Citation Nr: 18156329 Decision Date: 12/07/18 Archive Date: 12/07/18 DOCKET NO. 04-44 151 DATE: December 7, 2018 ORDER Entitlement to a rating in excess of 30 percent for service connected vestibular abnormality and positional vertigo is denied. FINDING OF FACT During the pendency of the appeal, the Veteran’s service-connected vestibular disorder and positional vertigo was manifested by dizziness and staggering more than once a week, with hearing impairment and tinnitus, but with no evidence of cerebellar gait. CONCLUSION OF LAW The criteria for a disability rating in excess of 30 percent for vestibular disorder and positional vertigo have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.14, 4.20, 4.87, Diagnostic Codes 6204, 6205 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from October 1963 to August 1967. In August 2009, entitlement to a total rating based upon individual unemployability due to service-connected disabilities (TDIU) was granted from December 1, 2003. In December 2013, the Veteran testified before the undersigned at a Board videoconference hearing. A transcript of the hearing is associated with the file. In April 2014, the Board sought an advisory medical opinion from the Veterans Health Administration (VHA). 38 U.S.C. § 7109; 38 C.F.R. § 20.901 (2018). The record reflects that the VHA requested the medical opinion from Southern Arizona VA Health Care System, and obtained the opinion of a VA otolaryngologist with respect to the medical questions raised in the Board’s April 2014 request. The opinion was received in June 2014, and is associated with the file. Upon further review of the VHA opinion, the Board determined that additional evidentiary development was necessary, and in an August 2014 letter, the Board sought another advisory medical opinion from either a VA neurologist or an otologist. The record reflects that the VHA obtained the opinion of another VA medical expert in December 2014 who addressed the medical questions raised in the Board’s August 2014 request. In March 2015 and May 2016, the Board remanded the case to the agency of original jurisdiction (AOJ) for additional development to include a search for treatment records and obtaining a medical opinion. The Board is satisfied that there has been substantial compliance with the remand directives and it may proceed with a decision at this time. See Stegall v. West, 11 Vet. App. 268 (1998). In December 2012 and March 2017, the Veteran submitted a waiver of AOJ consideration of new evidence pursuant to 38 C.F.R. § 20.1304 (2018). In its June 2017 decision, the Board denied the Veteran’s claim to a rating in excess of 30 percent for his service connected vestibular abnormality and positional vertigo. The Veteran filed an appeal to the U.S. Court of Appeals for Veterans Claims (CAVC) contesting the Board’s June 2017 decision. In an April 2018 memorandum decision, the CAVC vacated and remanded the Board’s denial of an increased rating for service connected vestibular abnormality and positional vertigo. In its decision, the CAVC found the Board erred when it failed to refer the claim for extraschedular consideration. Specifically, the CAVC found the Board did not discuss how all of the Veteran’s symptoms associated with his disability, including nausea, was contemplated in the rating schedule in its June 2017 decision. Accordingly, the appeal has been vacated and remanded to the Board for action consistent with the CAVC decision. The Board initially wishes to make it clear that it is aware of the CAVC’s reference to Fletcher v. Derwinski, 1 Vet. App. 394, 397 (1991). However, the Board finds the holding in Fletcher does not require it to simply move around words or change its analysis as part and parcel of a CAVC remand. Here, the parties to the April 2018 CAVC decision did not identify any error in the Board’s June 2017 schedular analysis, and the Board finds nothing that would otherwise change its analysis. As such, the Board’s schedular analysis remains unchanged. 1. Entitlement to a rating in excess of 30 percent for service connected vestibular abnormality and positional vertigo Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified. However, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Under 38 C.F.R. § 4.20, evaluation by analogy is permitted where the rating schedule does not provide a specific diagnostic code to rate the disability. 38 C.F.R. § 4.20. In deciding this appeal, VA has specifically considered whether separate ratings for different periods of time are warranted, assigning different ratings for different periods of the Veteran’s appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Under Diagnostic Code 6204, contemplating peripheral vestibular disorders, a 10 percent rating is warranted for manifestation of occasional dizziness, and a maximum 30 percent rating is warranted when there is dizziness and occasional staggering. 38 C.F.R. § 4.87, Diagnostic Code 6204 (2018). A note provides that objective findings supporting the diagnosis of vestibular disequilibrium are required before a compensable evaluation can be assigned under this code. Hearing impairment or suppuration shall be separately rated and combined. Id. Under Diagnostic Code 6205, contemplating Meniere’s syndrome (endolymphatic hydrops), a 30 percent rating is warranted for hearing impairment with vertigo less than once a month, with or without tinnitus, and a 60 percent rating is warranted for hearing impairment with attacks of vertigo and cerebellar gait occurring from one to four times a month, with or without tinnitus. A 100 percent rating is warranted for hearing impairment with attacks of vertigo and cerebellar gait occurring more than once weekly, with or without tinnitus. 38 C.F.R. § 4.87, Diagnostic Code 6205 (2018). A note provides that Meniere’s syndrome can be evaluated either under these criteria or by separately evaluating vertigo as a peripheral vestibular disorder, hearing impairment, and tinnitus, whichever method results in a higher overall evaluation. However, a combined evaluation for hearing impairment, tinnitus, or vertigo with an evaluation under Diagnostic Code 6205 is inappropriate. Id. In general, all disabilities, including those arising from a single disease entity, are rated separately, and disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.102, 4.3. A brief historical overview of the claim reflects that the Veteran’s service-connected vestibular abnormality and positional vertigo is currently evaluated as 30 percent disabling, pursuant to 38 C.F.R. § 4.87, Diagnostic Code 6204. In April 2006, the Veteran filed a claim for a higher rating for this disability. According to the Veteran, his disability had worsened, and he was experiencing bouts of vertigo two to three times a week, nausea, blurred vision and episodes of stumbling when walking. In the September 2007 rating decision, the RO denied a disability rating greater than 30 percent and noted that a higher evaluation would only be warranted if the Veteran had been diagnosed with Meniere’s syndrome. Indeed, 30 percent is the maximum rating allowable under 38 C.F.R. § 4.87, Diagnostic Code 6204. However, Meniere’s syndrome, which is rated under 38 C.F.R. § 4.87, Diagnostic Code 6205, provides for evaluations much higher than 30 percent based on the symptoms exhibited and whether such symptoms correspond with that required under the rating criteria. For example, the criteria required for a 60 percent rating under Diagnostic Code 6205 requires hearing impairment with attacks of vertigo and cerebellar gait occurring from one to four times a month, with or without tinnitus, and a 100 percent disability rating requires hearing impairment with attacks of vertigo and cerebellar gait occurring more than once weekly, with or without tinnitus. 38 C.F.R. § 4.87. The Veteran argues that he has Meniere’s syndrome (endolymphatic hydrops) and Diagnostic Code 6205 should be used to award a higher rating. In his November 2008 notice of disagreement, the Veteran stated that his physicians had diagnosed him with having Meniere’s syndrome. Along with this assertion, he submitted a November 2007 letter issued by G.P., M.D., and a January 2008 examination report issued by V.P.B., D.O. The Board finds that the evidence is at least in equipoise as to whether the service-connected vestibular abnormality and positional vertigo may be characterized or diagnosed as Meniere’s syndrome. In the March 2015 Remand, the Board indicated that in light of the December 2014 VHA opinion, along with the additional medical evidence of record and the determinations reached by Drs. V.P.B. and G.P., the Board found that the Veteran’s service-connected disorder can be re-characterized as Meniere’s disease. As noted, in an effort to further clarify whether the Veteran had a diagnosis of Meniere’s disease, the Board referred this case to the VHA to obtain a medical opinion from an appropriate health care professional in April 2014 and August 2014. The requested medical opinion was provided by J.G., M.D., an otolaryngologist, in December 2014. In the December 2014 opinion, Dr. J.G. determined that it is at least as likely as not that the Veteran has Meniere’s disease. According to Dr. J.G., Meniere’s disease is manifested by a “tetrad of symptoms,” to include (1) initially fluctuating, later constant hearing loss; (2) episodic vertigo, usually a spinning sensation; (3) tinnitus or ringing in the affected ear, and; (4) aural fullness or a pressure sensation within the ear. Dr. J.G. noted that not all four symptoms within the tetrad need to be present for the diagnosis of Meniere’s disease to be made. Upon review of the claims file, Dr. J.G. noted that the record clearly documents on multiple occasions dating back to as early as 2004, symptoms of vertigo becoming increasingly more frequent with the passage of time. Dr. J.G. also noted that as of 2007, the record reflected symptoms of decreased hearing and a ringing sound in the ears, with a sensation of feeling off balance. Dr. J.G. further noted that hearing tests at this time demonstrated an asymmetrical hearing loss that was greater in the left ear than the right ear. In addition, Dr. G. took note of the October 2003 infrared video nystagmography (VNG) report which reflected a peripheral vestibular abnormality and is consistent with the diagnosis of Meniere’s disease. According to Dr. G., many of the Veteran’s current symptoms of dizziness, a staggering sensation, vertigo, unsteadiness, ringing in the ears and nausea are more likely than not due to the diagnosis of Meniere’s disease. The Veteran submitted private medical evidence and opinions in support of his claim. In the November 2007 letter, Dr. G.P. indicated that the Veteran’s symptoms were vertigo, decreased hearing, a ringing sound in his ears, nausea, blurred vision, and the sensation of feeling off balance. Upon physical examination, the Veteran’s hearing was decreased bilaterally, more so in the left ear than the right. There were no signs of nystagmus, the Veteran’s facial sensation was normal, and the motor examination revealed no atrophy or focal weakness. Tandem as slightly impaired. Dr. G.P. noted that the October 2003 VNG report showed a vestibular abnormality that was most likely peripheral in origin. Based on his review of the record, Dr. G.P. determined that the neurological examination was consistent with decreased hearing bilaterally, diminished sensation peripherally in the upper and lower extremities, and decreased cervical range of motion. Dr. G.P. opined that the Veteran was dealing with symptoms of peripheral vestibulopathy and Meniere’s disease, symptoms which had worsened recently, but could be attributed to a worsening of his diabetes mellitus and drinking excessive amounts of caffeinated beverages. In the January 2008 report, Dr. V.P.B., a neurologist, reviewed the Veteran’s medical history, acknowledged the Veteran’s recent diagnosis of vestibulopathy and Meniere’s disease by Dr. P., and conducted a neurological evaluation of the Veteran. Based on his evaluation, Dr. V.P.B. diagnosed in pertinent part, hearing loss and vestibulopathy consistent with Meniere’s disease. In a May 2010 statement, Dr. V.P.B. indicated that he evaluated the Veteran in April 2010, during which time the Veteran complained of intermittent dizziness, vertigo, and unsteadiness. According to Dr. V.P.B., these symptoms were further complicated by diffuse peripheral neuropathy secondary to his diabetes. On examination, Dr. V.P.B. observed that the Veteran frequently stumbles, and experiences diffuse sensory loss in the lower extremities, particularly to pinprick and vibration. Dr. V.P.B. also noted that the Veteran had a mild Romberg sign, and decreased reflexes. According to Dr. V.P.B., the cranial nerves examination was clear for any signs of nystagmus. Based on his evaluation of the Veteran, Dr. V.P.B. determined that the Veteran suffers from vertigo, tinnitus and hearing loss, which has become chronic. Dr. V.P.B. further concluded that the Veteran’s bilateral tinnitus and hearing loss due to aural trauma would serve to aggravate, and therefore increase, the severity and symptoms of his Meniere’s disease. There is competent and credible evidence that the Veteran’s service-connected vestibular abnormality and positional vertigo is not Meniere’s’ syndrome. A February 2016 VA ear disease examination report indicates that after examination of the Veteran and review of the medical history and claims file, the VA examiner concluded that the diagnoses were multifactorial dysequilibrium due to diabetic peripheral neuropathy and severe cervical spine degenerative disease; cervicogenic dizziness; bilateral high frequency sensorineural hearing loss; bilateral tinnitus; and possible migraine-associated dizziness. The VA examiner opined that the Veteran does NOT have Meniere’s Disease or Meniere’s Syndrome. The VA examiner stated that: “the Veteran has many of the symptoms that would possibly lead one to suspect a diagnosis of Meniere’s disease (hearing loss, tinnitus, dizziness, some aural fullness). However, no Otologist/Neurotologist would accept the notion that the Veteran has Meniere’s disease. At a minimum, with such a longstanding condition of dizziness and staggering, we would have to see a bilateral asymmetric severe sensorineural hearing loss plus a history of episodic severe vertigo with nausea and vomiting (not daily or even weekly), which are simply not present. The VNG test from 2003 was essentially normal. If Meniere’s disease was the cause of veteran’s symptoms, we should be seeing at least a unilateral caloric weakness (note: a 21% caloric paresis score is within normal range, we would have to see at least a 60% caloric weakness score). Such longstanding and varied symptoms frequently cannot be encapsulated into one single diagnosis. I believe that [the Veteran] has Multifactorial Dysequilibrium, that is, balance problem and feeling of off balance related to: diabetic neuropathy and severe cervical spine degenerative disease. The diabetic neuropathy affects the sensation of the feet and lower legs that the brain uses to maintain balance. The cervical spine problem can also lead to poor balance especially if there is spondylosis or spinal stenosis. The cervical spine problem most likely would have been initially triggered by the auto accident with loss of consciousness. MRI imaging in the past has demonstrated degenerative changes in patient’s cervical spine.” The VA examiner noted that cervical spine problems tend to progress with age, and in addition, the Veteran may well have cervicogenic dizziness, that is, dizziness from cervical spine problems. He noted that in cervicogenic dizziness, the dizziness is usually triggered by movement of the head as this Veteran has, not spontaneous as in Meniere’s disease. The VA examiner indicated that the VNG revealed a low amplitude positional nystagmus (not BPPV) which is more likely related to cervicogenic dizziness that any ear disorder. The VA examiner stated that the Veteran has the trauma history and the exam findings of severely reduced cervical range of motion and pain on head motion as well as muscle tenderness, and he has bilateral symmetric high frequency sensorineural hearing and high pitch ringing tinnitus which are most likely related to the noise exposure in the military service. The VA examiner indicated that another possible factor in the Veteran’s case would be migraine, given the occipital headaches he frequently has and the fact that previous VA neurologic examination dated in November 2006 in which the VA examiner concluded that it was likely that the Veteran’s common migraines, intractable, are significantly interfering with his activities of daily living. The VA examiner stated that it was well accepted nowadays by all ear specialists and most neurologists that migraine disorder is a major cause of dizziness even in the absence of headache and a whole spectrum of ear symptoms. Many cases in the past that were thought to be variants of Meniere’s disease are more recently known to be migrainous in etiology. The VA examiner indicated that he reviewed and considered the enumerated reports including the VA ENT examination report dated in December 2006 (the VA examiner conceded the Veteran had a vague “vestibular abnormality”), the evaluation by Dr. G.P. dated in November 2007, and the evaluations by Dr. V.P.B. dated in January 2008 and May 2010. The VA examiner noted that Dr. V.P.B. believed the acoustic trauma caused the Veteran’s Meniere’s disease although such a notion was specifically investigated in Israeli soldiers with noise induced hearing loss and there is no causal connection between acoustic trauma and later developing Meniere’s disease which nevertheless the Veteran does not have. The VA examiner indicated that he was a medical doctor and was an Assistant Professor of Otology/Neurotology, Loyola University School of Medicine. In a March 2017 VA addendum opinion, the VA examiner was asked to render an opinion as to whether it was at least as likely as not that the Veteran has vertigo and cerebellar gait attributable to Meniere’s Disease. The VA examiner opined that the Veteran had benign positional vertigo and no clinical features of Meniere’s Disease. The VA examiner stated that the Veteran’s staggering gait is due to the Veteran bending sideways or forward and thereby triggering vertigo. The Board finds that in light of the December 2014 VHA opinion, along with the additional medical opinions and evaluations by Drs. V.P.B. and G.P, the competent and credible evidence is in equipoise and the Veteran’s service-connected disorder can be re-characterized as Meniere’s disease, and rated by analogy as Meniere’s syndrome under Diagnostic Code 6205. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the assignment of a disability rating in excess of 30 percent for the service-connected vestibular abnormality and positional vertigo under Diagnostic Code 6205 for the entire appeal period. The Board finds that the weight of the competent and credible evidence shows that for the time period of the appeal, the service-connected vestibular abnormality and positional vertigo is manifested by hearing impairment, attacks of vertigo, tinnitus, and stumbling or staggering but not cerebellar gait. “[C]erebellar gait” is “a staggering ataxic gait, sometimes with a tendency to fall to one side, indicative of cerebellar lesions.” See Dorland’s Illustrated Medical Dictionary 764 (31st ed. 2007). An “ataxic gait” is “an unsteady, uncoordinated walk, with a wide base and the feet thrown out, due to some form of ataxia.” Id. See also Camp v. Shinseki, 12-1559, 2013 WL 1868083 (Vet App. 2013). The Board finds that the weight of the competent and credible evidence shows that for the time period of the appeal, the service-connected vestibular abnormality and positional vertigo is not manifested by cerebellar gait. The December 2006 VA examination report indicates that the Veteran reported to experience symptoms of brief vertigo associated with quick head movements to the left and right approximately once a day, as well as symptoms of nausea and blurred vision. On physical examination, Romberg test was negative for any problems, the finger-to-nose test was shown to be good, and the Veteran exhibited a good tandem gait. In addition, the Veteran underwent the Dix-Hallpike test, the results of which were negative for signs of nystagmus or vertigo. In the November 2007 evaluation report, Dr. G.P. noted of the Veteran’s medical history, to include his reported symptoms of vertigo, staggering, and the sensation of feeling off balance. Upon physical examination, motor examination revealed no atrophy or focal weakness. Gait was mildly wide-based. Romberg was negative but the Veteran got very wobbly with his eyes closed. Romberg’s test is used to differentiate between peripheral and cerebellar ataxia and an increase in clumsiness in all movements and in the width and uncertainty of gait when the patient’s eyes are closed indicates peripheral ataxia; no change indicates the cerebellar type. See DORLAND’S ILLUSTRATED MEDICAL DICTIONARY, 1691 (27th ed. 1988). The November 2007 evaluation report indicates that tandem was slightly impaired. Dr. G.P. took note of the October 2003 infrared VNG report, the results of which indicated a vestibular abnormality that was most likely peripheral in origin. Based on his review of the record, as well as his discussion with, and evaluation of the Veteran, Dr. G.P. determined that the neurological examination was consistent with decreased hearing bilaterally, diminished sensation peripherally in the upper and lower extremities, and decreased cervical range of motion. In the January 2008 report, Dr. V.P.B. noted that the Veteran reported having vertigo as well as imbalance, and he would experience tinnitus and would get nauseated intermittently; these episodes would be prevalent by changing body position particularly when bending forward or suddenly arising or looking to the left or right. Sensory examination shows decreased vibratory response as well as decreased sensation in a stocking glove distribution. Reflexes were decreased but symmetric, being 1-2/4 and trace at the ankle. There was no Babinski sign. Gait was slightly broad-based but there was no ataxia. In a May 2010 statement, Dr. V.P.B. noted that he evaluated the Veteran in April 2010, during which time the Veteran complained of intermittent dizziness, vertigo, and unsteadiness; he frequently stumbled. According to Dr. V.P.B., these symptoms were further complicated by diffuse peripheral neuropathy. On examination, there was evidence of diffuse sensory loss in the lower extremities, particularly to pinprick and vibration. There was a mild Romberg sign and decreased reflexes. According to Dr. V.P.B., the cranial nerves examination was clear for any signs of nystagmus. Based on his evaluation, Dr. V.P.B. determined that the Veteran had vertigo, tinnitus and hearing loss, which has become chronic. It was noted that an EMG performed in April 2010 showed significant progression of his peripheral neuropathy from what was reported in 2004. Dr. V.P.B. attributed the Veteran’s gait and balance problems to his diffuse peripheral neuropathy. In the December 2014 VHA opinion, Dr. G. noted that the Veteran’s staggering sensation was a more likely than not a symptoms of Meniere’s disease. Dr. G. also noted that the diffuse peripheral neuropathy affects the lower extremities and may also contribute to his symptoms of unsteady gait. A February 2016 VA ear disease examination report indicates that the Veteran symptoms included bilateral high frequency ringing tinnitus; mild intermittent aural fullness left more often that right; brief spinning vertigo occurring about once per day, lasting 10-20 minutes, triggered by movement of the head when he is up and around; and a mild stumble described as having to stop and adjust the balance, occurs 1-2 times per day. The Veteran described “staggering” as a feeling like he is falling forward, he manages to tolerate it, does not use a cane, occurs 3-4 times per week; it was not falling. The Veteran reported that he has more trouble standing still than he does walking. He reported having cervical spine pain radiating to the occiput daily with occipital headaches 4 times per week which can last 2 hours. He reported that he had numbness in the hands and feet diagnosed as neuropathy and he had a diagnosis of diabetic neuropathy but he did not feel that diabetes explains the “staggering” because he had the staggering long before the diagnosis of diabetes. He did not have episodes of severe vertigo with nausea or vomiting. Physical examination revealed that the external ear, ear canal, and tympanic membrane were normal. Gait was unsteady and was a wide based gait. Romberg test was normal. The Dix Hallpike test for vertigo was normal with no vertigo or nystagmus during the test. Finger nose test was normal. The assessment was multifactorial dysequilibrium, due to diabetic peripheral neuropathy and severe cervical spine degenerative disease; cervicogenic dizziness; bilateral high frequency sensorineural hearing loss; bilateral tinnitus; and possible migraine-associated dizziness. The VA examiner opined that the Veteran has Multifactorial Dysequilibrium, that is, balance problem and feeling of “off balance” related to diabetic neuropathy and severe cervical spine degenerative disease. The VA examiner stated that the Veteran’s diabetic neuropathy affects the sensation of the feet and lower legs that the brain uses to maintain balance. He noted that the cervical spine problem can also lead to poor balance especially if there is spondylosis or spinal stenosis. The VA examiner stated that in addition, the Veteran may have cervicogenic dizziness, that is, dizziness from cervical spine problems. In cervicogenic dizziness, the dizziness is usually triggered by movement of the head as this Veteran has, not spontaneous as in Meniere’s disease. The VA examiner noted that the VNG revealed a low amplitude positional nystagmus (not BPPV) which is more likely related to cervicogenic dizziness that any ear disorder. The VA examiner stated that another possible factor in the Veteran’s case would be migraine, given the occipital headaches he frequently experiences. A February 2017 VA examination report indicates that the VA examiner concluded that the Veteran’s vestibular condition was manifested by occasional brief disequilibrium on walking, quick turn or lean over while sitting; mild spinning sensation and mild nausea since the motor vehicle accident in 1965; some dizziness and spinning; positive water test for vertigo in left ear; imbalance and nausea; and episode that last from a few minutes to 20 minutes occurring 3-4 times a week. The signs and symptoms of the vestibular disorder were hearing impairment with vertigo more than once weekly with a duration of less than an hour; tinnitus more than once weekly with a duration less than 1 hour; vertigo more than once weekly with a duration of less than an hour; and staggering more than once weekly with a duration of less than one hour. Physical examination revealed that gait was normal. Romberg test was abnormal or positive for unsteadiness. The Dix Hallpike test for vertigo was normal with no vertigo or nystagmus during the test. Finger nose finger test was normal. In a March 2017 VA addendum opinion, the VA examiner was asked to render an opinion as to whether it was at least as likely as not that the Veteran has vertigo and cerebellar gait attributable to Meniere’s Disease. The VA examiner opined that the Veteran had benign positional vertigo and no clinical features of Meniere’s Disease. The VA examiner stated that the Veteran’s staggering gait is due to the Veteran bending sideways or forward and thereby triggering vertigo. The Board further notes that the VA treatment records dated from March 2004 to November 2016 do not show any findings of cerebellar gait. An August 2004 VA neurologic clinic record indicates that the Veteran did not have ataxia, and he had normal tandem and Romberg. A December 2004 Internal Medicine evaluation report indicates that cerebellar testing was negative. Although an abnormal gait, stumbling, or staggering have been noted, the weight of the evidence does not establish that the Veteran had cerebellar gait, so as to warrant an increased rating analogous to Meniere’s disease. See 38 C.F.R. § 4.87, Diagnostic Code 6205. As noted, cerebellar gait is defined as a staggering ataxic gait, sometimes with a tendency to fall to one side, indicative of cerebellar lesions. Dorland’s Illustrated Medical Dictionary 753 (32nd Ed. 2012). Such a disorder is more than mere unsteadiness, or even staggering; it is a very specific, and more severe, level of gait impairment. The rating schedule makes this clear; in the criteria for Diagnostic Code 6204, “occasional staggering” is one symptom of a peripheral vestibular disorder rated 30 percent disabling. Had the authors of the schedule meant the same level of impairment for both conditions, the same plain language would have been used and the same disability rating would have been assigned. Instead, the authors used “occasional staggering” to describe symptoms warranting a 30 percent disability under Diagnostic Code 6204 and “cerebellar gait” to describe one of the more severe symptoms that form the disability constellation warranting a total schedular rating under Diagnostic Code 6205. The weight of the competent and credible evidence does not establish cerebellar gait at any time during the appeal period. In reaching the above conclusion, the Board has not overlooked the Veteran’s statements with regard to the severity of his disability. In this regard, the Veteran is competent to report on factual matters of which he had firsthand knowledge, for example, experiencing unsteadiness, dizziness, or lack of balance. The Board has considered the Veteran’s statements along with findings from examinations and treatment notes. However, the Board finds that the objective medical findings and opinions provided by the Veteran’s treatment and examination reports, which in the aggregate establish no showing of cerebellar gait, have been accorded greater probative weight. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (lay testimony is not competent to prove that which would require specialized medical training); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board also recognizes that the medical evidence discussed above attributes the Veteran’s staggering to various disabilities including peripheral neuropathy of the left and right lower extremities, and a cervical spine disability with headaches. The Board notes that service connection is in effect for these disabilities and 20 percent ratings are assigned to each disability. The Board notes that the 20 percent rating assigned to each lower extremity for peripheral neuropathy under Diagnostic Code 8520 contemplates impairment of motor function and disturbances of gait. See 38 C.F.R. § 4.120. Further, “occasional staggering” is specifically contemplated under the 30 percent rating for Diagnostic Code 6204. See 38 C.F.R. § 4.87, Diagnostic Code 6204. The Board finds that the 20 percent ratings under Diagnostic Code 8520 and the 30 percent rating assigned under Diagnostic Code 6204 contemplate the symptoms of staggering and gait disturbance and impairment in motor function of the lower extremities, and the Veteran is compensated for these manifestations. See 38 C.F.R. § 4.14; Esteban; supra. Accordingly, the Board finds that the Veteran is not entitlement to a higher schedular rating for the service-connected vestibular abnormality and positional vertigo. He is currently in receipt of the maximum rating under Diagnostic Code 6204 and his disability does not meet the criteria for a higher rating under Diagnostic Code 6205. Accordingly, the claim must be denied. In reaching the above conclusions, 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. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). REMANDED Entitlement to a rating in excess of 30 percent for service connected vestibular abnormality and positional vertigo on an extraschedular basis is remanded. REASONS FOR REMAND 1. Entitlement to a rating in excess of 30 percent for service connected vestibular abnormality and positional vertigo on an extraschedular basis is remanded. As to the claim for an extraschedular rating for vestibular abnormality and positional vertigo, the CAVC vacated the Board’s determination that extraschedular consideration was not warranted. Throughout the appeal period, medical evidence reflects the Veteran experienced nausea as a symptom of his service connected vestibular abnormality and positional vertigo. Nausea is not a symptom specified in the rating criteria for Diagnostic Code 6205, contemplating Meniere’s syndrome (endolymphatic hydrops). As such, VA must consider whether an extraschedular rating is warranted under 38 C.F.R. § 3.321 (b)(1) for symptoms of the Veteran’s disability that are not contemplated by the rating schedule. Thun v. Peake, 22 Vet. App. 111, 115 (2008). As the Board cannot adjudicate this question in the first instance, a remand is now required to refer this issue to the VA Director of Compensation Service and Pension Service for consideration of an extraschedular evaluation based on a disability with effects that are not captured by its schedular evaluation. The matter is REMANDED for the following action: 1. Refer the issue of entitlement to an extraschedular rating for vestibular abnormality and positional vertigo to VA’s Director of Compensation and Pension Services or the Undersecretary for Benefits, for adjudication of entitlement to an extraschedular rating for such disability under 38 C.F.R. § 3.321 (b)(1). (Continued on the next page)   2. After completing all indicated development, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If any benefit sought on appeal is not granted, the Veteran and his representative should be provided a Supplemental Statement of the Case (SSOC) and afforded the requisite opportunity to respond before the case is remanded to the Board. THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Peden, Associate Counsel