Citation Nr: 18161045 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 16-49 107 DATE: December 28, 2018 ORDER Reconsideration of a previously denied claim for service connection for hearing loss is granted. Entitlement to service connection for hypertension is denied. Entitlement to an earlier effective date, specifically, August 20, 2003, for the grant of service connection for lumbar spine degenerative arthritis is granted. Entitlement to an effective date earlier than November 6, 2014, for the grant of service connection for tinnitus is denied. Entitlement to an effective date earlier than November 6, 2014, for the grant of a 70 percent disability rating for posttraumatic stress disorder (PTSD) is denied. Entitlement to an effective date earlier than November 6, 2014, for the grant of a 30 percent disability rating for chronic migraine headaches is denied. Entitlement to a disability rating higher than 70 percent for PTSD is denied. Entitlement to a disability rating higher than 30 percent for chronic migraine headaches is denied. Entitlement to a disability rating higher than 10 percent for tinnitus is denied. REMANDED Entitlement to service connection for hearing loss is remanded. Entitlement to a disability rating higher than 20 percent for lumbar spine degenerative arthritis is remanded. Entitlement to a disability rating higher than 20 percent for cervical spine strain is remanded. Entitlement to a disability rating higher than 10 percent for right knee disability is remanded. Entitlement to a disability rating higher than 10 percent for left knee disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Since a June 1994 rating decision denying service connection for hearing loss, service department records not previously associated with the claims file were received. 2. The Veteran has not been found to have hypertension. 3. In a statement that VA received on August 20, 2003, the Veteran effectively requested reopening of a previously denied claim for service connection for a low back disability. 4. VA received on November 6, 2014, the Veteran’s earliest claim for service connection for tinnitus. 5. The increase of the Veteran’s PTSD to 70 percent disabling did not become factually ascertainable during the year preceding the November 6, 2014, receipt of her claim for a rating higher than 50 percent. 6. The increase of the Veteran’s migraines to 30 percent disabling did not become factually ascertainable during the year preceding the November 6, 2014, receipt of her claim for a rating higher than 10 percent. 7. The Veteran’s PTSD produces occupational and social impairment that does not reach or closely approach total impairment. 8. The Veteran’s chronic migraine headaches are manifested by prostrating attacks, but not by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 9. The Veteran’s tinnitus has not required frequent hospitalizations nor markedly interfered with her capacity for employment. CONCLUSIONS OF LAW 1. The claim for service connection for hearing loss that was denied in June 1994 is reconsidered. 38 U.S.C. §§ 5107, 5108, 7105; 38 C.F.R. § 3.156. 2. Hypertension was not incurred or aggravated in service, nor is presumed to be service connected. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria for an effective date of August 20, 2003, for the grant of service connection for lumbar spine degenerative arthritis have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 4. The criteria for an effective date earlier than November 6, 2014, for the grant of service connection for tinnitus have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 5. The criteria for an effective date earlier than November 6, 2014, for the grant of a 70 percent disability rating for PTSD have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 6. The criteria for effective date earlier than November 6, 2014, for the grant of a 30 percent disability rating for chronic migraine headaches have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 7. The criteria for disability rating higher than 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Code 9411. 8. The criteria for disability rating higher than 30 percent for chronic migraine headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.124a, Diagnostic Code 8100. 9. The rating schedule does not provide for a disability rating higher than 10 percent for tinnitus; and the Veteran’s tinnitus does not warrant referral for consideration of an extraschedular rating. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.321(b)(1), Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.87, Diagnostic Code 6260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1984 to May 1992 and from March 2003 to August 2003. 1. Reopening of a claim for service connection for hearing loss The Veteran essentially contends that she has hearing loss that is attributable to noise exposure in service. Service connection may be established on a direct basis for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. For VA disability benefits purposes, impaired hearing is considered a disability when the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2017). In a June 1994 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) denied service connection for several conditions, including hearing loss. A rating decision becomes final when a claimant does not file a notice of disagreement (NOD) within one year after a decision is issued. 38 U.S.C. § 7105. A rating decision also becomes final if a claimant files a timely NOD, but does not file a timely substantive appeal. 38 U.S.C. § 7105. The Veteran did not a file a timely NOD with the June 1994 rating decision, and that decision became final. A final decision on a claim that has been denied shall be reopened if new and material evidence with respect to that claim is presented or secured. 38 U.S.C. §§ 5108, 7104(b). The United States Court of Appeals for Veterans Claims (Court) has ruled that, if the Board of Veterans’ Appeals (Board) determines that new and material evidence has been submitted, the case must be reopened and evaluated in light of all of the evidence, both new and old. Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). New and material evidence received within a year after the rating decision will be considered as having been filed in connection with the claim. 38 C.F.R. § 3.156(b). If service department records not previously associated with the claims file are received, VA will reconsider the claim. 38 C.F.R. § 3.156(c). In November 2014, the Veteran submitted a claim that included a request to reopen a claim for service connection for hearing loss. In an April 2015 rating decision, an RO confirmed and continued the previous denial of service connection for hearing loss. The Veteran appealed the April 2015 rating decision. In order to reopen a previously and finally disallowed claim, there must be new and material evidence presented or secured since the last time that the claim was finally disallowed on any basis (not only since the last time that the claim was disallowed on the merits). Evans v. Brown, 9 Vet. App. 273 (1996). The June 1994 rating decision is the only final decision on the hearing loss service connection issue. The Board will consider whether new and material evidence has been submitted since that decision. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court has interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which “does not require new and material evidence as to each previously unproven element of a claim.” Shade v. Shinseki, 24 Vet. App. 110 (2010). See also Evans v. Brown, supra, at 284 (1996) (the newly presented evidence need not be probative of all the elements required to award the claim, but only need to be probative in regard to each element that was a specified basis for the last disallowance). For the purpose of establishing whether new and material evidence has been submitted, the credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992); Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19, 21 (1993). The evidence in the claims file in June 1994 includes service medical records, the Veteran’s claim, and reports of VA medical examinations. In the June 1994 rating decision, the reason for denying service connection for hearing loss was testing on VA examination in April 1994 showed hearing that did not meet the 38 C.F.R. § 3.385 criteria to be considered a hearing impairment disability for VA disability benefits purposes. The evidence added to the claims file since June 1994 includes the Veteran’s new claim, medical records from her later, 2003, period of active service, post-service medical records, and the report of a more recent VA examination, in 2015. The service department records from the 2003 period of active service were necessarily received after the June 1994 rating decision. In accordance with 38 C.F.R. § 3.156(c), the claim for service connection for hearing loss is to be reconsidered on its merits. Additional information is needed, however, so the claim is remanded for further development as explained in the remand section, below. 2. Service connection for hypertension In November 2014 the Veteran submitted a claim for service connection for several disorders, including hypertension. In general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, including hypertension, may be established based upon a legal presumption by showing that the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of discharge from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any   evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Medical records from the Veteran’s 1984 to 1992 period of active service do not show any finding of hypertension. On examination in October 1990, her blood pressure was 118/64. In a medical history the Veteran completed in March 1992, shortly before separation from that service period, she marked no for history of high blood pressure. On examination her blood pressure was 110/71. In May 1992 the Veteran submitted a claim for service connection for several disorders, including chest pain and irregular heartbeat, but not including hypertension. On VA medical examination in December 1992, her blood pressure was 95/80. Records of VA treatment in 1992 through 1994 contain no finding of elevated blood pressure or hypertension. During the Veteran’s active service in 2003, on examination in April 2003, her blood pressure was 113/72. In a medical history, she marked no for history of high blood pressure. The Veteran’s medical records do not reflect any finding of hypertension during the year following her 2003 active service period. Similarly, VA treatment records through 2015 do not show any diagnosis of hypertension. The Veteran’s medical records do not contain any finding that she has hypertension. Her claim for service connection for hypertension implies her belief that she has hypertension. On a question of diagnosis or existence of an objectively defined medical disorder such as hypertension, findings from medical professionals are more persuasive than opinions from persons without medical training. The greater persuasive weight of the evidence is against finding that she has hypertension. In the absence of current hypertension, service connection for hypertension is denied. 3. Effective date earlier than August 6, 2009, for the grant of service connection for lumbar spine degenerative arthritis The Veteran’s claims regarding low back disability have a long procedural history. In May 1992 she submitted a claim for service connection for several disorders, including low back pain. In a June 1994 rating decision, the RO denied service connection for chronic pathology causing low back pain. The Veteran did not file an NOD with the June 1994 rating decision, and it became final. In August 2003 the Veteran sought an increased disability rating for back strain. She apparently mistakenly believed that service connection for a back disability had been established. In a September 2004 statement, she wrote that she was never compensated for chronic back pain. In an August 2009 telephone contact, she requested increases in service-connected disability compensation for several disorders, including a disorder of her back. In a December 2010 rating decision, an RO granted reopening of a claim for service connection for pathology to account for low back pain. The RO considered the reopened claim on the merits, and denied service connection for low back pain. The Veteran appealed the December 2010 denial of service connection. In an April 2015 rating decision, an RO granted service connection for a low back disability, described as lumbar spine degenerative arthritis. The RO made service connection effective November 6, 2014. The Veteran appealed that effective date. In an August 2016 rating decision, the RO granted an earlier effective date, August 6, 2009, for the grant of service connection. Except as otherwise provided, the effective date of an evaluation and award of disability compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The effective date of reopened claims is the date of receipt of the claim or the date entitlement arose, whichever is later 38 C.F.R. § 3.400(r). In revising the effective date for the grant of service connection for lumbar spine degenerative arthritis to August 6, 2009, the RO considered the August 2009 telephone contact to be the date of receipt of the claim to reopen the claim that was denied in June 1994. The Veteran’s communications of August 2009, September 2004, and August 2003 are similar in that, in each, she asked for more compensation due to her back disability. The RO acknowledge each communication with a letter acknowledging the claim. The circumstances support accepting the 2003 communication as the claim to reopen. The RO received that communication on August 20, 2003. The Veteran’s service medical records reflect that she was seen for low back pain. Soon after her May 1992 separation from service, she reported ongoing low back pain. Thus, the date when entitlement to service connection for a low back disorder arose is earlier than August 20, 2003. The Board grants August 20, 2003, as the effective date for the grant of service connection for the lumbar spine degenerative arthritis. 4. Effective date earlier than November 6, 2014, for the grant of service connection for tinnitus On November 6, 2014, an RO received the Veteran’s claim for service connection for tinnitus. In the April 2015 rating decision, the RO granted service connection, effective November 6, 2014, for tinnitus. The Veteran appealed the effective date. As noted above, the effective date of an evaluation and award of disability compensation based on an original claim will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. In addition, service connection may be effective the day following separation from service if the claim is received within one year after separation from service. 38 C.F.R. § 3.400(b)(2). The Veteran’s original 2014 claim regarding tinnitus was not received within a year after either period of active service. Therefore, there is no basis for an effective date earlier than the date of receipt of the claim, which is the existing effective date of November 6, 2014. 5. Effective date earlier than November 6, 2014, for the grant of a 70 percent disability rating for PTSD In an October 2011 rating decision, an RO established for the Veteran’s PTSD disability ratings of 30 percent from August 22, 2003, and 50 percent from December 12, 2008. On November 6, 2014, the RO received the Veteran’s claim for an increased rating for PTSD. In an April 2015 rating decision, the RO granted a 70 percent rating effective November 6, 2014. The Veteran appealed that effective date. Except as otherwise provided, the effective date of an evaluation and award of an increased disability rating will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. The effective date of an award of increased disability compensation is the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if a claim is received within one year from such date, and otherwise is the date of receipt of the claim. 38 C.F.R. § 3.400(o)(2). VA assigns disability ratings by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.10. If two ratings are potentially applicable, 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. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. Under the rating schedule, the criteria for ratings of 50 percent or higher for mental disorders, including PTSD, are as follows: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name .........……........... 100 percent Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships 70 percent Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships ........…………………...………. 50 percent 38 C.F.R. § 4.130. Since 2003 the Veteran has had VA treatment for mental disorders, including PTSD. On VA examination in August 2010, she reported that she was on medication for PTSD. She indicated that she was employed as a supermarket cashier. She stated that, because of panic attacks and limited endurance for standing, she worked only two days a week. The examiner found that the Veteran’s PTSD produced occupational and social impairment with reduced reliability and productivity. Notes of VA treatment of the Veteran from 2011 through 2014 reflect ongoing medications and talk therapy for PTSD. She expressed that she preferred to stay home, where she felt safe, and was less likely to have panic attacks. She related mood lability and angry reactions to events. She stated that physical pain magnified her depression and irritability. Treatment notes did not reflect deficiencies in family relations or near-continuous panic or depression. On VA examination on March 30, 2015, the Veteran reported that she continued in treatment, including medications, for her PTSD. She related that she worked at a supermarket until 2011. She stated that she ceased working when it became clear that management kept doing things to provoke her. She stated that while working she had multiple outbursts that necessitated leaving before finishing her shift. She related that her next employment was at a gas station, but that she left after three months due to anxiety. She related that presently she primarily stayed home. She reported that she avoided contact with people as much as possible, to avoid having violent outbursts. The examiner found that the Veteran’s PTSD produced occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. VA treatment records from 2013 and 2014 do not reflect that it became factually ascertainable that the effects of her PTSD were more consistent with the criteria for a 70 percent rating. The March 2015 examination was the earliest date when it became factually ascertainable that a 70 percent rating was warranted. That increase did not become factually ascertainable during the year before the November 6, 2014, receipt of the claim for a rating higher than 50 percent. Therefore, an effective date earlier than November 6, 2014, for the 70 percent rating is denied. 6. Effective date earlier than November 6, 2014, for the grant of a 30 percent disability rating for chronic migraine headaches In a June 2004 rating decision, an RO granted service connection for the Veteran’s chronic migraine headaches, and assigned a 10 percent disability rating. On November 6, 2014, an RO received the Veteran claim for an increased rating for the migraines. In an April 2015 rating decision, the RO granted an increase to a 30 percent rating, effective November 6, 2014. The Veteran appealed that effective date. Under the rating schedule, a 10 percent rating is assigned for migraines with characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent rating is assigned with characteristic prostrating attacks occurring on an average once a month over the last several months. 38 C.F.R. § 4.124a, Diagnostic Code 8100. Records of VA treatment of the Veteran reflect that in January 2014 she had a major headache and rested most of the day. In April 2014 she sought refill of a medication used to prevent migraines. She reported pain and pressure in her head and left eye, accompanied by dizziness. Treatment records from November 2013 to November 2014 do not indicate how frequently she had prostrating migraine attacks during that period. On VA examination in April 2015, the Veteran reported having migraines three to four times a month. She stated that during a migraine she laid down in a dark, quiet room. She said that migraine pain lasted less than a day. She related that she kept her house dark to avoid migraines. The examiner found that over the preceding several months her prostrating migraine attacks occurred on average once a month. During the year preceding the Veteran’s November 2014 claim for an increased rating for her migraines, it did not become factually ascertainable that she was having prostrating attacks on average once a month, such as would warrant a 30 percent rating. Therefore, an effective date earlier than the November 6, 2014, date of receipt of the increased rating claim is denied. 7. Disability rating higher than 70 percent for PTSD In an April 2015 rating decision, an RO increased the rating for the Veteran’s PTSD to 70 percent. The Veteran appealed that rating. The Court has indicated that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating was filed until a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Records of VA mental health treatment of the Veteran reflect anxiety, depression, panic attacks, problems with anger, and problems with some relationships. Those records do not show that impairment meets or closely approaches total impairment of social functioning or of occupational capacity. They do not show disorientation, hallucinations, or gross impairment of thought, communication, or memory. On VA examination March 2015, the Veteran related depression and anxiety. She reported having panic attacks more than once a week. She indicated that she largely stayed home, to avoid panic attacks and angry outbursts. She stated that she kept in contact with some family members and friends. The examiner found that the Veteran’s PTSD produced occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Veteran did not relate, and the examiner did not observe, disorientation, hallucinations, or gross impairment of thought, communication, or memory. The Veteran’s PTSD disability picture has not met or closely approached the criteria for a 100 percent rating. The Board denies a rating higher than 70 percent. When there is an exceptional disability picture, such that the rating schedule criteria do not reasonably describe a claimant’s disability level and symptomatology, an RO may refer a case to the VA Under Secretary for Benefits or to the Director of the VA Compensation and Pension Service for consideration of an extraschedular rating. See 38 C.F.R. § 3.321(b)(1) (2017); see also Thun v. Peake, 22 Vet. App. 111, 115 (2008). Extraschedular ratings are limited to cases in which it is impractical to apply the regular standards of the rating schedule because there is an exceptional or unusual disability picture, with such related factors as frequent hospitalizations or marked interference with employment. 38 C.F.R. § 3.321(b)(1). The rating criteria appropriately address the effects of the Veteran’s PTSD. That disability has not required frequent hospitalizations. It has interfered with her capacity for employment, but not so markedly that the interference exceeds the occupational impairment addressed by a 70 percent rating. Therefore, it is not necessary to refer the issue of the rating for PTSD for consideration of extraschedular ratings. The Court has indicated that VA must consider, in an increased rating claim, whether the record indirectly raises the issue of unemployability. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran has indicated that her panic attacks, irritability, and angry outbursts contributed substantially to her leaving employment in 2011 and remaining unemployed since. In February 2018, she asserted, through her representative, that her PTSD and other, musculoskeletal, service-connected disabilities warranted a TDIU. The record thus does raise the issue of unemployability. The Board has added entitlement to a TDIU to the issues on appeal. 8. Disability rating higher than 30 percent for chronic migraine headaches In an April 2015 rating decision, an RO increased the rating for the Veteran’s migraines to 30 percent. The Veteran appealed that rating. The rating schedule provides for a 50 percent rating for migraines if there are very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. As noted above, VA treatment records reflect the Veteran’s January 2014 report of a major headache addressed by resting most of the day. In April 2014 she sought refill of a medication used to prevent migraines. She reported pain and pressure in her head and left eye, accompanied by dizziness. On VA examination in April 2015, she reported having migraines three to four times a month. She stated that during a migraine she laid down in a dark, quiet room. She said that migraine pain lasted less than a day. She related that she kept her house dark to avoid migraines. The examiner found that over the preceding several months her prostrating migraine attacks occurred on average once a month. While in 2015 the Veteran reported migraines three to four times a month, the examiner, who considered treatment records and the characteristics and effects of the reported headaches, concluded that prostrating migraine attacks had averaged once a month. The examiner’s conclusion and the other assembled information presents a picture of migraine attacks that are less than very frequent, completely prostrating, or prolonged. The Veteran has not asserted, and no clinician has indicated, that her migraine attacks have severe effects on her capacity for employment. The evidence regarding her migraines shows a disability picture more consistent with the criteria for a 30 percent rating than those for a 50 percent rating. The Board denies a rating higher than 30 percent. The rating criteria adequately address the effects of the Veteran’s migraines. Her migraines have not required frequent hospitalizations, nor markedly interfered with her capacity for employment. It is not necessary to refer the issue of ratings for her migraines for consideration of extraschedular ratings. The record regarding her migraines has not indirectly raised the issue of unemployability. 9. Disability rating higher than 10 percent for tinnitus In an April 2015 rating decision, the RO granted service connection for the Veteran’s tinnitus and assigned a disability rating of 10 percent. The Veteran appealed that rating. In a March 2015 VA examination, she reported constant tinnitus that she perceived mainly in her left ear. Under the rating schedule, a single 10 percent is the maximum rating for tinnitus, whether recurrent or continuous, and whether perceived in one or both ears. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note 2. Therefore there is no basis to assign a rating higher than 10 percent for her tinnitus. There is no indication that her tinnitus has required frequent hospitalizations or has markedly interfered with her capacity for employment, so it is not necessary to refer the issue for consideration of extraschedular ratings. REASONS FOR REMAND 1. Service connection for hearing loss As noted above, service department records were added after the previous June 1994 denial of service connection for hearing loss. That claim is to be reconsidered on its merits. In the April 2015 rating decision, the RO reconsidered the claim on the merits and denied it. The Veteran appealed that denial to the Board. The Board is remanding this issue for additional VA examination and opinion. The Veteran contends that noise exposure during one or both of her service periods caused hearing loss. As noted above, VA regulations at 38 C.F.R. § 3.385 define the auditory thresholds and speech recognition scores that constitute disabling hearing impairment for VA purposes. The Court has held, however, that 38 C.F.R. § 3.385 does not preclude service connection for current hearing disability where hearing was within normal audiometric testing limits at separation from service. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). The Court explained that, when audiometric test results do not meet the regulatory requirements for establishing a “disability” at the time of a veteran’s separation, the veteran may nevertheless establish service connection for a current hearing disability by submitting competent evidence that the current disability is causally related to service. In addition, the Court cited a 1988 medical treatise that stated that the threshold for normal hearing was from 0 to 20 decibels, and that higher threshold levels indicate some degree of hearing loss. During the Veteran’s active service period in 2003, she was examined in April 2003. On audiometric testing, in each ear, at the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz, none of the auditory thresholds was 40 decibels or greater, but several of the thresholds were 20 decibels or greater. The Veteran had a VA audiology examination in March 2015. On testing, in the left ear, the threshold at 4000 Hertz was 45 decibels. That ear thus had impaired hearing that is considered a disability for VA disability compensation purposes. The examiner provided findings of sensorineural hearing loss in the left ear and normal hearing in the right ear. The examiner found that the Veteran’s service duties in communications, as a multichannel transmission systems operator and maintainer, had a moderate probability of noise exposure. The examiner stated, however, that she could not provide an opinion as to the likely etiology of the Veteran’s left ear hearing loss without resorting to speculation. The history in the VA examination report did not include any account from the Veteran as to when she began to notice difficulty hearing. The Board is remanding the claim for a new VA examination to include such history, and with file review and opinion as to the relative likelihood that current hearing impairment disability is related to noise exposure or other events in service.   2. Disability rating higher than 20 percent for lumbar spine degenerative arthritis The Board is remanding this issue for additional medical examination. The Veteran appealed the initial 20 percent rating that the RO assigned for her low back disability, described as lumbar spine degenerative arthritis. When evaluation of a musculoskeletal disability is based on limitation of motion, that evaluation must include consideration of impairment of function due to such factors as pain on motion, weakened motion, excess fatigability, diminished endurance, or incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); see DeLuca v. Brown, 8 Vet. App. 202 (1995). In Correia v McDonald, 28 Vet. App. 158 (2016), the Court held that 38 C.F.R. § 4.59 indicates that evaluation of joints that have painful motion also should include consideration of whether there is pain on both active and passive motion, consideration of whether there is pain with and without weightbearing, and comparison of the range of motion to that of any opposite undamaged joint. The Veteran had a VA examination of his back in April 2015. That examination addressed some but not all of the considerations addressed in Correia. It did not address whether there was pain on motion without weightbearing, or whether there was pain on both active and passive motion. The Board is remanding the claim for a new VA examination to address all of the relevant considerations, including those. 3. Disability rating higher than 20 percent for cervical spine strain The Board is remanding this issue for additional medical examination. In November 2014, the Veteran sought an increase above the existing 20 percent rating for her neck disability, described as cervical spine strain. In an April 2015 rating decision, the RO continued the 20 percent rating. The Veteran appealed that decision. An April 2015 examination of her neck addressed some but not all of the considerations addressed in Correia. It is not clear that presence or absence of weightbearing is a relevant consideration in function of the cervical spine. The 2015 examination did not address, however, whether there was pain on both active and passive motion. The Board is remanding the claim for a new VA examination to address all of the relevant considerations, including pain on active and passive motion. 4. Disability rating higher than 10 percent for right knee disability The Board is remanding this issue for additional medical examination. In November 2014, the Veteran sought an increase above the existing 10 percent rating for her right knee disability. In an April 2015 rating decision, the RO continued the 10 percent rating. The Veteran appealed that decision. An April 2015 examination of her knees addressed some but not all of the considerations addressed in Correia. It did not address whether there was pain on motion without weightbearing, or whether there was pain on both active and passive motion. The Board is remanding the claim for a new VA examination to address all of the relevant considerations, including those. 5. Disability rating higher than 10 percent for left knee disability The Board is remanding this issue for additional medical examination. In November 2014, the Veteran sought an increase above the existing 10 percent rating for her left knee disability. In an April 2015 rating decision, the RO continued the 10 percent rating. The Veteran appealed that decision. An April 2015 examination of her knees addressed some but not all of the considerations addressed in Correia. It did not address whether there was pain on motion without weightbearing, or whether there was pain on both active and passive motion. The Board is remanding the claim for a new VA examination to address all of the relevant considerations, including those. 6. Entitlement to a TDIU As noted above, the record has raised the issue of entitlement to a TDIU. The Board is remanding the TDIU issue for the development of additional information. The Veteran has indicated that the effects of her service-connected disabilities including her PTSD, and disorders of her neck, back, and knees make her unable to maintain or obtain employment. VA regulations allow for the assignment of TDIU when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, and the veteran has certain combinations of disability ratings for service-connected disabilities. 38 C.F.R. § 4.16 (2017). Records of VA treatment and examinations provide some information about the effects of those disabilities, but do not sufficiently address the effects of her service-connected disabilities on her capacity for employment. The Board is remanding the TDIU issue for new examinations with file review and opinions as to the effects of each disability on her capacity for occupational functioning. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA audiology examination to address the likely etiology of her hearing loss. Provide the claims file to the examiner. Ask the examiner to review the claims file. Ask the examiner to record history from the Veteran, specifically including her noise exposure during her periods of active service in 1984 to 1992 and in 2003, and her recollection as to when she began to perceive difficulty hearing. Ask the examiner to test the Veteran’s hearing and diagnose any hearing loss in either or both ears. Ask the examiner, for any current hearing loss, to provide an opinion as to whether it is at least as likely as not (at least a 50 percent likelihood) that the hearing loss was incurred in or is otherwise causally related to noise exposure or other events during either or both of her active service periods. Ask the examiner to explain the conclusions and opinions. Continued on next page   2. Schedule the Veteran for a VA examination to address the current manifestations of her disabilities of the back, neck, and knees. Provide the claims file to the examiner for review. Ask the examiner to review the claims file and examine the Veteran. Ask the examiner to conduct all necessary tests of the function and functional impairment of those areas. Findings should include whether there is pain on active and passive ranges of motion. Findings regarding the back and knees should include whether there is pain on motion with and without weightbearing. Ask the examiner to report, for the back, neck, and each knee, whether the area has functional impairment due to pain, weakness, fatigability, or incoordination, or with repeated use or flare-ups. Ask the examiner to describe any functional impairment from such factors as equivalent to degrees of additional loss of motion, if feasible. Ask the examiner to indicate whether any of those areas is in ankylosis, or has functional impairment equivalent to or nearly equivalent to ankylosis. Ask the examiner to provide findings as to the likely effects of the disorders of the back, neck, and each knee on her capacity for occupational tasks and ability to obtain and retain substantially gainful employment. Ask the examiner to explain the conclusions and opinions. 3. Schedule the Veteran for a VA examination to address the effects of her PTSD on her capacity for employment. Provide the claims file to the examiner. Ask the examiner to review the claims file and examine the Veteran. Ask the examiner to provide findings as to the likely effects of her PTSD on her capacity for occupational tasks and ability to obtain and retain substantially gainful employment. Ask the examiner to explain the conclusions and opinions. 4. Then review the expanded claims file and review the claims for service connection for hearing loss and higher ratings for disabilities of the back, neck, and knees. Then consider the claim for a total disability rating based on individual unemployability (TDIU). 5. Thereafter, if any of the remanded claims is not granted to the Veteran’s satisfaction, issue a supplemental statement of the case and afford the Veteran and her representative an opportunity to respond. Thereafter, return the case to the Board for appellate review, if otherwise in order. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. J. Kunz, Counsel