Citation Nr: 20079865 Decision Date: 12/17/20 Archive Date: 12/17/20 DOCKET NO. 16-23 643 DATE: December 17, 2020 ORDER Entitlement to service connection for a respiratory disability, to include sleep apnea, is denied. Entitlement to service connection for hepatitis C is denied. Entitlement to service connection for a heart disability, claimed as the result of herbicide agent exposure, is denied. Entitlement to service connection for a pancreas disability, claimed as the result of herbicide agent exposure, is denied. Entitlement to service connection for a gastrointestinal disability, claimed as the result of herbicide agent exposure, is denied. Entitlement to service connection for diabetes mellitus, claimed as the result of herbicide agent exposure, is denied. Entitlement to a rating higher than 0 percent prior to January 9, 2020, and higher than 20 percent as of January 9, 2020, for bilateral hearing loss is denied. REMANDED Entitlement to service connection for a liver disability is remanded. Entitlement to a total rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence shows that the Veteran does not have a respiratory disability other than sleep apnea, and that the respiratory disability of sleep apnea that is present was not incurred in or permanently aggravated by service. 2. The preponderance of the competent and credible evidence of record shows that the Veteran’s hepatitis C is not related to active service. 3. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of a heart disability. 4. The preponderance of the evidence weighs against associating diagnosed pancreatitis with any incident of service. 5. The preponderance of the evidence weighs against associating diagnosed esophageal reflux with any incident of service. 6. The preponderance of the evidence weighs against associating diagnosed diabetes mellitus with any incident of service. 7. Prior to January 9, 2020, the Veteran had, at worst, Level I hearing loss in the right ear and Level II hearing loss in the left ear. 8. From January 9, 2020, the Veteran had, at worst, Level VI hearing loss in the right ear and Level IV hearing loss in the left ear. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a respiratory disability, to include sleep apnea, have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. § 3.303. 2. The criteria for entitlement to service connection for hepatitis C have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. § 3.303. 3. The criteria for entitlement to service connection for a heart disability, claimed as the result of herbicide agent exposure, have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. § 3.303. 4. The criteria for entitlement to service connection for a pancreas disability, claimed as the result of herbicide agent exposure, have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. § 3.303. 5. The criteria for entitlement to service connection for a gastrointestinal disability, claimed as the result of herbicide agent exposure, have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. § 3.303. 6. The criteria for entitlement to service connection for diabetes mellitus, claimed as the result of herbicide agent exposure, have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. § 3.303, 3.307, 3.309. 7. The criteria for entitlement to a rating higher than 0 percent prior to January 9, 2020, and higher than 20 percent from January 9, 2020, for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.385, 4.1-4.14, 4.85, 4.86, Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from December 1973 to December 1976. The Veteran appeared at a June 2019 hearing before the undersigned Veterans Law Judge. The hearing transcript is of record. In October 2019, the Board remanded the appeal to the Agency of Original Jurisdiction (AOJ) for additional action. In light of the treatment records that have been obtained and associated with the record, the obtaining of the requested VA medical opinion, and the further adjudicatory actions taken, the Board finds that there has been substantial compliance with the prior remand requests concerning the issues of entitlement to service connection for a respiratory disability to include sleep apnea, hepatitis C, a heart disability, a pancreas disability, a gastrointestinal disability, and diabetes mellitus; and entitlement to higher ratings for bilateral hearing loss. Stegall v. West, 11 Vet. App. 268 (1998); D’Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141 (1999). Service Connection Service connection may be established for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, 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) evidence, generally medical, of a causal relationship between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be established for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Furthermore, service incurrence will be presumed for certain chronic diseases if manifest to a compensable degree within the year after active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. 1. Entitlement to service connection for a respiratory disability, to include sleep apnea The service medical records do not show any signs, symptoms, or treatment for any respiratory disability, to include sleep apnea. The November 1976 service separation examination report shows that the Veteran had a normal lungs and chest. At a January 2020 VA examination, the Veteran signed a waiver acknowledging that he was specifically declining a pulmonary function test that may be required in the processing the claim. After reviewing the records and performing an examination, the examiner stated that the Veteran did not currently have and had never been diagnosed with a respiratory condition other than obstructive sleep apnea. Concerning the Veteran’s sleep apnea, the examiner noted that a diagnosis of obstructive sleep apnea was confirmed in 2007, and the Veteran left active service in 1976. The examiner acknowledged the lay statement that the Veteran snored during service but stated that did not substantiate a formal diagnosis of obstructive sleep apnea. The examiner opined that it was less likely than not that the obstructive sleep apnea was caused or incurred due to service. The Veteran has a current diagnosis of sleep apnea. The Board finds that the preponderance of evidence is against a finding that current obstructive sleep apnea was caused or aggravated by active service. The Veteran has sought ongoing medical treatment through the VA. However, the Board finds that the competent evidence of record does not support a finding that relates any current obstructive sleep apnea to service. The Board ultimately places the most probative weight on the opinion offered by the January 2020 VA examiner. The VA examiner is an objective medical professional, who has the medical training and knowledge to perform and interpret the necessary medical tests. In addition, the Veteran has not submitted any competent medical evidence that supports a finding that the Veteran has a respiratory disorder, or that currently diagnosed obstructive sleep apnea is due to service. Therefore, as there is no competent evidence linking a currently diagnosed disability to service, the claim must be denied on a direct basis. The Board acknowledges the Veteran’s contentions that he experiences a respiratory disability, to include sleep apnea, as a result of active duty. The Veteran can attest to factual matters of which he had first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). However, while the Veteran is competent to report what comes to him through his senses, he does not have medical expertise to provide an opinion on the presence or diagnosis of respiratory disabilities or the etiology of obstructive sleep apnea. The diagnosis of respiratory disabilities and etiology of obstructive sleep apnea presents a complex medical question as there is no observable cause and effect relationship. Layno v. Brown, 6 Vet. App. 465 (1994). While the Board has considered the Veteran’s contentions regarding the presence of symptoms, the Board ultimately places more probative weight on the objective laboratory findings and observations of the VA medical professionals, who have the medical training and knowledge to perform and interpret the necessary medical tests. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for a respiratory disability, to include obstructive sleep apnea, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for hepatitis C The Veteran has claimed that he contracted the Hepatitis C virus during service as a result of air-gun injections. The Board notes that medically recognized risk factors for hepatitis C include: (a) transfusion of blood or blood product before 1992; (b) organ transplant before 1992; (c) hemodialysis; (d) tattoos; (e) body piercing; (f) intravenous drug use (with the use of shared instruments); (g) high-risk sexual activity; (h) intranasal cocaine use (also with the use of shared instruments); (i) accidental exposure to blood products as a healthcare worker, combat medic, or corpsman by percutaneous (through the skin) exposure or on mucous membrane; and (j) other direct percutaneous exposure to blood, such as by acupuncture with non-sterile needles, or the sharing of toothbrushes or shaving razors. See VBA Training Letter 211A (01-02), dated April 17, 2001. Additionally, VA Fast Letter 04-13 states that “[t]he large majority of HCV [hepatitis C] infections can be accounted for by known modes of transmission, primarily transfusion of blood products before 1992, and injection drug use. Despite the lack of any scientific evidence to document transmission of HCV with air gun injectors, it is biologically plausible. It is essential that the report upon which the determination of service connection is made includes a full discussion of all modes of transmission, and a rationale as to why the examiner believes the air gun was the source of the veteran’s hepatitis C.” See VA Fast Letter 04-13 (June 29, 2004). After a review of all the evidence of record, the Board finds that the preponderance of the evidence is against a finding that currently diagnosed hepatitis C was incurred in service or is otherwise related to service. The service medical records are negative for any diagnoses or treatment for hepatitis C. The November 1976 service separation examination shows no indication of any hepatitis C. On VA examination in January 2020, the examiner diagnosed hepatitis C. The examiner reviewed the records and stated that the Veteran’s records did not show any evidence of transmission during service, but did show numerous high-risk exposures following service. The examiner specified that the Veteran’s post-service risk factors included receiving blood transfusions in 1978 following a motor vehicle accident, cocaine abuse, and tattoos. Therefore, the examiner opined that it was less likely than not that the Veteran’s hepatitis C was caused or incurred due to service. The Board acknowledges that VA Fast Letter 04-13 indicates that it is “biologically plausible” that hepatitis C may be transmitted by air gun inoculations. However, there have been no actual reports of such an occurrence. Further, while the VA Fast Letter states that it is biologically plausible to transmit hepatitis C by air gun inoculations, that letter does not provide an etiological opinion on the Veteran’s hepatitis C. Instead, the January 2020 VA examiner reviewed the Veteran’s medical history and service medical records in detail and opined that it was less likely than not that the Veteran’s hepatitis C was caused by or a result of service. The January 2020 VA examiner found that the Veteran’s hepatitis C was more likely due to risk factors not associated with service, which were listed as receiving blood transfusions in 1978 following a motor vehicle accident, cocaine abuse, and tattoos. Additionally, despite the Veteran’s theory regarding in-service incurrence by airgun injections, there is no competent opinion of record that the airgun injections as likely as not infected him with hepatitis C. The mere possibility of such a relationship is insufficient to warrant a grant of the claim. 38 C.F.R. § 3.102 (reasonable doubt does not include resort to speculation or remote possibility); Stegman v. Derwinski, 3 Vet. App. 228 (1992); Obert v. Brown, 5 Vet. App. 30 (1993) (The term “possibility” also implies that it “may not be possible” and it is too speculative to establish a nexus.). The Board has carefully considered the Veteran’s statements purporting to relate his hepatitis C to service. As a lay person, however, the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorder of hepatitis C. Kahana v. Shinseki, 24 Vet. App. 428 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). Hepatitis C is a medically complex disease process because of its multiple possible etiologies, requires specialized testing to diagnose, and manifests symptomatology that may overlap with other disorders. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). The etiology of the Veteran’s current hepatitis C is a complex medical etiological question involving internal and unseen system processes unobservable by the Veteran. Despite the Veteran’s theory regarding in-service incurrence via airgun injections, there is no indication that airgun injections as likely as not infected him with hepatitis C. The competent medical evidence of record attributes the Veteran’s hepatitis C to nonservice-related risk factors. Because of the lack of evidence demonstrating the incurrence of hepatitis C during service, and the persuasive opinion that hepatitis C is more likely related to post-service risk factors, the Board finds that the preponderance of the evidence is against the claim, and the appeal is denied. 3. Entitlement to service connection for a heart disability, claimed as the result of herbicide agent exposure The service records do not show any signs, symptoms, or diagnoses of any heart disability. The Board finds that the evidence of record does not provide any medical basis for finding that the Veteran is currently diagnosed with a heart disability. The evidence does not show any currently diagnosed disability or medical findings of disability that would constitute a disability for which service connection could be established. While the Veteran has received regular treatment from VA medical facilities, the medical records do not show any signs, symptoms, or a diagnosis of a heart disability. Under applicable regulations, the term disability means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; Hunt v. Derwinski, 1 Vet. App. 292 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Notably, none of the competent evidence of record demonstrates that the Veteran is currently diagnosed with a heart disability. Service connection may not be granted for symptoms unaccompanied by a diagnosed disability. Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001); Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). In the absence of a diagnosis of a current disability, or any abnormality which is attributable to some identifiable disease or injury during service, an award of service connection is not warranted. The presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). Because there was no actual disability diagnosed at any time since the claim was filed or contemporary to the filing of the claim, and there remains no current evidence of the claimed disability, no valid claim for service connection for a heart disability exists. As the preponderance of the evidence is against the claims for service connection for a heart disability, the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for a pancreas disability, claimed as the result of herbicide agent exposure 5. Entitlement to service connection for a gastrointestinal disability, claimed as the result of herbicide agent exposure 6. Entitlement to service connection for diabetes mellitus, claimed as the result of herbicide agent exposure The Veteran’s service medical records are negative for any signs, symptoms, or treatment of a pancreas disability, a gastrointestinal disability, or diabetes mellitus. The November 1976 service separation examination report shows that the Veteran had a normal heart, vascular system, genitourinary system, and endocrine system. A urinalysis was negative for glucose. The Veteran indicated on a November 1976 Report of Medical History that he did not experience heart trouble, frequent indigestion, stomach, liver, or intestinal trouble, or sugar in his urine. As can be seen in the VA medical records, the Veteran has current diagnoses of pancreatitis, esophageal reflux, and diabetes mellitus, such as in February 2016 and June 2019 VA treatment records. The Veteran has asserted that pancreatitis, esophageal reflux, and diabetes mellitus, were incurred secondary to herbicide agent exposure during service. A Veteran who served in the Republic of Vietnam from January 9, 1962, to May 7, 1975, shall be presumed to have been exposed during that service to herbicide agents, unless there is affirmative evidence to establish that the Veteran was not exposed to any herbicide agent during that service. 38 U.S.C. § 1116(f). The Veteran’s service records do not show that he served in Vietnam. The Veteran himself has not claimed to have set foot in the Republic of Vietnam. Therefore, he is not presumed to have been exposed to herbicide agents during that service. At his June 2019 Board hearing, the Veteran asserted that he had been exposed to an herbicide agent when loading a truck in Kansas and during a two-week exercise in California. In October 2019, the Board remanded the claims and instructed the AOJ to have the Veteran identify the specific military facilities at which he was exposed to herbicide agents during active service. The AOJ was instructed to undertake appropriate development to verify the claimed inservice herbicide exposure upon receipt of the Veteran’s response. In January 2020, the AOJ sent the Veteran and accredited representative letters asking them to provide the information necessary to verify the claimed inservice herbicide exposure. No response from either the Veteran or the accredited representative to the January 2020 letter is of record. The Board notes that the duty to assist a claimant is not a one-way street, and in this case, the Veteran has not cooperated to the full extent in the development of the claims. Wood v. Derwinski, 1 Vet. App. 406 (1991). Although the AOJ asked the Veteran, the Veteran has not provided the information necessary to further develop the claim of asserted exposure to herbicide agents. The service records of record do not support the Veteran’s contention that he was exposed to any herbicide agent while on active duty. The Board finds that the official service records of record outweigh the Veteran’s contentions as they were created by impartial professionals who were tasked with creating official records of herbicide exposure. The more probative evidence is against the Veteran’s claim that the Veteran was exposed to herbicide agents while on active duty. Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (concluding that the Board did not err by rejecting appellant’s assertion of in-service chemical exposure on the basis that exposure was not documented in personnel records). As the evidence of record does not rise to the level of equipoise to show that it is at least as likely as not that the Veteran was exposed to an herbicide agent while on active duty, service connection for a pancreas disability, a gastrointestinal disability, and diabetes mellitus cannot be established as secondary to herbicide agent exposure. 38 C.F.R. §§ 3.307, 3.309. In addition, the Board finds that the Veteran’s bare assertion, without more, that he was exposed to herbicide agents does not require more of VA’s duty to assist. Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (rejecting the theory that medical examinations are to be routinely and virtually automatically provided to all Veterans in disability cases involving nexus issues simply because there are lay statements that the condition is linked to service). Moreover, VA is not obligated to grant a claim for benefits simply because there is no evidence disproving it. A claimant has the responsibility to present and support a claim for benefits. A claimant must provide an evidentiary basis for a benefits claim, consistent with VA’s duty to assist, and recognizing that whether submitted by the claimant or VA, the evidence must rise to the requisite level of an approximate balance of positive and negative evidence regarding any issue material to the determination. A claimant has the burden to present and support a claim for benefits. While reasonable doubt will be resolved in favor of the claimant, that is not applicable based on pure speculation or remote possibility. 38 U.S.C. § 5107(a); Skoczen v. Shinseki, 564 F.3d 1319 (2009); Fagan v. Shinseki, 573 F.3d 1282 (2009). The Board has considered whether service connection for a pancreas disability, a gastrointestinal disability, and diabetes mellitus, could be warranted on a direct basis. However, none of the Veteran’s medical treatment providers has given any indication that the Veteran’s pancreatitis, esophageal reflux, or diabetes mellitus, could be related to active duty, and there were no findings of diabetes mellitus during service or within one year following separation from service. The only evidence which provides any connection between the Veteran’s pancreatitis, esophageal reflux, diabetes mellitus, and service comes from the Veteran’s own statements. It is to be noted that the Board is not free to substitute its own judgment for a medical expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991). However, the Board is required to assess the credibility and weight to be given to the evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The Board has considered the Veteran’s lay statements. Although laypersons are competent to provide opinions on some medical issues, as to the specific issue in this case, whether pancreatitis, esophageal reflux, or diabetes mellitus were caused by active service, that issue falls outside the realm of common knowledge of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As a layperson, it is not shown that the Veteran possesses the medical expertise to provide such opinions, and there are no competent nexus opinions are of record. As previously stated, the medical evidence of record does not support the claims. The Board is sympathetic to the Veteran in that it is clear he sincerely believes that pancreatitis, esophageal reflux, and diabetes mellitus were caused by herbicide agent exposure during active service. However, the evidence of record does not support that contention. Although the Board is appreciative of the Veteran’s faithful and honorable service to our country, considering the record before the Board, the claims must be denied. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1991). As the preponderance of the evidence is against the claims of entitlement to service connection for a pancreas disability, a gastrointestinal disability, and diabetes mellitus, the claims for service connection must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 7. Entitlement to a rating higher than 0 percent prior to January 9, 2020, and higher than 20 percent from January 9, 2020, for bilateral hearing loss Ratings for hearing loss range from 0 to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests combined with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 Hertz. To rate the degree of disability for hearing loss, the Rating Schedule has established eleven auditory acuity levels, designated from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85(h), Table VI. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. The results are charted on Table VI, or Table VIA in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII. 38 C.F.R. § 4.85. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. In the cases with exceptional patterns of hearing loss, the Roman numeral value is determined using both Table VI and VIA and whichever table results in a higher Roman numeral value is used to calculate a rating using Table VII. 38 C.F.R. § 4.86. Prior to January 9, 2020 On VA examination in December 2014, the Veteran’s pure tone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 AVG RIGHT 20 25 45 45 34 LEFT 25 25 70 50 43 Maryland CNC word recognition was 94 percent in the right ear and 90 percent in the left ear. The Veteran reported that he had difficulty hearing people speak, and he had to wear headphones to hear his television without disturbing other people. At that June 2019 Board hearing, the Veteran stated that he had to turn up the volume on the television to hear properly. Prior to January 9, 2020, the Board notes that neither ear displays an exceptional pattern of hearing loss by regulation. Thus, Table VI will be used to determine the appropriate disability rating. 38 C.F.R. § 4.86(a). Applying the results for the Veteran’s right ear to Table VI shows that he had, at worst, Level I hearing loss, as shown by the December 2014 VA examination results. Under Table VI, the left ear had, at worst, Level II hearing loss, as shown by the December 2014 VA examination results. Applying Level I for the right ear and Level II for the left ear results in a 0 percent rating. 38 C.F.R. § 4.85. Therefore, the Board finds that the preponderance of the evidence is against the assignment of any higher rating prior to January 9, 2020. As of January 9, 2020 On VA examination in January 2020, the Veteran’s pure tone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 AVG RIGHT 65 70 70 70 69 LEFT 55 50 70 65 60 Maryland CNC word recognition was 72 percent in the right ear and 80 percent in the left ear. The Veteran reported that he had difficulty hearing clearly, and he had to turn up the volume on his television. The examiner stated that the Veteran had moderately severe to severe sensorineural hearing loss in the right ear and moderate to severe sensorineural hearing loss in the left ear. The examiner stated that degree of hearing loss would be expected to cause significant handicaps with communication, whether in quiet or noisy environments. In order to understand what was being said, the Veteran needed to be able to face the person speaking to him, and ambient noise needed to be minimal. The examiner stated that telephone communication would likely be extremely difficult, if possible at all. The use of assistive devices may mitigate but not eliminate the difficulties. The Board notes that the Veteran’s right ear displays an exceptional pattern of hearing loss by regulation. An exceptional pattern of hearing impairment appears when the pure tone threshold at each of the four specified frequencies of 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more. 38 C.F.R. § 4.86(a). Applying the January 2020 VA audiology examination findings to Table VI, the Veteran rates Roman Numeral designations of VI for the right ear, and IV for the left ear corresponding to a 20 percent rating under 38 C.F.R. § 4.85, Diagnostic Code 6100. Application of Table VIA to the right ear is not more advantageous to the Veteran with a Roman Numeral designation of V, which, when combined with the respective Roman Numeral designation for the left ear, corresponds to a 10 percent rating under 38 C.F.R. § 4.85, Diagnostic Code 6100. Those findings do not suggest that a rating higher than 20 percent is warranted. Therefore, the Board finds that the preponderance of the evidence is against the assignment of a higher rating as of January 9, 2020, and the claim must be denied. Both Periods The Board in no way discounts the difficulties that the Veteran experiences as a result of bilateral hearing loss. However, it must be emphasized that the assignment of disability ratings for hearing impairment is derived by a mechanical application of the rating schedule to the numeric designation assigned after audiometry results are obtained. The Board has no discretion in this matter and must predicate its determination on the basis of the results of the audiology studies of record. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The Board is bound by law to apply VA’s rating schedule based on the Veteran’s audiometry results. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Lay persons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, in this case, a lay opinion falls outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). To the extent that the Veteran contends that his hearing loss is more severe than currently rated, while he is competent to report symptoms such as difficulty understanding speech, he is not competent to report that his hearing acuity is of sufficient severity to warrant a certain percentage rating because such an opinion requires medical expertise and training in evaluating hearing impairment, which he does not possess, and the use of audiometric equipment. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Based upon the results from the VA examinations, the Board finds that the criteria for higher ratings for bilateral hearing loss have not been met. 38 C.F.R. §§ 4.85, 4.86. The Board finds that the preponderance of the evidence is against the claim for increased ratings and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a liver disability is remanded. In the October 2019 remand, the Board noted that a VA treatment record from October 2014 showed that the Veteran had cirrhosis of the liver. The Board remanded the claim for a VA examination to obtain an etiology opinion regarding cirrhosis of the liver. The requested examination was performed in January 2020. The VA examiner stated that for the Veteran’s claimed condition of liver disability, there was no diagnosis because the condition had resolved. The presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). The VA examiner did not address the etiology of the documented cirrhosis. Therefore, further VA examination is required. Barr v. Nicholson, 21 Vet. App. 303 (2007). 2. Entitlement to a total rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) is remanded. Because a decision on the other remanded issue could significantly impact a decision on the issue of entitlement to TDIU, the issues are inextricably intertwined. A remand of the claim for a TDIU is required. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Obtain the Veteran’s outstanding VA treatment records. 2. Schedule the Veteran for a VA examination, by a medical examiner with the appropriate expertise to determine the nature and etiology of any liver disability, to include the cirrhosis of the liver mentioned in the VA treatment record from October 2014. The examiner must review the claims file, and a complete history should be elicited from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. The examiner should identify any pertinent pathology found and should diagnose any liver disability, to include the cirrhosis of the liver mentioned in the VA treatment record from October 2014. As to any pertinent liver disability, to include cirrhosis, identified on examination, the examiner should opine whether it is at least as likely as not (50 percent probability or more) that liver disability had its onset in service, was aggravated by service, or is otherwise related to any incident of service. The examiner must provide an opinion regarding whether the diagnosed cirrhosis of the liver was related to service, even if it has resolved because that condition manifested during the period of pendency of the claim. Any opinion expressed must be accompanied by a complete rationale. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Layton, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.