Citation Nr: 18156095 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 08-32 086 DATE: December 6, 2018 ORDER Entitlement to service connection for hypertension is granted. Entitlement to service connection for a bilateral hip disorder, claimed as secondary to service-connected disabilities, is denied. Entitlement to service connection for a bilateral shoulder disorder, claimed as secondary to service-connected disabilities, is denied. Entitlement to service connection for a bilateral ankle disorder, claimed as secondary to service-connected disabilities, is denied. Entitlement to an initial rating in excess of 0 percent for left ear hearing loss is denied. REMANDED Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance is remanded. FINDINGS OF FACT 1. The Veteran’s hypertension clearly and unmistakably pre-existed his second period of active service, beginning in January 2003. 2. The evidence of record raises the presumption of aggravation and does not clearly and unmistakably show that the Veteran’s pre-existing hypertension disorder was not aggravated by an in-service injury or as a result of any incident in service. 3. The Veteran’s bilateral hip disorder is not related to any injury, disease, or event incurred in service, or to a service-connected disability. 4. The Veteran’s bilateral shoulder disorder is not related to any injury, disease, or event incurred in service, or to a service-connected disability. 5. The Veteran’s bilateral ankle disorder is not related to any injury, disease, or event incurred in service, or to a service-connected disability. 6. Throughout the pendency of the appeal, the Veteran’s left ear hearing loss was manifested by no worse than Level I hearing loss. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 1131, 5103(a), 5103A (2012); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309 (2017). 2. The criteria for service connection for a bilateral hip disorder, claimed as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. The criteria for service connection for a bilateral shoulder disorder, claimed as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. The criteria for service connection for a bilateral ankle disorder, claimed as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 5. The criteria for a compensable rating for left ear hearing loss have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.85, 4.86 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1977 to October 1981 and from January 2003 to April 2004. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In September 2018, after the issuance of the most recent supplemental statement of the case in January 2018, VA treatment records were associated with the record, for which the Veteran has not submitted a waiver of agency of original jurisdiction (AOJ) review. 38 C.F.R. § 20.1304(c). However, as such records are duplicative to those previously submitted and/or irrelevant to the issues decided herein, no waiver of AOJ consideration is necessary. Furthermore, correspondence received from the Veteran’s representative indicates acknowledgment of all evidence received and requests re-adjudication proceed. This claim was previously before the Board in July 2016, at which time it was remanded for additional development. The claim has now been returned to the Board for review. Upon reviewing the development since July 2016, the Board finds there has been substantial compliance with its remand instructions. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that “only substantial compliance with the terms of the Board’s engagement letter would be required, not strict compliance”); Stegall v. West, 11 Vet. App. 268, 271 (1998) (finding that a remand by the Board confers on the appellant the right to compliance with the remand orders). Thus, the Board will proceed to review and decide the claim with respect to the issues now on appeal based on the evidence that is of record. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty, in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, to establish service connection for a disability resulting from a disease or injury incurred in service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). Service connection for certain chronic diseases may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year (three years for active tuberculous disease and Hansen’s disease; seven years for multiple sclerosis) from the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term “chronic disease” refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where a chronic disease under 3.309(a) is “shown as such in service” (“meaning clearly diagnosed beyond legitimate question,” Walker, 708 F.3d at 1339) or in the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In cases where a chronic disease is “shown as such in service,” the Veteran is “relieved of the requirement to show a causal relationship between the condition in service and the condition for which service connected disability compensation is sought.” Walker, 708 F.3d at 1336. A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. Only such conditions as are recorded in examination reports are considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). When determining whether a defect, infirmity, or disorder is “noted” at entrance into service, supporting medical evidence is needed. Crowe v. Brown, 7 Vet. App. 238 (1994). Mere transcription of medical history does not transform such information into competent medical evidence. LeShore v. Brown, 8 Vet. App. 406 (1995). VA’s General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA’s duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 3-2003; see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). The United States Court of Appeals for Veterans Claims (Court) has held that lay statements by a veteran concerning a preexisting condition are not sufficient to rebut the presumption of soundness. Paulson v. Brown, 7 Vet. App. 466, 470 (1995) (a lay person’s account of what a physician may or may not have diagnosed is insufficient to support a conclusion that a disability preexisted service); Crowe v. Brown, 7 Vet. App. 238 (1994) (supporting medical evidence is needed to establish the presence of a preexisting condition); see also Leshore v. Brown, 8 Vet. App. 406 (1995) (the mere transcription of medical history does not transform the information into competent medical evidence merely because the transcriber happens to be a medical professional). A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Temporary or intermittent flare-ups of symptoms of a preexisting condition, alone, do not constitute sufficient evidence for a non-combat veteran to show increased disability for the purposes of determinations of service connection based on aggravation under section 1153 unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). If an increase in disability is shown during service, clear and unmistakable evidence is required to rebut the presumption of aggravation. 38 C.F.R. § 3.306(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Hypertension The Veteran seeks entitlement to service connection for hypertension, which is defined as high arterial blood pressure. Dorland’s Illustrated Medical Dictionary 801 (28th ed. 1994). Various criteria for its threshold have been suggested, ranging from 140 systolic and 90 diastolic to as high as 200 systolic and 110 diastolic. Id. For purposes of rating the disease, VA defines the term as meaning “that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm.” See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). At the Veteran’s September 1977 entrance examination, his blood pressure was 120/70. There were no blood pressure abnormalities noted, and the examiner indicated that the Veteran was in good health. In March 1978, a Worksheet for Screening Medical Records of Newly Assigned Active Duty Personnel was completed, and it indicated that there were no deviations from normal in the Veteran’s blood pressure. The Veteran received a medical examination in May 1987 which noted an elevated blood pressure of 148/100. At the Veteran’s January 2003 enlistment examination, his blood pressure was 165/91. He was diagnosed with hypertension, but the examiner noted that it was not disqualifying. The Veteran received a VA examination in July 2004 and his blood pressure was 140/100. The examiner indicated that the Veteran was diagnosed with hypertension when he was on active duty in 1979, and was treated with hydrochlorothiazide. As a result of the examination, the Veteran was diagnosed with essential hypertension dating back to 1979, when he was on active duty. It was also noted as currently poorly controlled by medication. The Veteran received a VA examination in March 2008 and the examiner noted blood pressure readings of 155/88 and 168/108 during service in 2003. On examination, the Veteran’s blood pressure was 134/91, 140/82, and 142/90. He was diagnosed with hypertension, and the examiner noted that there were multiple hypertensive blood pressures during service. The examiner opined that the hypertension found on examination was the same hypertension that he was diagnosed with while he was in military service. Pursuant to the July 2016 Board remand, the Veteran received another VA examination in May 2017, and the examiner confirmed the diagnosis of hypertension. The examiner opined that it was less likely as not that the Veteran’s hypertension incurred in or caused by elevated blood pressure readings during his first period of service from November 1977 to October 1981. He found that the evidence as a whole went against the presence of a chronic condition of hypertension, as treatment records documented the absence of such during or proximate to the first period of active duty service. The Veteran’s treatment records documented a history of hypertension in multiple first-degree relatives, including his parents and siblings. The examiner concluded that the disability was most likely due to non-service connected etiologic factors, including his ethnicity and family history. The Veteran’s increasing weight and increasing age also contributed to his condition. The examiner then opined that it was less likely as not that the Veteran’s hypertension, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by the high blood pressure readings throughout the second period of service from January 2003 to February 2004. Treatment records documented that blood pressure readings were higher prior to, and at the beginning of, the second period of service than they were later in that period. Furthermore, an echocardiogram showed that concentric left ventricular hypertrophy was present at the beginning of the second period of service, which was indicative of a significant condition of hypertension prior to this period of active duty. The examiner also opined that treatment records documented an overall improvement in blood pressure control during the second period of service. Finally, he indicated that recent blood pressure readings were better than those recorded prior to, and at the beginning of, the second period of active duty service. The Veteran’s hypertension was noted at his entrance to service. Thus, the presumption of soundness does not apply. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The Board finds the May 2017 VA examination less probative, as it did not consider the elevated blood pressure reading from the July 2004 VA examination, just two months after the Veteran’s separation from service. Based on the elevated reading within one year of discharge, the Board finds that there’s an adequate basis to apply the presumption of aggravation. The Board notes that the May 2017 VA examiner’s conclusions do not rise to the level of “clear and unmistakable evidence” as is needed to overcome the high evidentiary burden needed to rebut the presumption of aggravation. She concluded that it was less likely as not that the Veteran’s hypertension was aggravated beyond its natural progression throughout the second period of service. However, considering the Veteran’s elevated blood pressure immediately after service, and the lack of clear and unmistakable evidence to rebut the presumption that his condition was aggravated by service, the Board finds that service connection is warranted for hypertension. 2. Bilateral Hip Disorder The Veteran received a VA examination in September 2007 and described development of bilateral hip pain between 1995 and 1996. He did not, however, relate a specific mechanism of injury. The Veteran complained of pain over the lateral aspects of both hips that was worse with standing, walking long distances, and ascending and descending stairs. The left hip was more symptomatic than the right, but the Veteran denied any flare ups in the last year. Based on the examination, the Veteran was diagnosed with moderate bilateral hip osteoarthritis. The examiner opined that the disabilities were not caused by or a result of trauma while in service, but were most likely caused by or a result of a normal aging process. Furthermore, the examiner felt that the hip conditions were neither adjunct nor aggravated by the Veteran’s service-connected low back or knee conditions. Pursuant to the July 2016 Board remand, the Veteran received a VA examination in May 2017 and the examiner noted a history of degenerative joint disease and bilateral total hip arthroplasty. The Veteran believed his hip issues began when he fell down stairs during active duty in 2003. He stated that the steps were wet and he fell on his back. Based on a review of the available evidence, the examiner opined that it was less likely as not that the Veteran’s hip disabilities were related to service. The Veteran denied any traumatic injury to either hip, and radiographic signs of degenerative joint disease were first noted in 2008. Treatment records documented the absence of a chronic hip disability during or proximate to active duty service. The examiner continued that it was most likely that the radiographic degenerative joint disease changes of the hips developed during or related to the stresses placed upon the hip joints during the Veteran’s many years outside of active duty service. The examiner further opined that the Veteran’s bilateral hip disability was less likely as not caused or aggravated by any service-connected disabilities. She found that the development of hip degenerative joint disease was etiologically separate from a bladder disability, tinnitus, and/or left ear hearing loss. Furthermore, the Veteran’s low back disability, knee disabilities, and left lower extremity radiculopathy were highly unlikely to have played any etiological role in the development of the Veteran’s hip disabilities. Biomechanically, there was no clear scientific evidence to suggest that a spine or knee condition could cause major problems of another lower extremity joint except for specific conditions, such as a major leg length discrepancy. The examiner reiterated that it was most likely that the hip disabilities developed during or related to the stresses placed upon the hip joints during the Veteran’s many years outside of active duty service. The Board finds the May 2017 VA examination results to be the most probative evidence of record. The examiner’s findings are credible and competent, as they were provided with thorough rationales with regards to the Veteran’s bilateral hip disability and its lack of connection to service or a service-connected disability. She considered all the medical evidence and concluded that a hip disorder was less likely as not caused by service, or caused or aggravated by a service-connected disability. Furthermore, the examiner provided an alternative etiology, finding it most likely developed during or was related to the stresses placed upon the hip joints outside of service, including occupational stressors, recreational stressors, and the aging process. In sum, the most probative evidence of record shows no link between his bilateral hip disorder and an event, injury, or disease in service or a service-connected disability. Therefore, the Board finds the criteria for service connection have not been met and the Veteran’s claim must be denied. 3. Bilateral Shoulder Disorder At the September 2007 VA examination, the Veteran described development of bilateral shoulder pain between 1995 and 1996. He did not, however, relate a specific mechanism of injury. The Veteran complained of loss of range of motion, popping, and crepitus, worse with overhead reaching, pushing, and pulling. Both shoulders were equally symptomatic, and the Veteran denied any significant flare-ups or incapacitating bilateral shoulder pain that had precluded non-use in the last year. Based on the examination results, the Veteran was diagnosed with early osteoarthritis of the right acromioclavicular joint and moderate arthritis of the left acromioclavicular joint. The examiner opined that the disabilities were not caused by or a result of trauma while in service, but were most likely caused by or a result of a normal aging process. Furthermore, the examiner felt that the shoulder conditions were neither adjunct to nor aggravated by the Veteran’s service-connected low back or knee conditions. Pursuant to the July 2016 Board remand, the Veteran received a VA examination in May 2017, and the examiner noted a diagnosis of bilateral degenerative joint disease. The Veteran indicated that his shoulders hurt most of the time, and it was hard to raise his arms to get his shirt on. He described that he had to lift and move things during his civilian shipping and receiving job, as well as in his military career. Based on a review of the available evidence, the examiner opined that it was less likely as not that the Veteran’s shoulder disabilities were related to service. The Veteran denied any traumatic injury to either shoulder, and radiographic signs of degenerative joint disease were first noted in 2008. Treatment records documented the absence of a chronic shoulder disability during or proximate to active duty service. The examiner continued that it was most likely that the radiographic degenerative joint disease changes of the shoulders developed during or related to the stresses placed upon them during the Veteran’s many years outside of active duty service. The examiner further opined that the Veteran’s bilateral shoulder disability was less likely as not caused or aggravated by any service-connected disabilities. She found that there were multiple entries which described normal findings for shoulder examinations prior to the 2008 radiographic degenerative joint disease. Furthermore, the examiner indicated that pathophysiology for development of shoulder degenerative joint disease was etiologically separate from a low back disability, a bilateral knee disability, a bladder disability, tinnitus, left lower extremity radiculopathy, or left ear hearing loss. The examiner reiterated that it was most likely that the hip disabilities developed during or related to the stresses placed upon the hip joints during the Veteran’s many years outside of active duty service. The Board finds the May 2017 VA examination results to be the most probative evidence of record. The examiner’s findings are credible and competent, as they were provided with thorough rationales with regards to the Veteran’s bilateral shoulder disability and its lack of connection to service or a service-connected disability. She considered all the medical evidence and concluded that a current shoulder disorder was less likely as not caused by service, or caused or aggravated by a service-connected disability. Furthermore, the examiner provided an alternative etiology, finding a bilateral shoulder disorder most likely developed during or was related to the stresses placed upon the shoulder joints outside of service, including occupational stressors, recreational stressors, and the aging process. In sum, the most probative evidence of record shows no link between his bilateral shoulder disorder and an event, injury, or disease in service, nor is there a link with any other service-connected disability. Therefore, the criteria for service connection have not been met and the Veteran’s claim is denied. 4. Bilateral Ankle Disorder At the September 2007 VA examination, the Veteran described development of bilateral ankle pain between 1995 and 1996. He did not, however, relate a specific mechanism of injury. The Veteran complained of pain and swelling along the Achilles tendon. The left ankle was more symptomatic than the right, but the Veteran denied any significant flare-ups or incapacitating bilateral ankle pain that prevented ambulation. Based on the examination results, the Veteran was diagnosed with bilateral calcaneal spurs, and the examiner indicated that the radiographic changes were consistent with Achilles tendonitis bilaterally. The examiner opined that the disabilities were not caused by or a result of trauma while in service, but were most likely caused by or a result of a normal aging process. Furthermore, the examiner felt that the shoulder conditions were neither adjunct to nor aggravated by the Veteran’s service-connected low back or knee conditions. Pursuant to the July 2016 Board remand, the Veteran received a VA examination in May 2017, and the examiner noted a diagnosis of bilateral degenerative joint disease. The Veteran indicated that he had arthritis in his ankles and had to wear cushions in some of his shoes. He stated that it began several years prior, and he denied any specific ankle traumas or procedures Based on a review of the available evidence, the examiner opined that it was less likely as not that the Veteran’s ankle disabilities were related to service. The Veteran denied any traumatic injury to either ankle, and radiographic signs of degenerative joint disease were first noted in 2008. Treatment records documented the absence of a chronic ankle disability during or proximate to active duty service. The examiner noted that there was an acute and transient soft tissue injury noted within the service treatment records, but there was a normal x-ray and it was highly unlikely to be responsible for the subsequent degenerative joint disease changes. The examiner continued that it was most likely that the radiographic degenerative joint disease changes of the ankles developed during or related to the stresses placed upon the them during the Veteran’s many years outside of active duty service. The examiner further opined that the Veteran’s bilateral ankle disability was less likely as not caused or aggravated by any service-connected disabilities. She found that the pathophysiology for the development of ankle degenerative joint disease was etiologically separate from a bladder disability, tinnitus, and/or left ear hearing loss. Furthermore, the Veteran’s low back disability, knee disabilities, and left lower extremity radiculopathy were highly unlikely to have played any etiological role in the development of the Veteran’s hip disabilities. Biomechanically, there was no clear scientific evidence to suggest that a spine or knee condition could cause major problems of another lower extremity joint except for specific conditions, such as a major leg length discrepancy. The examiner reiterated that it was most likely that the hip disabilities developed during or related to the stresses placed upon the hip joints during the Veteran’s many years outside of active duty service. The Board finds the May 2017 VA examination results to be the most probative evidence of record. The examiner’s findings are credible and competent, as they were provided with thorough rationales with regards to the Veteran’s bilateral ankle disability and its lack of connection to service or a service-connected disability. She considered all the medical evidence and concluded that it was less likely as not caused by service, or caused or aggravated by a service-connected disability. Furthermore, the examiner provided an alternative etiology, finding it most likely developed during or was related to the stresses placed upon the shoulder joints outside of service, including occupational, recreational, and the aging process. In sum, the most probative evidence of record shows no link between his bilateral ankle disorder and an event, injury, or disease in service, nor is there a link with any other service-connected disability. Therefore, the criteria for service connection have not been met and the Veteran’s claim is denied. Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified by the schedule are considered adequate to compensate veterans for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in this decision is, therefore, undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Left Ear Hearing Loss The Veteran was granted service connection for his left ear hearing loss in a May 2011 rating decision under Diagnostic Code 6100 for sensorineural hearing loss. 38 C.F.R. § 4.85. A noncompensable rating was assigned effective April 27, 2005. Ratings for defective hearing range from 0 percent to 100 percent, based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests, together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz. To rate the degree of disability from service-connected hearing loss, the rating schedule establishes eleven auditory acuity levels ranging from numeric level I for essentially normal acuity, through numeric level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII, Diagnostic Code 6100. When the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, Table VI or Table VIa is to be used, whichever results in the higher numeral, to determine the Roman numeral designation for hearing impairment. 38 C.F.R. § 4.86(a). Additionally, when the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, Table VI or Table VIa is to be used, whichever results in the higher numeral. That numeral will be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). The Veteran received a VA audiological examination in July 2015. The examiner indicated that pure tone thresholds could not be tested, as the tests results were not reliable and were not suitable for rating purposes. The Veteran submitted correspondence in April 2016 and indicated that he had to wear hearing aids all the time just so he can hear people when they speak to him. Even with the hearing aids, however, he could not fully hear people; he had to read lips when people spoke. The Veteran also indicated that people had to tell him to lower his voice when he speaks because he yells but does not realize it because he cannot hear himself. Pursuant to the July 2016 Board remand, the Veteran received a VA examination in May 2017. Audiometric testing revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 LEFT 20 15 15 35 65 The average decibel loss in the left ear was 32.5, and speech audiometry revealed speech recognition ability of 96 percent. The ratings for disability compensation for hearing loss are determined by the mechanical application of the criteria in Table VI and Table VII. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The results of the May 2017 VA examination correlate to Level I hearing loss in the left ear. 38 C.F.R. § 4.85, Table VI. No exceptional pattern of hearing loss was shown. Since the Veteran is service-connected in only one ear, the non-service connected ear is assigned a Roman Numeral designation for hearing impairment of I. 38 C.F.R. § 4.85(f). The combination of Level I hearing loss and Level I hearing loss corresponds to a noncompensable disability rating. 38 C.F.R. § 4.85, Table VII. Consequently, based on the results of the examination of record, the Board concludes that the competent evidence of record does not support a compensable rating for the Veteran’s service-connected left ear hearing loss at any time during the pendency of the appeal. The Board recognizes and has considered the Veteran’s assertions, as noted above, regarding the impact of his hearing loss on his daily life. In this regard, while the Veteran is competent to report the effects of his hearing loss on his daily functioning, he is not competent to report that his hearing acuity is of sufficient severity to warrant a 10 percent or greater evaluation under VA’s tables for rating hearing loss disabilities because such an opinion requires medical expertise (training in evaluating hearing impairment), which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In Doucette v. Shulkin, 28 Vet. App. 366 (2017), the Court held 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 the effects that VA’s audiometric tests are designed to measure. The Veteran has not otherwise described functional effects that are considered exceptional or, that are not otherwise contemplated by, the assigned evaluation. Thus, his complete disability picture is compensated under the rating schedule. Further, neither he nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. Id. (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND TDIU The Veteran contends that his service-connected disabilities prevent him from obtaining and maintaining substantially gainful employment. Total disability ratings are authorized for any disability or combination of disabilities for which the Schedule for Rating Disabilities prescribes a 100 percent disability evaluation, or, with less disability, if certain criteria are met. Id. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person is considered to be unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In reaching such a determination, the central inquiry is “whether the veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In the process of determining whether unemployability exists for TDIU, consideration may be given to the veteran’s level of education, special training, and previous work experience, but not to his age or to any impairment caused by any nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. For a veteran to prevail on a claim for a TDIU, the record must reflect some factor that takes his or her case outside of the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran’s service-connected disabilities include: (i) herniated nucleus pulposus (40 percent); (ii) right knee patellofemoral degenerative joint disease (30 percent); (iii) bladder dysfunction (20 percent); (iv) left knee patellofemoral degenerative joint disease (10 percent); (v) tinnitus (10 percent); (vi) left lower extremity radiculopathy (10 percent); (vii) left ear hearing loss (zero percent). The Veteran’s combined schedular disability was 70 percent from September 11, 2007, 100 percent from April 17, 2017, and 80 percent from June 1, 2018. The Veteran submitted his VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, in April 2016 and indicated that he worked as a shipping clerk from January 1995 to September 2015. However, he last worked full time in October 2014. He was a high school graduate, but did not have any additional education or training. Throughout the pendency of the appeal, the Veteran underwent multiple VA examinations that addressed the nature and severity of his service-connected disabilities and their resulting functional impairment. Upon review, however, the Board finds the majority of the opinions, do not adequately addresses whether each of the Veteran’s service-connected disabilities alone renders him unemployable, nor do they reflect an opinion addressing the functional impact the Veteran’s service-connected disabilities, in combination, had on his employability. As a result, the Board finds remand is warranted to obtain an addendum opinion that describes the functional impact of the Veteran’s service-connected disabilities, alone and in combination, on his ability to work, considering his education level, prior vocational training, work experience, and vocational history. Entitlement to SMC based on the need for aid and attendance The Veteran submitted an affidavit in October 2018 and indicated that his wife played a critical role in his activities of daily living. She drove him to and from appointments, cooked and cleaned, and ran errands that did not required him to be present. The Veteran continued that his wife bathed him as he held onto to support bars in the shower and clothed him. The Veteran further stated that he spent approximately half of his day laying down in bed and the other half in a recliner. He tried to avoid walking, but when he walked around his house, he used the walls for support. Based on the foregoing, it appears that the Veteran may require aid and attendance as a result of his service-connected disabilities. A remand is therefore necessary in order to obtain a VA examination which addresses whether he requires aid and attendance as a result of solely his service-connected disabilities. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (a VA examination must be based on an accurate factual premise). The matter is REMANDED for the following actions: 1. Forward the record, to include a copy of this Remand, to an appropriate VA medical professional to obtain an addendum opinion regarding the functional impact of the Veteran’s service-connected disabilities, in combination, on his employability. The need for another examination is at the discretion of the examiner. Following review of the record, the examiner is requested to describe the functional impact of the Veteran’s service-connected disabilities (herniated nucleus pulposus; right knee patellofemoral degenerative joint disease; bladder dysfunction; left knee patellofemoral degenerative joint disease; tinnitus; left lower extremity radiculopathy; left ear hearing loss), in combination, on his ability to work, considering his education level, prior vocational training, work experience, and vocational history. A rationale should be provided for any opinion offered. If the examiner is unable to provide an opinion without resorting to speculation, then the examiner shall explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, the examiner shall comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. (The AOJ shall ensure that any additional evidentiary development suggested by the examiner be undertaken with the goal so that a definite opinion can be obtained.) 2. Schedule the Veteran for a VA examination to determine whether the Veteran requires aid and attendance as a result of his service-connected disabilities. The claims folder must be made available to and be reviewed by the examiner in conjunction with the examination. All tests deemed necessary should be conducted and the results reported in detail. After review of the claims file and examination of the Veteran, the examiner should opine whether the Veteran’s service-connected disabilities—at present, herniated nucleus pulposus, bilateral knee degenerative joint disease, bladder dysfunction, tinnitus, left lower extremity radiculopathy, and left ear hearing loss—render the Veteran helpless or so nearly helpless that he requires the regular aid and attendance of another person. The examiner should particularly address whether: (a) the Veteran’s service-connected disabilities render him unable to perform the following activities: dress, undress, keep ordinarily clean and presentable, feed oneself through loss of coordination of the upper extremities or through extreme weakness, requires frequent adjustment of a special prosthetic or orthopedic appliance, or is otherwise unable to attend to the wants and needs of nature, including being incapable due to either physical or mental incapacity to protect himself against the hazards and dangers incident in his daily environment; or, (b) the Veteran is bedridden as a result of his service-connected disabilities. In so discussing the above, the examiner must discuss the Veteran’s October 2018 affidavit that his spouse bathes and dresses him, he requires support walking around his house, and he spends half of his day in bed and the other half in his recliner chair. All findings should be reported in detail and all opinions must be accompanied by a clear rationale. M. M. Celli Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Daniels, Associate Counsel