pursuant to 38 C.F.R. § 4.79, Diagnostic Codes 6061 through Diagnostic Code 6081. The Veteran’s right and left eye retinopathy does not more nearly approximate a compensable rating under any of the diagnostic codes pertaining to vision impairment. 38 C.F.R. §§ 4.7, 4.79, Diagnostic Codes 6061 through 6081 (2017). Diagnostic Code 6006 also indicates retinopathy can be rated based upon incapacitating episodes under the General Rating Formula for Diagnostic Codes 6000 through 6009; however, the Veteran has had no incapacitating episodes related to his eyes. Thus, the evidence does not show a compensable rating is warranted for the right and left eye retinopathy under any of the applicable rating criteria, to include loss of visual acuity or visual fields, or incapacitating episodes. Bilateral Hearing Loss Disability ratings for hearing loss disability are derived from mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating schedule establishes 11 auditory hearing acuity levels based upon average puretone thresholds and speech discrimination. See 38 C.F.R. § 4.85. An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. Examinations will be conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). Table VI, “Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination,” is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination (horizontal rows) and the puretone threshold average (vertical columns). The Roman numeral designation is located at the point where the row and column intersect. 38 C.F.R. § 4.85(b). Table VIa, “Numeric Designation of Hearing Impairment Based Only on Puretone Threshold Average,” is used to determine a Roman numeral designation (I through XI) for hearing impairment based only on puretone threshold average. Table VIa is used when the examiner certifies that the use of the speech discrimination test is not appropriate due to language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of § 4.86. 38 C.F.R. § 4.85(c). “Puretone threshold average” as used in Tables VI and VIa is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz and divided by four. This average is used in all cases (including those of § 4.86) to determine a Roman numeral designation from Tables VI and VIa. 38 C.F.R. § 4.85(d). Table VII, “Percentage Evaluations of Hearing Impairment,” is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment in each ear. The horizontal rows represent the ear having better hearing and the vertical columns represent the ear having the poorer hearing. The percentage evaluation is located at the point where the row and the column intersect. 38 C.F.R. § 4.85(e). Provisions for evaluating exceptional patterns of hearing impairment are as follows: (a) When the puretone thresholds at each of the four specified frequencies (1000, 2000, 3000 and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. (b) When the puretone thresholds are 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral; the numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86. The Veteran was initially awarded service connection for bilateral hearing loss in May 2010 and a 10 percent rating was assigned. Following his November 2011 claim, the Veteran was afforded a VA audiological evaluation in February 2012. At this time, pure tone thresholds in the right ear at 1000, 2000, 3000 and 4000 Hertz were 15, 20, 50 and 95 decibels, respectively, and in the left ear 20, 45, 80 and 105 decibels, respectively. Thus, the Puretone Threshold Average for rating purposes was 45 in the right ear and 63 in the left ear. Speech audiometry revealed speech recognition ability of 84 percent in the right ear and 92 percent in the left ear. Based upon these findings and the Veteran’s reports, the examiner also noted that the Veteran’s hearing loss makes it difficult for him to understand speech in certain situations, especially those with excessive background noise. The Veteran reported that he has to be more attentive and that he cannot have any other noise around him when he is trying to listen. The examiner found that the Veteran should be able to hear well in most work environments that do not require acute listening skills and that the Veteran’s bilateral hearing loss does not render him unemployable. Applying the values above to Table VI results in a Level II Roman numeral designation for each ear. Application of two Level II designations to Table VII results in a noncompensable rating. The readings reported in this evaluation do not meet the requirements for evaluation as an exceptional pattern of impairment. The RO noted the improvement in the Veteran’s hearing, but decided not to propose a reduced rating based upon a single examination. The 10 percent rating was continued. More recently, the Veteran was afforded a VA examination in May 2015. At this time, pure tone thresholds in the right ear at 1000, 2000, 3000 and 4000 Hertz were 15, 20, 45 and 75 decibels, respectively, and in the left ear 20, 45, 75 and 95 decibels, respectively. Thus, the Puretone Threshold Average for rating purposes was 39 in the right ear and 59 in the left ear. Speech audiometry revealed speech recognition ability of 94 percent in each ear. Consistent with the prior report, this examiner noted that the Veteran’s hearing loss makes it difficult for him to understand speech when there is background noise or an absence of visual cues. This creates potential difficulty with face-to-face communications, in meetings and on the phone. Meetings around the table with the potential for lip reading was noted as a possible help. Thus, this examiner suggested the need for adjustments in the workplace, but made no suggestion that the hearing loss would render the Veteran unemployable. Applying the values above to Table VI results in a Level I Roman number designation for the right ear, and a Level II Roman numeral designation for the left ear. Application of these findings to Table VII results in a noncompensable rating. The readings reported in this evaluation do not meet the requirements for evaluation as an exceptional pattern of impairment. There were no additional VA audiological examinations conducted. The Board has reviewed the Veteran’s statements and the VA clinical records and there is no suggestion of a worsening of hearing loss since the May 2015 examination; thus, the Board finds a remand for a new examination to be unnecessary. The clinical records include treatment such as hearing aid issuance and management, but no audiological testing. The use of hearing aids, however, does not provide a basis for an increased rating. The assignment of an appropriate rating for a hearing loss disability is determined through the mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. The Court has held that, “in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report.” Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). In accordance with this decision, the examiners in this case noted the Veteran’s report of difficulty hearing conversationally. The Board indeed recognizes this functional impact of the Veteran’s hearing loss. On review of the file, even including consideration of the functional impact of the hearing loss on the Veteran’s life, it is evident the criteria for a compensable rating under Diagnostic Code 6100 are not met. Although the audiological evaluations clearly show the Veteran has hearing loss, the hearing loss has not met the criteria for a rating in excess of the 10 percent presently assigned at any time during the pendency of this claim. Tinnitus The Veteran was awarded service connection for tinnitus with an evaluation of 10 percent by way of a May 2010 rating decision. As noted above, he filed this claim for increase in November 2011. Under 38 C.F.R. § 4.87, DC 6260, there is no provision for assignment of a rating in excess of 10 percent for tinnitus, including no rating allowing separate 10 percent rating for tinnitus of each ear. In Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006), the United States Court of Appeals for the Federal Circuit concluded that 38 C.F.R. § 4.25(b) and 38 C.F.R. § 4.87, Diagnostic Code 6260, limit a Veteran to a single disability rating for tinnitus, regardless of whether the tinnitus is unilateral or bilateral. The Veteran’s service-connected tinnitus has been assigned the maximum schedular rating available. 38 C.F.R. §4.87, DC 6260. As there is no legal basis upon which to award an increase, to include a separate schedular ratings for tinnitus in each ear, the Veteran’s appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). All Claims With regard to each of the claims discussed above, VA must consider all favorable lay evidence of record. 38 U.S.C. § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Board has accordingly considered the lay evidence offered by the Veteran, in the form of correspondence to VA and the medical evidence cited above. The Veteran is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). However, even affording the Veteran full competence and credibility, the evidence simply does not show entitlement to ratings in excess those assigned for the disabilities discussed above. These appeals must be denied. REASONS FOR REMAND Entitlement to a TDIU The Veteran filed his claim for a TDIU in November 2011. His VA Form 21-8940 was received in July 2012. He claimed that his diabetes, heart disease and neuropathy were the service-connected disabilities that caused him to become unable to work. He also claimed non-service connected disabilities, such as tremors and a skin disorder, caused him to be unemployable. At the time of his September 2015 VA Form 9, the Veteran, via his representative, specifically alleged that the sum of all conditions should be evaluated to determine whether the Veteran is able to maintain gainful employment. VA’s duty to assist does not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities in TDIU cases. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir 2013). However, following and taking note of the Federal Circuit’s decision in Geib, the Court stated in Floore v. Shinseki, 26 Vet. App. 376, 381 (2013), that the need for a combined-effects medical examination report or opinion with regard to multiple-disability TDIU entitlement decisions is to be determined on a case-by-case basis, and depends on the evidence of record at the time of decision by the RO or the Board. Here, the Board finds that such an opinion would be useful in deciding the Veteran’s claim. On remand, the RO is asked to undertake appropriate development to ascertain the impact of his service-connected disabilities on his activities of daily living and occupational ability. The matter is REMANDED for the following action: 1. Seek an opinion from an appropriate person to evaluate the impact of the Veteran’s service-connected disabilities, when considered in the aggregate, on his ability to secure and maintain substantially gainful employment in light of his education and work history. A complete rationale should be given for all opinions and conclusions expressed. 2. After completing the above actions, to include any other development as may be indicated by any response received as a consequence of the action taken in the preceding paragraph, the Veteran’s TDIU claim should be readjudicated based on the entirety of the evidence. If any claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. MICHAEL KILCOYNE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Adamson, Counsel