Citation Nr: 21005107 Decision Date: 01/29/21 Archive Date: 01/29/21 DOCKET NO. 16-41 118 DATE: January 29, 2021 ORDER Entitlement to an initial compensable rating for bilateral hearing loss prior to November 5, 2019, and thereafter in excess of 30 percent prior to November 9, 2020, and thereafter in excess of 20 percent, is denied. From May 7, 2014, entitlement to an initial compensable rating for left ear scars status post cholesteatoma removal is denied. FINDINGS OF FACT 1. From May 7, 2014 to November 5, 2019, the Veteran’s bilateral hearing loss was manifested by hearing acuity of no worse than Level I in the right ear and no worse than Level II in the left ear. 2. From November 5, 2019 to November 9, 2020, the Veteran’s bilateral hearing loss was manifested by hearing acuity of no worse than Level IV in the right ear and no worse than Level IX in the left ear. 3. From November 9, 2020, the Veteran’s bilateral hearing loss was manifested by hearing acuity of no worse than Level IV in the right ear and no worse than Level VIII in the left ear. 4. Throughout the appeal, the Veteran’s left ear scars status post cholesteatoma have not been painful, or unstable, or manifested by any characteristic of disfigurement, and do not cover an area of six or more square inches (39 or more square centimeters). CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial compensable rating for bilateral hearing loss prior to November 5, 2019, and thereafter in excess of 30 percent prior to November 9, 2020, and thereafter in excess of 20 percent, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.85, 4.86, Diagnostic Code (DC) 6100. 2. From May 7, 2014, the criteria for entitlement to an initial compensable rating for left ear scars status post cholesteatoma removal, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.118, DCs 7800-7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1972 to March 1974. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2015 rating decision of an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). In October 2018, the Board remanded this matter for additional development. Pursuant to a June 2020 rating decision, the AOJ granted an increased 30 percent rating for bilateral hearing loss effective November 5, 2019. The June 2020 rating decision also granted entitlement to service connection for bilateral pruritis of the ears and assigned an initial noncompensable (zero percent) rating effective May 7, 2014. On August 19, 2020, the Board granted entitlement to service connection for otitis media and otitis externa. The Board also remanded for additional development the issues of entitlement to an initial compensable rating for a left ear scar and entitlement to an initial compensable rating for bilateral hearing loss from May 7, 2014 to November 5, 2019, and thereafter in excess of 30 percent. On August 23, 2020, the AOJ issued a rating decision that implemented the awards of service connection granted in the August 2020 Board decision. The AOJ assigned an initial 10 percent rating effective May 7, 2014 for otitis media and otitis externa with adhesive otitis with bilateral pruritis of the ears, residuals status post-left ear cholesteatoma removal. In September 2020, the Veteran filed a VA Form 10182. This matter will be addressed separately. In December 2020, the AOJ reduced the Veteran’s rating for bilateral hearing loss from 30 percent disabling to 20 percent disabling, effective November 9, 2020. The Board observes that this rating reduction is a distinct issue from the issue on appeal. See Dofflemyer v. Derwinski, 2 Vet. App. 277, 279-80 (1992) (noting that the issue of propriety of a rating reduction is factually and legally distinct from the issue of entitlement to an increased rating). If the Veteran disagrees with the December 2020 rating reduction, he should request review of that decision on the appropriate VA-promulgated form. Substantial Compliance with Prior Remand Directives There has been substantial compliance with the Board’s prior remand directives. In this regard, updated VA treatment records have been obtained. Furthermore, the AOJ attempted to obtain outstanding relevant private treatment records, as directed by the Board. However, it was unable to do so, as the Veteran did not provide necessary assistance. In this regard, in October 2019 the Veteran returned a partial, unsigned copy of VA Form 21-4142a that identified private medical providers, and he also submitted a private audiological examination report and private treatment records. See October 2019 Medical Treatment Records. The August 2020 Board Decision and Remand explained that the incomplete form submitted by the Veteran was inadequate, as no signature page was included. See August 2020 Board Decision at 5-6. In compliance with Board Remand directives, the Veteran was provided with a general release to obtain records and was requested that he return a completed copy of the same. See August 2020 Subsequent Development Letter. However, no copy was returned. The Board finds that the AOJ substantially complied with the Board’s directive to obtain relevant outstanding private treatment records, as it provided the Veteran with the forms necessary to obtain outstanding records but was unable to obtain any because no signed release was returned. The duty to assist is not a one-way street, and the Veteran must cooperate with the Board in developing evidence in his appeal. See Wood v. Derwinski, 1 Vet. App. 190 (1991). Additionally, the Board directed that the AOJ schedule the Veteran for an examination to determine the nature and severity of his bilateral hearing loss, ideally during an ear infection, if possible. The Board also requested an opinion from an examiner as to the whether the September 2019 private audiology examination report was medically consistent with examination findings. The Board directed the AOJ to obtain this evidence to inform the Board in its credibility findings. See Miller v. Wilkie, 32 Vet. App. 249, 259-60 (2020) (explaining that the Board may develop medical evidence to inform its credibility findings). In November 2020, the Veteran presented for an examination with a VA-contracted examiner. The examiner evaluated the severity of the Veteran’s hearing loss and provided a well-reasoned opinion as to why the private audiology examination report was not medically consistent with the November 2020 VA examination findings. The examiner explained that, while the Veteran was believed to have had an active ear infection at the time of the September 2019 private examination, it was documented as being only in the left ear. See December 2020 Addendum Opinion; see also September 6, 2019 VA Treatment Note (associated with the claims file November 13, 2019) (left ear pain and left otitis media). Thus, the examiner explained, the right ear test results should be consistent from one test to another, but the thresholds documented at the private audiology examination were significantly higher in both ears compared to the November 2020 examination findings. Moreover, the examiner explained that during an active ear infection one would expect elevated air conduction thresholds only and with bone conduction thresholds not changing. However, comparing bone conduction thresholds between the private audiology examination and the November 2020 audiology examination shows inconsistencies. The examiner concluded that in light of these consistencies, the private audiology findings were supra-threshold and should be deemed unreliable for rating purposes. See December 2020 Addendum Opinion. The Board finds that the AOJ has achieved substantial compliance with the Board’s directive to secure an updated examination and addendum opinion. The examiner’s opinion includes a sound rationale for the conclusion that the September 2019 examination report is inconsistent with examination findings, even assuming that the Veteran was undergoing an active ear infection at the time of the September 2019 examination. As discussed below, this opinion is probative evidence that aids the Board in making necessary credibility determinations and in concluding that the September 2019 examination report is not based on an accurate factual basis. Thus, substantial compliance has been achieved. The Board acknowledges that the record does not show that the November 2020 examination was scheduled during an active ear infection. However, the Board emphasizes that its remand directive explicitly stated that this should be scheduled during an active infection “if possible” and that the Board did not state that examination during an infection was strictly necessary. A major motivation in the Board’s directive to attempt an examination during an active infection was to determine whether the September 2019 examination report findings accurately measured the Veteran’s organic hearing loss during such an infection. However, as noted above and as discussed below, the December 2020 addendum opinion has aided the Board in resolving this question. Moreover, the evidence does not show, and the Veteran does not assert, that his ear infections are of such a nature and regularity as would permit the VA to prospectively schedule an examination during an anticipated future infection. Finally, as the Veteran has not cooperated with the Board’s efforts to secure accurate objective examination findings during an active infection, the Board’s efforts to assist the Veteran in developing his claim have been frustrated. See Wood, 1 Vet. App. 190. 1. Entitlement to an initial compensable rating for bilateral hearing loss prior to November 5, 2019, and thereafter in excess of 30 percent prior to November 9, 2020, and thereafter in excess of 20 percent, is denied. The Veteran asserts that he is entitled to a higher rating because he has experienced decreased hearing loss and ear infections since 1974 with attendant pain and suffering. He also asserts he has constant drainage and infections and a “cavernous hole” in his ear. See, e.g., October 2015 Notice of Disagreement (NOD); August 2016 VA Form 9. The Veteran is currently in receipt of an initial noncompensable rating prior to November 5, 2019, and thereafter a 30 percent rating prior to November 9, 2020, and thereafter a 20 percent rating. The period on appeal is from May 7, 2014, the effective date of service connection. Law and Regulations Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, DC 6100. To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, 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. Further, when the average 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, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). October 2015 Audiology Examination Report An October 2015 VA-contracted audiology examination reveals that the Veteran reported difficulty in understanding speech in noisy environments, at a distance, and on the telephone. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran’s Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: Oct. 2015 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 40 20 35 35 33 92% LEFT 45 35 40 55 44 88% Applying the results to Table VI, the findings yield a numeric designation of Level I in the right ear and Level II in the left ear. Entering the resulting bilateral numeric designation of Level I for the right ear and Level II for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a zero percent disability rating under DC 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. September 2019 Audiology Examination Report The Veteran submitted a private September 2019 audiology examination conducted by B.W., Au. D, CCC-A. The examination report shows that the examiner was a state-licensed audiologist and that the examiner tested the frequencies required for VA rating purposes and the examiner used the required Maryland CNC test. See September 2019 B.W. Audiology Report. However, as discussed below, this examination report is not probative evidence of the Veteran’s hearing loss disability. In this regard, in a December 2020 addendum opinion, a VA-contracted examiner acknowledged that the Veteran reported an active ear infection at the time of the September 2019 examination and noted that the evidence showed an infection in the left ear. The examiner explained that the right ear hearing thresholds should be consistent from one test to another, even during a left ear infection. However, the examiner explained that when compared to the November 2020 examination findings, the hearing thresholds recorded at the September 2019 examination were significantly higher in both the left and the right ear. Moreover, the December 2020 examiner explained that the bone conduction thresholds recorded in September 2019 and November 2020 should be comparable, even during an ear infection. However, the examiner noted that in comparing the bone conduction thresholds from September 2019 to November 2020, “again there [are] inconsistencies.” The examiner explained that based on these inconsistencies, she believed that the September 2019 audiology findings are supra-threshold and “should be deemed unreliable [for] rating purposes.” See December 2020 Addendum Opinion. The December 2020 Addendum Opinion is probative. The examiner, L.F., Au. D., is competent to provide an audiological opinion as to the effects of an ear infection on audiology examination findings. Moreover, the December 2020 examiner explained why the September 2019 audiological findings are inconsistent with the November 2020 examination findings and provided a readily-comprehensible rationale for her conclusion based her interpretation of the evidence of record. This probative evidence has informed the Board in making its credibility determinations. See Miller v. Wilkie, 32 Vet. App. 249 (2020). The Board finds that the September 2019 private audiology examination report does not accurately reflect the severity of the Veteran’s organic hearing loss. In this regard, while the audiologist who conducted the September 2019 examination is competent to provide an opinion as to the severity of the Veteran’s hearing loss, the September 2019 examination report does not show that the September 2019 examiner attempted to verify that the examination findings represented organic hearing loss. In contrast, the December 2020 examiner explained why the September 2019 examination findings are inconsistent with the November 2020 audiology examination report. The Board gives greater probative weight to the November 2020 audiology findings based on the persuasive, evidence-based explanation provided by the December 2020 examiner. Indeed, as the evidence shows that the findings in the September 2019 examination report are based on factors other than organic hearing loss, the Board concludes that the findings in the September 2019 report are not based on an accurate factual basis and the report is entitled to no probative weight. Accordingly, the Board will not consider the September 2019 examination findings in assessing the severity Veteran’s bilateral hearing loss. November 2019 Audiology Examination Report A November 2019 VA-contracted audiology examination reveals that the Veteran reported decreased hearing sensitivity bilaterally causing increasing clarity and speech understanding issues. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). Nov. 2019 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT CNT CNT CNT CNT CNT 68% LEFT CNT CNT CNT CNT CNT 28% The examiner stated that pure tone hearing thresholds could not be reliably tested due to inconsistencies in pure tone responses, a positive Stenger test, and repeating words that were presented at lower levels than any volunteered pure tone thresholds, which is physiologically impossible, as well as worse than expected word recognition testing with errors rhyming with presented words. The examiner concluded that the findings were inconsistent with organic hearing loss and stated that the results are considered to be of poor reliability and rating hearing loss accordingly would be resorting to mere speculation. See November 2019 Audiology Examination Report. Notwithstanding the examiner’s explicit narrative disclaimer that the examination findings were unreliable, the examiner provided contradictory responses to other questions in the examination report. Specifically, the examiner checked a box indicating the pure tone results and speech discrimination scores were valid for rating purposes. This is inconsistent with the narrative response, as a response “CNT,” could not test, is obviously inadequate for rating purposes. Likewise, despite the narrative that word recognition scores were problematic, the examiner checked the box indicating that use of speech discrimination scores were appropriate for the Veteran. The Board finds that based on the narrative description of inability to measure accurate hearing thresholds, the November 2019 examiner most likely intended to express that the examination findings as a whole were inadequate for rating purposes. However, notwithstanding the lack of adequate examination findings, the AOJ took the approach of adopting a pure tone threshold of “zero” and applying the speech discrimination scores to Table VI, yielding Level IV acuity for the right ear and Level IX acuity for the left ear, which 38 C.F.R. § 4.85, Table VII, equates to a 30 percent disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown, as the Veteran did not provide reliable pure tone responses. November 2020 Audiology Examination Report A November 2020 VA-contracted audiology examination reveals that the Veteran reported decreased hearing sensitivity bilaterally causing increasing speech clarity and noise interference issues. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran’s Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: Oct. 2015 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 55 55 60 65 59 76% LEFT 60 60 65 85 68 52% Applying the results to Table VI, the findings yield a numeric designation of Level IV in the right ear and Level VIII in the left ear. Entering the resulting bilateral numeric designation of Level IV for the right ear and Level VIII for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a 20 percent disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was shown in both ears. Applying the results to Table VIa yields Level IV in the right ear and Level V in the left ear. Entering the resulting bilateral numeric designation of Level IV for the right ear and Level VIII for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a 20 percent disability rating under Diagnostic Code 6100. An Increased Rating is Not Warranted Based on the evidence discussed above, a compensable rating is not warranted prior to November 5, 2019. In this regard, there are no examination findings showing entitlement to a compensable rating prior to the AOJ’s award of a 30 percent rating effective November 5, 2019. The Board acknowledges that in September 2019, the Veteran sought treatment for an ear infection and submitted a copy of a private audiological examination conducted that month. See September 6, 2019 VA Treatment Note (associated with the claims file November 13, 2019) (left ear pain and left otitis media). However, there are no objective findings from this date that would support an increased rating prior to November 5, 2019. As noted above, the September 2019 private examination findings are not probative. Moreover, the Board applied the November 2019 examination findings to any increase in disability reflected by the September 2019 ear infection, as notwithstanding the AOJ’s determination that a 30 percent rating could be awarded based solely on the November 2019 speech discrimination scores, the Board concludes that the November 2019 examination findings are not adequate for rating purposes. In this regard, the November 2019 examiner’s narrative demonstrates the examiner’s opinion that the totality of the results obtained at the November 2019 examination were not reliable. To the extent that check boxes indicate otherwise, the narrative section of the examination report is more probative as it includes a rationale. Moreover, the rating schedule does not contemplate measurement of hearing loss based solely upon speech discrimination scores, where reliable pure tone hearing thresholds are not available. The Board emphasizes that the regulations expressly provide for ratings based solely on pure tone thresholds in certain instances, which demonstrates that the regulations do not contemplate a rating based solely on speech discrimination scores. The Board acknowledges that here, the AOJ’s approach was to assume “zero” average pure tone hearing loss, but this is not what the November 2019 examiner found – instead, he found that the pure tone hearing thresholds were not adequate for rating purposes. Additionally, a rating in excess of 30 percent is not warranted from November 5, 2019 to November 9, 2020. Indeed, there are no adequate examination findings during this period other than the October 2015 examination findings, which do not support a compensable rating. Even assuming arguendo that the November 2019 examination findings are adequate for rating purposes, which they are not, those findings do not support a rating in excess of 30 percent. From November 9, 2020, a rating in excess of 20 percent is not warranted. In this regard, the November 2020 examination report is adequate for rating purposes and shows entitlement to a 20 percent rating and, critically, the September 2019 and November 2019 examination reports are not adequate for rating purposes. Again, the Board emphasizes that the AOJ’s approach of deriving a rating based on the November 2019 examination report was impermissible. Moreover, even assuming arguendo that the November 2019 examination findings are adequate for rating purposes, which they are not, the November 2020 findings are the most probative evidence of record as to the severity of hearing loss prospectively from November 9, 2020. The Board expressly acknowledges its consideration of the lay evidence of record when adjudicating this claim, including that the Veteran has difficulty hearing and has had painful ear infections for many years. The Veteran is competent to report difficulty with his hearing; however, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes, is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran’s main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). Additionally, the Board acknowledges the Veteran’s statement that he believes that the October 2015 examination findings do not accurately reflect the functional impairment of his disability because the examination was conducted after a nurse “used different equipment to clean out my ear for approx[imately] 20 min[ute]s before the test.” See July 2016 Veteran Statement (including January 20, 2016 and January 30, 2016 letters). While VA regulations state that examinations are to be conducted without the use of hearing aids, they do not require, or prohibit, any pre-examination procedures regarding ear cleaning. See 38 C.F.R. § 4.85(a). However, the regulations do require examinations to be conducted by a state-licensed audiologist. Id. Here, the October 2015 VA-contracted examiner, Dr. R.B.D., is an otolaryngologist and is a licensed state audiologist. See October 2015 Hearing Loss and Tinnitus Disability Benefits Questionnaire (DBQ) at 8. Thus, he is qualified to assess hearing loss for VA compensation purposes, and he is competent to determine what pre-examination preparations are necessary to accurately measure the Veteran’s hearing loss disability. While the Veteran may disagree with the examiner’s audiological judgment, the Veteran does not assert, and the record does not show, that the examiner’s preparations were not appropriate. Moreover, to the extent that the Veteran’s ear infections require regular cleaning to achieve maximum hearing acuity or result in functional impairment other than loss of hearing acuity, the Veteran has been granted service connection for his ear infections and these infections are rated separately. See August 2020 Board Decision and Remand; August 2020 Rating Decision. If the Veteran disagrees with the effective date of service connection or disability rating assigned for his otitis media and otitis externa, he should request review of the August 2020 rating decision. However, the Board is legally prohibited from increasing his rating for hearing loss or assigning an earlier effective date based on historical pain and suffering prior to the filing of a claim, as the Board is bound by the rating schedule and the law and regulations governing disability compensation. Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to an increased rating for hearing loss. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. From May 7, 2014, entitlement to an initial compensable rating for left ear scars is denied. The Veteran has two left ear scars related to his cholesteatoma excision. See November 2019 Scars Examination Report; see also September 2015 Ear Conditions DBQ. The examiner described an external left ear scar that was healed and unseen on the day of the examination. See November 2019 Scars Examination Report at 2, 8. The examiner also noted that the Veteran reported an internal left ear drum scar that was unseen on examination. See id. The September 2015 examiner noted a scarred ear drum, with retraction adhesion and end aural incision on the left. See September 2015 Ear Conditions Examination Report. The Veteran is currently in receipt of an initial noncompensable rating for left ear scar, status post cholesteatoma under DC 7800. The period on appeal is from May 7, 2014, the effective date of service connection. Effective August 13, 2018, the schedule of ratings for the skin was amended. 83 Fed. Reg. 32664 (July 13, 2018) (codified at 38 C.F.R. § 4.118). However, the rating criteria and Notes applicable to this appeal were not changed by the August 2018 amendments. Scars of the head, face, and neck are rated under DC 7800. Under DC 7800, a 10 percent rating is warranted for scars with one characteristic of disfigurement. A 30 percent rating is warranted for scars with two or three characteristics of disfigurement, or where there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes, ears, cheeks). A 50 percent rating is warranted for scars with four or five characteristics of disfigurement, or where there is visible or palpable tissue loss and gross distortion or asymmetry of two features or paired sets of features. A maximum schedular 80 percent rating is warranted where there are six or more characteristics of disfigurement, or where there is visible or palpable tissue loss and gross distortion or asymmetry of three or more features or paired sets of features. There are eight characteristics of disfigurement for the purposes of DC 7800. These are: a scar five or more inches (13 or more centimeters) in length; a scar at least one-quarter inch (0.6 centimeters) wide at the widest part; a scar with surface contour elevated or depressed on palpation; a scar that is adherent to underlying tissue; a scar with hypo- or hyper-pigmented skin in an area exceeding six square inches (39 square centimeters); a scar with abnormal skin texture, such as irregular, atrophic, shiny, or scaly skin, in an area exceeding six square inches (39 square centimeters); a scar with underlying soft tissue missing in an area exceeding six square inches (39 square centimeters); and a scar with skin indurated and inflexible in an areas exceeding six square inches (39 square centimeters). Effects of scars other than disfigurement are rated under the appropriate DC and then are combined with any rating under DC 7800 pursuant to 38 C.F.R. § 4.25. Burn scars or scars due to other causes, not of the head, face, or neck, that are deep and nonlinear are rated under DC 7801. Under DC 7801, a 10 percent rating is warranted for area or areas of scarring of at least 6 square inches (39 square centimeters) but less than 12 square inches (77 square centimeters). Higher ratings are warranted for larger areas. Burn scars or scars due to other causes, not of the head, face, or neck, that are superficial and nonlinear are rated under DC 7802. Under DC 7802, a 10 percent rating is warranted for area or areas of scarring of at least 144 square inches (929 square centimeters). Painful and/or unstable scars are rated under DC 7804. A 10 percent rating is warranted for one or two scars that are painful or unstable. A 20 percent rating is warranted for three or four scars that are painful or unstable. A 30 percent rating is warranted for five or more scars that are painful or unstable. If one or more scars are both painful and unstable, 10 percent is added to the evaluation that is based on the total number of unstable or painful scars. Other scars (including linear scars) are evaluated under DC 7805, which provides that disabling effects not considered under DC 7800-7804 should be rated under the appropriate DC. Here, DC 7800 is appropriate for rating the Veteran’s external ear scar. A noncompensable rating is appropriate, as the external ear scar was not visible on examination and no characteristics of disfigurement were found on examination, including characteristics of disfigurement noted on palpation. The Veteran’s internal ear scar would be appropriately rated under DC 7805, which directs the use of the appropriate DC. A rating under DC 7800 is not appropriate, as the scar is internal. Even assuming DC 7800 was appropriate, no disfigurement was shown on examination. No compensable rating under DC 7801 or 7802 is warranted. The Veteran’s two scars were not shown to cover at least six square inches. No rating is warranted under DC 7804. The Veteran’s ear scars are not shown to be painful or unstable. And while the Veteran has credibly reported left ear pain, he is in receipt of service connection and a separate rating for his ear infections. Critically, no examiner opined that his ear pain or any emission was related to painful and/or unstable scars. There are no other effects of scars shown that would warrant a rating under a different DC. In this regard, the Board acknowledges the Veteran’s report of a “hole in the ear.” However, the Board emphasizes that the Veteran is in receipt of a separate rating for otitis media and otitis externa with adhesive otitis with bilateral pruritus of the ears. The record does not show any other service-connected residual warranting separate compensation. Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to an initial compensable rating for left ear scars. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D.M. Badaczewski, Associate 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.