Citation Nr: 1815242 Decision Date: 03/13/18 Archive Date: 03/19/18 DOCKET NO. 10-22 872A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a bunionette. 2. Entitlement to service connection for mantle cell lymphoma, including as due to ionizing radiation exposure. 3. Entitlement to service connection for Waldenstrom macroglobulinemia, including as due to ionizing radiation exposure. 4. Entitlement to higher initial ratings for bilateral hearing loss, currently rated as noncompensable effective September 29, 2007; and rated as 50 percent disabling effective November 3, 2017. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The Veteran served on active duty from June 1961 to October 1966. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was remanded in August 2014 for further development. In August 2014, the Board remanded the issues of entitlement to service connection for right ear hearing loss, and entitlement to an increased rating for left ear hearing loss. The RO issued a January 2018 rating decision in which it granted service connection for bilateral hearing loss (thereby granting service connection for right ear hearing loss). The grant of service connection constitutes a complete grant of the claim. Consequently, it is no longer before the Board. Moreover, the claim for entitlement to a higher initial rating for left ear hearing loss has become entitlement to higher initial ratings for bilateral hearing loss. The Veteran presented testimony at a Board hearing in June 2014. A transcript of the hearing is associated with the Veteran's claims folder. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. The weight of the evidence is against a finding that the Veteran's bunionette was manifested during active duty service or is otherwise related to service. 2. The weight of the evidence is against a finding that the Veteran's mantle cell lymphoma was manifested during active duty service or is otherwise related to service. 3. The weight of the evidence is against a finding that the Veteran's Waldenstrom macroglobulinemia was manifested during active duty service or is otherwise related to service. 4. Audiometric testing conducted June 16, 2010 did not utitlize Maryland CNC speech recognition scores. 5. Effective November 3, 2017, the Veteran's service-connected bilateral hearing loss disability is productive of level IX hearing acuity in the right ear and level VII hearing acuity in the left ear. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for a bunionette have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.6, 3.159, 3.303, 3.307, 3.309 (2017). 2. The criteria for an award of service connection for mantle cell lymphoma have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.6, 3.159, 3.303, 3.307, 3.309 (2017). 3. The criteria for an award of service connection for Waldenstrom macroglobulinemia have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.6, 3.159, 3.303, 3.307, 3.309 (2017). 4. Prior to November 3, 2017, the criteria for entitlement to a compensable disability evaluation for the Veteran's service-connected bilateral hearing loss have not been met. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.10, 4.85, 4.86, Diagnostic Code 6100 (2017). 5. Effective November 3, 2017, the criteria for entitlement to a disability evaluation in excess of 50 percent for the Veteran's service-connected bilateral hearing loss have not been met. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.10, 4.85, 4.86, Diagnostic Code 6100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) In February 2008 and May 2008 letters, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2014) and 38 C.F.R. § 3.159(b) (2017). The RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that he was expected to provide. The Veteran was informed of the process by which initial disability ratings and effective dates are assigned, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The "duty to assist" contemplates that VA will help a claimant obtain records relevant to the claim, whether or not the records are in Federal custody, and that VA will provide a medical examination when necessary to make a decision on the claim. 38 C.F.R. § 3.159 (2017). VA has done everything reasonably possible to assist the Veteran with respect to the claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2014) and 38 C.F.R. § 3.159(c) (2017). Relevant service treatment and other medical records have been associated with the claims file. The Veteran was given VA examinations in July 2008 and November 2017, which are fully adequate. The examiners were aware of the Veteran's medical history and they fully addressed all relevant issues. The duties to notify and to assist have been met. Service Connection Applicable law provides that service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. 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). Bunionette At his June 2014 Board hearing, the Veteran testified that he dropped a large, five inch shell onto his foot. He stated that it hurt and it bruised, and that he limped for a long time. He also stated that it hurt off and on for the rest of his Navy career, but since he was young, it was not that big of an issue. He stated that as he has aged, the left toe joint got larger and larger to the point where he had to have surgery to pare it down (correct the distending joint). He stated that the surgery occurred six years earlier; but that he still cannot wear normal shoes. He has to wear soft sided shoes. The service treatment records reflect that in May 1959, the Veteran sought treatment for a wart on his foot (the examination report did not specify which foot). In January 1961, the Veteran sought treatment for a tender metatarsal on the right foot. In February 1965, he sought treatment for pain in the left heel. The examination report noted that the pain was of sudden onset, with no preceding trauma, and without any previous history. He was assessed with tendinitis plantar fascia. He reported continued pain in his left heel in May 1965. He underwent a separation examination in September 1966. It yielded normal findings with regards to the Veteran's feet. In the Veteran's April 2009 notice of disagreement, he stated that in 1966, he dropped a heavy brass nozzle on the side of his left foot. He stated that it was badly bruised and resulted in a distending joint at the base of his little toe. He stated that it was treated by an on-sight corpsman. He stated that throughout his life, it stayed slightly distended and would get sore with high activity. In the Veteran's July 2010 substantive appeal, he stated that there is no mention of a foot problem in the service treatment records because "at first this was only an irritant but continued to be more of a problem." He acknowledged that he became service connected for a left foot strain. As the pain became worse, he had a custom made latex shield that slid over his little toe to help keep his toe off of the protrusion. He stated that it continued to get worse until April 2008 (when he had it surgically removed). An April 2008 treatment report reflects that the Veteran underwent surgery for bunion correction (Medical Treatment Record - Non - Government Facility, 7/6/10, p. 3). The Veteran underwent a VA examination in June 1967 (in conjunction with his claim for a left foot disability). He reported a left foot disability since 1964. He stated that if he rotates his left foot arch too far, then he gets to the point where he does not want to walk on it at all. Upon examination, the arches were not too low. There was slight deformity of the little toes. He was diagnosed with foot strain from inadequate muscles, without pes planus. The Veteran underwent a VA examination in November 2017. The examiner reviewed the claims file in conjunction with the claims file. He noted that in 2008, the Veteran was diagnosed with a bunionette in the left 5th metatarsophalangeal (MTP) joint (or toe). When the examiner asked about the alleged in-service injury, the Veteran stated "it's been there so long that I don't actually remember." He thought that he dropped a shell on it. When asked about the first treatment for it, he stated that it occurred "right after whatever happened." He could not recall any post service treatment for it, and he specifically denied having surgery for it. When the examiner pointed out that Dr. D.O. had surgically removed the bunion in April 2008, the Veteran stated that the name (Dr. O.C.) "rings a bell." The examiner noted that the Veteran used over the counter inserts in both shoes to provide additional padding for the soles of the feet. The examiner noted that these do not affect the lateral aspect of the 5th MTP joint. After a thorough examination of the Veteran and the claims file, the examiner opined that it was less likely than not (less than 50% probability) that the Veteran's current disability was incurred in or caused by the claimed in-service injury. The examiner noted that at the examination, the Veteran had only vague recall of dropping something on his foot during service and could not recall any other details of the event. The Veteran previously acknowledged that there are no records of this event. Nonetheless, the examiner rendered his opinion with consideration of the fact that the Board determined that he credibly reported an incident where a brass nozzle or shell fell on his left foot. The examiner acknowledged the Notice of Disagreement reflecting that a student dropped a heavy brass hose nozzle on his foot in 1966. The Veteran believed that the trauma had permanently distended the joint at the base of his little toe. The examiner noted that many theories have been proposed as the cause of bunionettes, which are also known as Tailor's bunions, derived from the fact that tailors sat in a crossed-legged fashion on the floor when performing their work, thereby putting pressure on the lateral side of the forefoot, particularly the fifth metatarsal head, causing symptoms in that area. The great majority of the theories are based on the structure and biomechanics of the foot and are a function of genetics and embryonic development. The examiner noted that traumatic causes are not unheard of but are rare and typically require a significantly severe injury, such as rupture of the collateral ligaments. The examiner further noted that the service treatment records are contradictory to an injury of that level of severity, not only in that the injury was not documented, but also that no profile was required, and that a normal physical examination of the feet was documented at his retirement examination in September 1966. Consequently, the examiner opined that it is less likely than not that the purported injury did actually permanently distend the joint as opined by the Veteran. The examiner further explained that the Veteran, in his July 2010 appeal (VA Form 9) equated his current complaints with a "left foot strain" (which was service connected in 1967). The examiner noted that the reports of foot pain in the service treatment records are symptomatic of the Veteran's service connected left foot strain. These symptoms were localized to the left heel and, as such, were remote from the current site of pain at the base of the toe. The examiner stated that because the statements in the appeal, consist of a transposition of two distinct and separate problems, they are not logically consistent and do not support the current claim. The examiner noted that the post service records reflect that the Veteran had a corrective surgery in 2008, more than 40 years after his discharge from service, and at the age of 70 years. He noted that the Veteran has not supplied any documentation of any evaluation or treatment prior to that, nor does he recall any treatment prior to that. Consequently, the examiner opined that the purported injury was less likely than not to have resulted in a permanent structural alteration to the left foot. He noted that "consistent with that, the service treatment records clearly document that the Veteran's left foot was normal when he retired from the Navy. Therefore, it is less likely than not that the Veteran's bunionette was incurred in, caused by, or in any way related to his military service." Analysis In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Board finds that the Veteran has satisfied the first two elements of service connection. He has a current disability as evidenced by his continued complaints of foot pain following April 2008 surgery. Moreover, although there is no record of a bunion in the service treatment records, the Board has found his testimony regarding an in-service injury (wherein he dropped something heavy onto his foot) to be credible. It is the third element of service connection in which the Veteran's claim falls short. As the service treatment records are unobtainable, and the Veteran has admitted that they would contain no record of treatment, chronicity in service is not adequately supported. However, service connection may be established by continuity of symptomatology under 38 C.F.R. § 3.303(b) or based on initial diagnosis after service under 38 C.F.R. § 3.303(d). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In support of his claim for service connection the Veteran states that he has had foot pain service, and he is competent to describe symptoms of foot pain. 38 C.F.R. § 3.159 (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (lay testimony is competent as to symptoms, which are within the realm of one's personal knowledge, personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness). At the outset, the Board notes the gap of approximately 4 decades between the Veteran's separation from service and the first documented treatment for a bunion. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. However, such absence of documented treatment, in and of itself, is not a basis for discrediting his lay statements of continuity. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Thus, the Board must consider the totality of the record, and not just the absence of clinical treatment, in weighing the Veteran's statements asserting continuity of symptomatology. In this case, the Veteran filed a claim for a foot disability in April 1967 (six months after being discharged from service). The RO granted service connection for a left foot disability by way of an August 1967 rating decision. In so doing, the RO noted closed tenderness under the left heel. The Board notes that the Veteran was service connected for this left foot disability for more than 40 years without ever mentioning a second foot disability. Moreover, his statements at the 2017 examination indicate that he was unable to remember the specific in-service trauma causing the alleged foot injury. This is not consistent with statements made elsewhere in the record and at the Veteran's hearing. Such inconsistency calls into question the reliability of the statements describing in detail the in-service injury. For the above reasons continuity of symptomatology is not demonstrated here, either by the clinical record or by the Veteran's own statements. As noted above, service connection is not warranted in this case on the basis of continuity of symptomatology. However, if the competent medical evidence indicates that the current foot disability is related to the Veteran's active service, then an award of service connection would be appropriate. In this vein, the VA examiner in November 2017 concluded that the Veteran's bunionette is less likely than not related to service because there was no evidence of acute or chronic injury at the time of the Veteran's separation from service. The Board finds the opinion of the VA physician to be persuasive evidence. Indeed, it was based on a review of the record and was offered following a physical evaluation of the Veteran. Moreover, it was accompanied by a clear rationale; and no other competent evidence of record refutes that opinion. The Veteran himself believes that his current bunionette is related to service. The Veteran is considered competent to report the observable manifestations of his claimed disability. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) ("ringing in the ears is capable of lay observation"); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (lay testimony iterating knowledge and personal observations of witness are competent to prove that claimant exhibited certain symptoms at particular time following service). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, the etiology of a specific foot disability falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In sum, his statements as to etiology in this case are not competent and therefore lack probative value. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim for entitlement to service connection for a bunionette must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Mantle cell lymphoma; Waldenstrom macroglobulinemia Service connection for a disability that is claimed to be attributable to radiation exposure during service can be accomplished in three different ways. See Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd, 120 F.3d 1239 (Fed. Cir. 1997). First, there are specific diseases which may be presumptively service-connected if manifest in a radiation-exposed Veteran. A "radiation-exposed Veteran" is defined as a Veteran who, while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. 38 U.S.C.A. § 1112 (c)(3); 38 C.F.R. § 3.309 (d)(3). A "radiation-risk activity" is defined as onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima or Nagasaki, Japan by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupational forces in Hiroshima or Nagasaki during the period from August 6, 1945 through July 1, 1946; or the Veteran's presence at certain specified additional locations. Id. The term "occupation of Hiroshima or Nagasaki, Japan, by United States forces" means official military duties within 10 miles of the city limits of either Hiroshima or Nagasaki, Japan, which were required to perform or support military occupation functions such as occupation of territory, control of the population, stabilization of the government, demilitarization of the Japanese military, rehabilitation of the infrastructure or deactivation and conversion of war plants or materials. 38 C.F.R. § 3.309 (d)(3)(vi). The second avenue for achieving service connection is found under 38 C.F.R. § 3.311 (b)(2). This section provides that certain listed "radiogenic" diseases found five years or more after service in an ionizing-radiation-exposed Veteran may be service connected if the VA Under Secretary for Benefits determines that they are related to ionizing radiation exposure while in service or if they are otherwise linked medically to ionizing radiation exposure while in service. When it has been determined that: (1) a Veteran has been exposed to ionizing radiation as a result of participation in the atmospheric testing of nuclear weapons, the occupation of Hiroshima or Nagasaki, Japan, from September 1945 until July 1946, or other activities as claimed; (2) the Veteran subsequently develops a specified radiogenic disease; and (3) the disease first becomes manifest in the period specified, the claim will be referred to the VA Under Secretary for Benefits for further consideration in accordance with 38 C.F.R. § 3.311 (c). When such a claim is forwarded for review, the VA Under Secretary for Benefits shall consider the claim with reference to 38 C.F.R. § 3.311 (e) and may request an advisory medical opinion from the VA Under Secretary of Health. 38 C.F.R. § 3.311 (b), (c)(1). The medical adviser must determine whether sound scientific and medical evidence supports a conclusion that it is at least as likely as not that the disease resulted from in-service radiation exposure or whether there is no reasonable possibility that the disease resulted from in-service radiation exposure. 38 C.F.R. § 3.311 (c)(1). Pursuant to 38 C.F.R. § 3.311 (b)(2), radiogenic diseases include: (i) All forms of leukemia except chronic lymphatic (lymphocytic) leukemia; (ii) Thyroid cancer; (iii) Breast cancer; (iv) Lung cancer; (v) Bone cancer; (vi) Liver cancer; (vii) Skin cancer; (viii) Esophageal cancer; (ix) Stomach cancer; (x) Colon cancer; (xi) Pancreatic cancer; (xii) Kidney cancer; (xiii) Urinary bladder cancer; (xiv) Salivary gland cancer; (xv) Multiple myeloma; (xvi) Posterior subcapsular cataracts; (xvii) Non-malignant thyroid nodular disease; (xviii) Ovarian cancer; (xix) Parathyroid adenoma; (xx) Tumors of the brain and central nervous system; (xxi) Cancer of the rectum; (xxii) Lymphomas other than Hodgkin's disease; (xxiii) Prostate cancer; and (xxiv) any other cancer. A disease is also considered a radiogenic disease where competent scientific or medical evidence that the claimed condition is a radiogenic disease is received. 38 C.F.R. § 3.311 (b)(4). Finally, the United States Court of Appeals for the Federal Circuit held that when a Veteran is found not to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 24 F.3d 1039, 1043-44 (Fed. Cir. 1994). In relevant part, 38 U.S.C.A. 1154 (a) (West 2014) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102 (2016); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The appellant is competent to report symptoms and experiences observable by the senses, but not to diagnose the cause of symptoms or identify the etiology of a disability, as this requires specialized medical training. See 38 C.F.R. § 3.159 (a); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this case, the Veteran was diagnosed with (1) mantle cell lymphoma of the cecum, and (2) lymphoplasmacytoid lymphoma of the bone marrow with Waldenstrom's macroglobulinemia July 2006 (Medical Treatment Records - Non - Government Facility, 5/27/08, p. 72). He argues that these conditions are related to service, specifically due to exposure to ionizing radiation. In the Veteran's April 2009 notice of disagreement, he stated that after graduating from Annapolis in 1961, he served aboard the USS Norfolk for two years. He stated that they received nuclear weapons at approximately the end 1961 and that he became the nuclear weapons officer. He stated that for the first few months, they did not wear DT 60s out of ignorance. He acknowledged DD forms 1141 dated February 1963 to March 1964 (that failed to reflect radiation exposure) but he wondered about his possible exposure prior to this time period. He stated that his commanding officer was paranoid about having nuclear weapons. He wondered if possible exposure was not recorded. An October 2007 correspondence includes a contention that the Veteran could have been exposed to ionizing radiation while service aboard the USS Wasp (Caseflow, Third Party Correspondence, 9/29/07). The Board notes that assignment to the USS Norfolk and USS Wasp is not one of the radiation-risk activities enumerated in Section 3.309(d)(3). Accordingly, the Board finds that the competent and probative evidence does not show that the Veteran participated in a radiation-risk activity as defined by VA regulation. 38 C.F.R. § 3.309 (d)(3). Therefore, service connection for the Veteran's mantle cell lymphoma or Waldenstrom macroglobulinemia is not warranted on a presumptive basis due to exposure to radiation. See 38 C.F.R. §§ 3.309 (d)(3), 3.311. With Combee in mind, the Board will next consider the claim under a theory of direct causation. The evidence of record does not show that the Veteran had in-service radiation exposure. The Veteran's service treatment records are silent for complaints of, or treatment for, exposure to radiation, or complaints of, or treatment for, mantle cell lymphoma and Waldenstrom macroglobulinemia. Though the Veteran asserts that he was exposed to radiation while serving aboard the USS Norfolk and the USS Wasp, there is no evidence of record that supports such a contention. The Board notes that the film badges from the USS Norfolk reflect no exposure to ionizing radiation (STR - Medical, 10/17/66, p. 4). The Board acknowledges that these badges are not wholly inclusive of the time that the Veteran spent aboard to USS Norfolk and USS Wasp. In response to a PIES request, the service department replied that all available records have been sent (VA 21-3101 Request for Information, 8/7/17). Moreover, the Veteran has suggested that the commanding officer may not have recorded possible exposures prior to 1962. The Board is satisfied that all steps have been taken to determine whether the Veteran was exposed to ionizing radiation. No such exposure has been found. The Veteran submitted an April 2010 correspondence from Dr. H.M. of the University of Colorado Hospital. The correspondence stated in toto: [The Veteran's] Non-Hodgkin Lymphoma and Waldenstrom's are as likely as not the result of radiation exposure while in the military." (Medical Treatment Record - Non - Government Facility, 7/6/10, p. 7). The Board once again notes that in order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Veteran has satisfied the first element of service connection in that the Veteran has been diagnosed with both mantle cell lymphoma and Waldenstrom macroglobulinemia. However, the Veteran has failed to satisfy the second element of service connection. The alleged in service injury is exposure to ionizing radiation. There has been no medical evidence to support that contention. The Board notes that even the Veteran frequently refers only to "possible" exposure to ionizing radiation. With regard to the third element of service connection, the Board acknowledges that the Veteran submitted a medical nexus opinion. However, the opinion was that the Veteran's disabilities were related to exposure to ionizing radiation. As noted, this fact has never been established. Moreover, Dr. H.M. provided absolutely no rationale in support of his opinion. Consequently, the Board finds the opinion to lack any probative value and thus finds that the third element of service connection has not been established. In the absence of an in-service injury (exposure to ionizing radiation) and a competent medical nexus, the Board finds that the preponderance of the evidence weighs against the claims. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claims of entitlement to service connection for mantle cell lymphoma and Waldenstrom macroglobulinemia must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Increased Ratings Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet.App. 119 (1999). The current version of the Ratings Schedule provides a table for ratings purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, established by a state-licensed audiologist including a controlled speech discrimination test (Maryland CNC), and based upon a combination of the percent of speech discrimination and the pure tone threshold average which is the sum of the pure tone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by four. See 38 C.F.R. § 4.85. Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. Id. A noncompensable evaluation is provided where hearing in the better ear is I and hearing in the poorer ear is I through IX; where hearing in the better ear is II, and hearing in the poorer ear is II to IV; or where there is level III hearing in both ears. A 10 percent disability rating is warranted where hearing in the better ear is I, and hearing in the poorer ear is X to XI; or where hearing in the better ear is II, and hearing in the poorer ear is V to XI; or where hearing in the better ear is III, and hearing in the poorer ear is IV to VI. A 20 percent disability rating is warranted where hearing in the better ear is III, and hearing in the poorer ear is VII to XI; or where hearing in the better ear is IV, and hearing in the poorer ear is VI to VIII; or where hearing in the better ear is V, and hearing in the poorer ear is V to VI. 38 C.F.R. § 4.85, Table VII, Diagnostic Code 6100. Table VIa will be used when the examiner certifies that the use of speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of 38 C.F.R. § 4.86. 38 C.F.R. § 4.85(c). When the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). When the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be elevated to the next higher. 38 C.F.R. § 4.86(b). Pertinent case law provides that the assignment of disability ratings for hearing impairment are to be derived by the mechanical application of the Ratings Schedule to the numeric designations assigned after audiometry evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The Veteran underwent a VA examination in July 2008. Puretone thresholds for the ears were as follows: HERTZ 1000 2000 3000 4000 Avg. RIGHT 50 75 80 85 72.5 LEFT 50 80 80 85 73.75 The pure tone average was 72.5 (73) decibels in the right ear and 73.75 (74) decibels in the left ear. Speech recognition scores were 96 percent bilaterally. Such examination findings translate to level II hearing in the right ear and level II hearing in the left ear. 38 C.F.R. § 4.85, Table VI. The Board notes that these examination findings do not reflect an exceptional pattern of hearing loss as defined by 38 C.F.R. § 4.86. Applying Table VII, Diagnostic Code 6100, this equates to a 0 percent rating. The Veteran underwent a private examination in June 2010 (Medical Treatment Record - Non-Government Facility, 7/6/10). Puretone thresholds for the ears were as follows: HERTZ 1000 2000 3000 4000 Avg. RIGHT 50 75 80 75 70 LEFT 45 75 80 80 70 The pure tone average was 70 decibels in the right ear and 70 decibels in the left ear. Speech recognition scores were not taken utilizing the Maryland CNC test and thus the entire test cannot be considered for rating purposes. The Veteran underwent a VA examination in November 2017. Puretone thresholds for the ears were as follows: HERTZ 1000 2000 3000 4000 Avg. RIGHT 85 90 100 105 95 LEFT 60 80 85 95 80 The pure tone average was 95 decibels in the right ear and 80 decibels in the left ear. Speech recognition scores were 44 percent in the right ear and 68 percent in the left ear. Such examination findings translate to level IX hearing in the right ear and level VI hearing in the left ear. 38 C.F.R. § 4.85, Table VI. The Board notes that both ears reflect an exceptional pattern of hearing loss. Pursuant, to 38 C.F.R. § 4.86, each ear may be evaluated under Table VIa if it results in a higher rating. Under Table VIa, such examination findings translate to level IX hearing in the right ear and level VII hearing in the left ear. Applying Table VII, Diagnostic Code 6100, this equates to a 50 percent rating. Analysis Effective September 29, 2007, the Veteran has been assigned a 0 percent rating. This rating was based on the results of the July 2008 examination. This examination showed puretone averages and speech recognition scores which translated to level II hearing in the right ear and level II hearing in the left ear. Exceptional patterns of hearing loss were not shown. Based on these audiological test results, a compensable rating is not warranted. However, the June 16, 2010 private examination showed puretone averages and speech recognition scores which translated to level VII hearing in the right ear and level IV. Exceptional patterns of hearing loss were not shown. Based on these audiological test results, the Board finds that a rating of 20 percent, but no higher, is warranted effective June 16, 2010. Effective November 3, 2017, the Veteran has been assigned a 50 percent rating. This rating was based on the results of the November 2017 examination. This examination showed puretone averages and speech recognition scores which translated to level IX hearing in the right ear and level VII hearing in the left ear (after applying Table VIa due to an exceptional pattern of hearing loss). Based on these audiological test results, a rating in excess of 50 percent is not warranted. The Board acknowledges the Veteran's contentions regarding the impact of his hearing loss on his daily activities. The Board also acknowledges VA's obligation to resolve all reasonable doubt in the Veteran's favor. However, as noted previously, because assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometry evaluations are rendered there is no doubt as to the proper evaluation to assign. See Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017) (finding that when a claimant's hearing loss results in an inability to hear or understand speech or to hear other sounds in various contexts, those effects are contemplated by the schedular rating criteria); 38 C.F.R. § 4.85, Tables VI, VIA, and VII, Diagnostic Code 6100. Applying the audiological test results to the regulatory criteria, the Board is compelled to conclude that the preponderance of the evidence is against entitlement to a compensable rating. ORDER Entitlement to service connection for a bunionette is denied. Entitlement to service connection for mantle cell lymphoma is denied. Entitlement to service connection for Waldenstrom macroglobulinemia is denied. Entitlement to a compensable rating for bilateral hearing loss prior to November 3, 2017, and in excess of 50 percent therefrom is denied. ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs