Citation Nr: 21062232 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 16-19 850 DATE: October 6, 2021 ORDER 1. Entitlement to rating in excess of 30 percent for coronary artery disease (CAD) is denied. 2. Entitlement to a rating in excess of 20 percent for a lumbar spine disability is denied. 3. Entitlement to a rating in excess of 10 percent for hypothyroidism is denied. 4. Entitlement to a compensable rating for gastroesophageal reflux disease (GERD) with hiatal hernia is denied. 5. Entitlement to a compensable rating for a left ear hearing loss is denied. FINDINGS OF FACT 1. The Veteran's CAD is not shown to have been manifested by more than one episode of acute congestive heart failure in the previous year, or; workload greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 2. The Veteran's lumbar spine disability is not shown to have been manifested by forward flexion limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine; or incapacitating episodes of intervertebral disc syndrome (IVDS) having a total duration of at least 4 weeks but less than 6 weeks during a 12-month period; or additional (to bilateral lower extremity radiculopathy) separately ratable neurological manifestations. 3. The Veteran's hypothyroidism is not shown to have been manifested by fatigability, constipation, and mental sluggishness. 4. The Veteran's GERD with hiatal hernia is not shown to have been manifested by two or more symptoms (from among dysphagia, pyrosis, regurgitation, and substernal or arm or shoulder pain). 5. The Veteran's hearing acuity is not shown to at any time have been worse than Level I in the left ear; service connection for right ear hearing loss is not established. CONCLUSIONS OF LAW 1. A rating in excess of 30 percent for CAD is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.104, Diagnostic Code (Code) 7005. 2. A rating in excess of 20 percent for lumbar spine disability is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.21, 4.40, 4.45, 4.71a, Codes 5237, 5242. 3. A rating in excess of 10 percent for hypothyroidism is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.20, 4.21, 4.119, Code 7903. 4. A compensable rating for GERD with hiatal hernia is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.20, 4.21, 4.114, Code 7346. 5. A compensable rating for a left ear hearing loss is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.85, 4.86, Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from February 1970 to September 2000. These matters are before the Board on appeal from an August 2013 Department of Veterans Affairs (VA) rating decision. In September 2019, a videoconference Board hearing was held before the undersigned; a transcript is in the record. In November 2019, the matters were remanded for additional development. Increased Rating Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C. § 1155. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. When 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. All reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, "staged" ratings may be assigned when the evidence shows distinct periods during the evaluation period when manifestations of the disability warranted varied ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). 1. Entitlement to rating in excess of 30 percent for CAD is denied. On July 2013 VA examination, the Veteran's treatment plan was noted to include taking metoprolol and Plavix daily. There was no history of myocardial infarction, percutaneous coronary intervention, heart transplant, or implanted cardiac pacemaker or automatic implantable cardioverter defibrillator. He had coronary bypass surgery in November 2002. He did not have congestive heart failure. He denied experiencing symptoms with any level of physical activity. There was no evidence of cardiac hypertrophy or dilatation. Left ventricular ejection fraction was 55 percent on November 2002 testing. The examiner noted that the Veteran has other conditions affecting his exercise tolerance, and opined that subjective METs is not an accurate measurement of a patient's cardiac status. An echocardiogram was ordered to determine the presence of ejection fraction, left ventricular hypertrophy, and chamber enlargement. Ejection fraction was normal at 60 percent, there was mild left ventricular hypertrophy, and the left atrium was enlarged at 4.4 centimeters. Based on this evidence, the August 2013 rating decision granted service connection for CAD, rated 10 percent, effective July 19, 2012. An April 2016 rating decision increased the initial rating to 30 percent, also effective July 19, 2012. On August 2017 VA treatment, the Veteran reported that his metoprolol was changed by his cardiologist to Bystolic. He reported having a left heart catheterization by a non-VA cardiologist about two months earlier that found no significant blockage. On June 2019 VA treatment, the Veteran reported that he recently spent a night in a local non-VA chest pain unit for numbness to the left arm and hand. He reported that testing was negative; that he had not had any signs or symptoms since; and that he was to see a local non-VA cardiologist the following week to discuss possible heart catheterization. At the September 2019 Board hearing, the Veteran testified that his most recent cardiac catheterization showed two new blockages of 50 percent in the back of his heart. He testified that he routinely sees a private cardiologist, and underwent a stress test about three weeks prior to the hearing. On December 2019 VA examination, the Veteran reported he underwent a quadruple coronary artery bypass graft in November 2002 and had not required any further treatment or procedure. It was noted that the Veteran was hospitalized in June 2019 for left arm pain, and a cardiac work-up was negative for any acute process. The Veteran reported he was stable, without chest pain or shortness of breath. He had no current symptoms. He took aspirin, Plavix, Atorvastin, and Xetia daily for his heart condition. There was no history of myocardial infarction, congestive heart failure, cardiac arrhythmia, a heart valve condition, infectious cardiac condition, or pericardial adhesions. He had not had any other hospitalizations for treatment of heart conditions (other than the non-surgical and surgical procedures noted). On physical exam, heart rhythm was regular with point of maximal impact at the 4th intercostal space. Heart sounds were normal. There was no jugular-venous distension, and the lungs were clear on auscultation. Peripheral pulses were normal and there was no peripheral edema. Blood pressure was 168/90. There was no evidence of cardiac hypertrophy or dilatation. A May 2019 Cardiolite perfusion scan with SPECT imaging and stress test showed no reversible ischemic changes and no wall motion abnormalities; ejection fraction was greater than 70 percent. Exercise stress testing was not required as part of the Veteran's treatment plan and the test was not without significant risk. On interview-based METs test, the Veteran denied experiencing any symptoms attributable to a cardiac condition with any level of physical activity. The examiner opined that the Veteran's MET score and ejection fraction reflect that he has no limitation in any physical activity based on his cardiac status; he has a normal ejection fraction and no cardiac symptoms with activity. The Veteran's heart disability is rated under 38 C.F.R. § 4.104, Code 7005 for coronary artery heart disease. A 30 percent rating is warranted for workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted for more than one episode of acute congestive heart failure in the previous year, or; workload greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted for chronic congestive heart failure, or; workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104. The reports of the VA examinations, the VA treatment records, and lay statements, overall, provide evidence against this claim, as the evidence does not show that the Veteran's CAD manifestations met criteria for a rating in excess of 30 percent at any time. There is no evidence of workload of 5 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 50 percent or less. There is no evidence at any time of congestive heart failure. The findings do not meet or approximate the criteria for a 60 percent or 100 percent schedular rating. Consequently, a rating for CAD in excess of 30 percent is not warranted. The preponderance of the evidence is against this claim; therefore, the appeal in the matter must be denied. 2. Entitlement to a rating in excess of 20 percent for lumbar spine disability is denied. On July 2013 VA examination, the Veteran reported that he had intermittent lower back pain. He reported flare-ups of severe lower back pain twice per year, typically lasting 7 to 10 days, at which time he applies heat and takes medication; range of motion and functional disability during these episodes could not be measured. On physical examination, forward flexion was to 70 degrees, extension was to 30 degrees or greater, right and left lateral flexion were each to 30 degrees or greater, and right and left lateral rotation were each to 30 degrees or greater; there was no objective evidence of painful motion in any range of motion. There was no additional limitation in range of motion following repetitive-use testing. Functional loss consisted of less movement than normal. The Veteran did not have localized tenderness or pain to palpation of the back. There was no guarding or muscle spasm of the back. Muscle strength testing was normal and there was no muscle atrophy. Reflex testing and sensory testing were normal. Straight leg raising was negative bilaterally. There were no signs or symptoms due to radiculopathy. There were no other neurologic abnormalities or findings related to a back condition. The Veteran was noted to have IVDS of the thoracolumbar spine but had not had any incapacitating episodes over the previous 12 months due to IVDS. He did not use assistive devices. Based on this evidence, the August 2013 rating decision granted service connection for L5-S1 disc degeneration, rated 10 percent, effective July 19, 2012. On June 2016 VA treatment, the Veteran reported that he was still having a lot of back pain that was worse on standing or walking; tramadol helped with the pain. There was tenderness to palpation at the lumbar spine. Straight leg lift was negative. On August 2017 VA treatment, the Veteran reported ongoing back pain that was worse when standing or walking, and helped by tramadol. There was tenderness to palpation of the lumbar spine. Range of motion was painful and limited. Straight leg lift was negative. An August 2018 private MRI of the lumbar spine was interpreted as showing multi-level central stenosis "please correlate for bilateral L 4 radiculopathies". Early 2019 treatment records show that On January 2019 VA treatment, the Veteran requested a consult for back injections for severe pain. In April 2019, he received an epidural steroid injection. At the September 2019 Board hearing, the Veteran testified that he cannot sit for extended periods without experiencing back pain, and that standing for more than 15 to 20 minutes brings on pain that radiates down his legs. He testified that he cannot do much heavy lifting or gardening because it exacerbates his lower back. He testified that he seeks regular treatment for back disability. The Veteran submitted an October 4, 2019 back conditions Disability Benefits Questionnaire completed by a private nurse practitioner who indicated that no records were reviewed. He reported progressively worse back pain with flare-ups that limit his functions including walking, lifting, and bathing. On physical examination, forward flexion was to 15 degrees, extension was to 15 degrees, right and left lateral flexion were each to 10 degrees, and right and left lateral rotation were each to 10 degrees. He was unable to perform repetitive use testing due to pain. The range of motion movements were painful on active, passive, and/or repetitive use testing, and the pain contributed to functional loss or additional limitation of range of motion. There was pain with weight-bearing that contributed to functional loss or additional limitation of range of motion. There was tenderness to palpation of the lumbar spine at the right flank area. There was guarding of the thoracolumbar spine. Spinal contour was normal. Contributing factors of disability included less movement than normal, weakened movement, and pain on movement. Pain, weakness, fatigability, or incoordination significantly limited functional ability during flare-ups or when the joint was used repeatedly over a period of time; the functional loss consisted of decreased range of motion throughout and decreased functioning with lifting and walking. Muscle strength testing was 4/5 due to the back disability. Muscle atrophy was noted to both thighs. Deep tendon reflexes were normal. Sensation to light touch was decreased bilaterally at the thigh/knee (L3/4); sensory testing was otherwise normal. Straight leg raising was positive to both sides. Radiculopathy symptoms included moderate constant pain to both lower extremities and mild paresthesias and/or dysesthesias to both lower extremities; the assessment was moderate radiculopathy of both lower extremities with involvement of the sciatic nerve. There were no other objective neurologic abnormalities associated with a back condition. The Veteran had less than 1 week of incapacitating episodes over the previous 12 months due to IVDS of the thoracolumbar spine. The provider indicated that radiology studies showed multiple HNP (herniated nucleus pulposus) [note: the examination report does indicate when those studies or include the radiology report on which the diagnosis was based.] It was noted that the Veteran occasionally used a walker. On December 2019 VA examination, the Veteran reported chronic low back pain that limits his standing ability. He reported that the pain is dull and achy with occasional sharp stabbing pain, without radiation. He was not receiving current treatment. He did not report flare-ups or functional loss or impairment of the back. On physical examination, forward flexion was to 60 degrees, extension was to 20 degrees, right lateral flexion was to 25 degrees, left lateral flexion was to 20 degrees, and right and left lateral rotation were each to 20 degrees. The range of motion itself did not contribute to a functional loss. Pain was noted on forward flexion and extension but did not result in or cause functional loss. There was no evidence of pain with weight bearing or in non-weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the back. There was no additional loss of function or range of motion after repetitive use testing. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time or with flare-ups. There was no guarding or muscle spasm of the thoracolumbar spine. There were no additional factors contributing to disability. Muscle strength testing was normal and there was no muscle atrophy. Reflex testing and sensory testing were normal. Straight leg raising was negative bilaterally. He did not have radicular pain or any other signs or symptoms due to radiculopathy. The spine was not ankylosed. There were no other neurologic abnormalities or findings related to a thoracolumbar spine condition. The Veteran was not noted to have IVDS of the thoracolumbar spine. He did not use assistive devices. On February 2020 VA treatment, the Veteran complained of back pain described as constant and achy with intermittent sharp shooting pain. He denied difficulty with gait. On physical exam, there was no tenderness to palpation of the lumbar region and no point tenderness. He was able to flex forward and touch his knees. There was no paraspinous muscle spasm. Tenderness, more with extension than with flexion, was noted. He had limited range of motion with twist tilt due to pain. Based on this evidence, a September 2020 rating decision increased the initial rating for the Veteran's lumbar spine disability to 20 percent, effective July 19, 2012. The September 2020 rating decision also granted service connection for left lower extremity radiculopathy and right lower extremity radiculopathy, rated 20 percent each, effective October 4, 2019. August 2021 written argument by the Veteran's representative indicates the matter of the rating for the low back was rendered moot by the September 2020 rating decision. While that statement suggests the Veteran is satisfied with the ratings now assigned, it is not a clear expression of withdrawal of the appeal in this matter, and the Board proceeds with the analysis below. When evaluating a service-connected disability based on limitation of motion, the Board must take into consideration functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see Johnson v. Brown, 9 Vet. App. 7 (1996). A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Nonetheless, a rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). The VA Rating Schedule provides for the following ratings for spine disabilities, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. According to the General Rating Formula for Diseases and Injuries of the Spine (General Formula), the following ratings are to be assigned: [The ratings listed below apply to Codes 5235 through 5243 (unless a disability rated under Code 5243 is alternatively rated under the "Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes").] Under the General Formula, a 20 percent rating is warranted when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, with combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, with muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted when forward flexion of the thoracolumbar spine is 30 degrees or less; or, for favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. 38 C.F.R. § 4.71a and note 1 following the General Formula. If the service-connected spine disability includes IVDS, it may alternatively be rated under the Formula for Rating IVDS Based on Incapacitating Episodes. A 20 percent rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during a 12-month period. A 40 percent rating is warranted with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during a 12-month period. A 60 percent rating is warranted with incapacitating episodes having a total duration of at least 6 weeks during a 12-month period. Additional VA treatment records throughout show symptoms largely similar to those found on the VA examinations described above. At the outset, the Board notes that service connection has been established for separately rated neurological manifestations of both lower extremities, and that those ratings were not appealed and are not before the Board at this time. Other neurological manifestations are not shown or alleged, and further discussion of additional separate ratings for neurological manifestations is not necessary. The Board notes the October 2019 DBQ when a nurse practitioner noted forward flexion of the thoracolumbar spine of 15 degrees (and it was noted that repetitive testing could not be done due to reports of pain). However, on December 2019 VA examination (just two months later), forward flexion was to 60 degrees. Repetitive testing was done, and did not reveal further limitations; and each of the ranges of motion was significantly less limited on December 2019 VA examination than was reported on the October 2019 DBQ. There is no indication that the Veteran underwent any treatment or intervention for his lumbar spine disability between October 2019 and December 2019 to explain such discrepancies. In December 2019 he denied having had flare-ups and it was noted that he did not use assistive devices (while in October 2019 it was noted that he used a walker on occasion -with no further explanation). Treatment records in the file do no show spine limitations of the severity reported on October DBQ. Notably, on February 2020 VA treatment, the Veteran was able to flex forward and touch his knees, which is clearly inconsistent with forward flexion limited to 15 degrees, and more reasonably consistent with the 60 degrees of flexion, and other ranges of motion, found on December 2019 examination. As the provider of the October 2019 DBQ indicated no records were reviewed (expressly lack of familiarity with the Veteran's medical history), the report of the examination (completed for compensation purposes) merits only limited probative value, and is not accepted as evidence identifying a distinct period when symptoms of the disability warranted a higher rating. The reports of the VA examinations, the VA treatment records, and lay statements, overall, provide evidence against this claim, as they do not show that for any distinct period symptoms of the Veteran's lumbar spine disability included forward flexion of the thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine, or resulted in incapacitating episodes having a total duration of at least 4 but less than 6 weeks in a 12-month period (the criteria for a 40 percent rating). The criteria for a schedular rating in excess of 20 percent under the General Formula have not been met, and a higher rating is not warranted. Notably, the Veteran's representative has not proffered any argument regarding further increase in the rating following the September 2020 rating decision, and in August 2021 written argument suggested that the Veteran is satisfied with the rating now assigned. 3. Entitlement to a rating in excess of 10 percent for hypothyroidism is denied. On July 2013 VA examination, the Veteran's hypothyroidism was noted to require Synthroid daily for control. He had not undergone surgery, radioactive iodine treatment, or any other type of treatment. He did not have any residual endocrine dysfunction following treatment for a thyroid condition. He did not currently have any findings, signs or symptoms attributable to a hypothyroid condition. On physical exam, his eyes and neck were normal, and his pulse was regular. Reflex testing was normal. Based on this evidence, the August 2013 rating decision granted service connection for hypothyroidism, rated 10 percent, effective July 19, 2012. On August 2018 VA treatment, the Veteran reported that he had been hospitalized the previous week and indicated there were concerns with his thyroid. On March 2019 VA treatment, his Synthroid dosage was increased. At the September 2019 Board hearing, the Veteran testified that he currently has fatigability, constipation, and/or mental sluggishness due to his hypothyroidism. He testified that he has received extensive private treatment for fatigue over the previous two years, and sees his doctor about every two to three months. On December 2019 VA examination, it was noted that Veteran was continuing to receive treatment with Synthroid; the dosage was recently lowered as his TSH was at the low end. He had no current symptoms related to his thyroid condition. He had not undergone radioactive iodine treatment or any other type of treatment. He did not have any residual endocrine dysfunction following treatment for a thyroid condition. He did not currently have any findings, signs or symptoms attributable to a thyroid condition. He did not currently have any findings of thyroid enlargement. On physical exam, his eyes and neck were normal, and his pulse was regular. His blood pressure was 169/93. Reflex testing was normal. The Veteran's hypothyroidism is rated under Code 7903. A 10 percent rating is warranted when there is fatigability, or; continuous medication required for control. A 30 percent rating is warranted when there is fatigability, constipation, and mental sluggishness. A 60 percent rating is warranted when there is muscular weakness, mental disturbance, and weight gain. A 100 percent rating is warranted when there is cold intolerance, muscular weakness, cardiovascular involvement, bradycardia (less than 60 beats per minute), and sleepiness. 38 C.F.R. § 4.119. The reports of the VA examinations, the VA treatment records, and lay statements, overall, provide evidence against this claim, as the evidence does not show that the Veteran's hypothyroidism manifestations has met the criteria for a rating in excess of 10 percent. There is no evidence at any time that the hypothyroidism resulted in fatigability, constipation, and mental sluggishness, to meet or approximate the criteria for the next higher, 30 percent, rating. While he testified before the Board that he had fatigability, constipation, and mental sluggishness due to hypothyroidism, fatigability is encompassed by the criteria for a 10 percent rating, and constipation and mental sluggishness due to hypothyroidism were not noted on examinations before, or soon after, the hearing. Consequently, a rating for hypothyroidism in excess of 10 percent is not warranted. The preponderance of the evidence is against this claim; therefore, the appeal in the matter must be denied. 4. Entitlement to a compensable rating for GERD with hiatal hernia is denied. On July 2013 VA examination, the Veteran reported that he had developed symptoms of reflux that did not respond to medical therapy and required surgery. He reported having pyrosis (heartburn) approximately once weekly. His treatment plan did not include taking continuous medication. He did not have an esophageal stricture, spasm of the esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms related to GERD with hiatal hernia. Based on this evidence, the August 2013 rating decision granted service connection for GERD (with hiatal hernia), rated 0 percent, effective July 19, 2012. At the September 2019 Board hearing, the Veteran testified that he has acid reflux and regurgitation occasionally, which he treats with over-the-counter medication such as Pepto Bismol. On December 2019 VA examination, the Veteran was noted to have no current symptoms per the treatment records. His treatment plan did not include taking continuous medication. He did not have any signs or symptoms due to any esophageal condition including GERD. He did not have esophageal stricture, spasm of the esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms related to GERD with hiatal hernia. The Veteran's GERD with hiatal hernia is rated under Code 7346. A 30 percent rating is warranted when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. With two or more symptoms for the 30 percent rating of lesser severity, a 10 percent rating is warranted. 38 C.F.R. § 4.114. In every instance where the rating schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31. The reports of the VA examinations, the VA treatment records, and lay statements, overall, provide evidence against this claim, as the evidence does not show that the Veteran's GERD manifestations have met (or approximated) the criteria for a 30 percent, or higher, rating. On July 2013 VA examination, his only reported symptom was occasional pyrosis (heartburn, approximately weekly). At the Board hearing, he testified that he has acid reflux and regurgitation occasionally, treated with over-the-counter medication. On December 2019 VA examination, he did not have any signs or symptoms due to an esophageal condition including GERD. The findings do not meet or approximate the criteria for the next higher, 10 percent, rating. Consequently, a compensable rating for GERD with hiatal hernia is not warranted. The preponderance of the evidence is against this claim; therefore, the appeal in the matter must be denied. 5. Entitlement to a compensable rating for a left ear hearing loss is denied. On July 2013 VA examination, audiometry revealed that puretone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 LEFT 20 30 30 35 Speech discrimination was 96 percent in each ear. Based on this evidence, the August 2013 rating decision granted service connection for left ear hearing loss, rated 0 percent, effective July 19, 2012. On October 2019 private treatment audiometry, puretone thresholds were: HERTZ 1000 2000 3000 4000 LEFT 40 35 30 30 Speech discrimination was 100 percent in each ear. On December 2019 VA examination audiometry, puretone thresholds were: HERTZ 1000 2000 3000 4000 LEFT 35 45 45 45 Speech discrimination score was 94 percent in each ear. Ratings for hearing loss disability are determined by considering the puretone threshold average and speech discrimination percentage scores. 38 C.F.R. § 4.85(b), Table VI. Disability ratings are assigned by combining a level of hearing loss in each ear. 38 C.F.R. § 4.85(e), Table VII. When the puretone 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 (based on puretone thresholds, alone), whichever is more favorable. 38 C.F.R. § 4.86(a). Only left ear hearing loss is service connected (and for rating purposes right ear hearing acuity is considered Level I). Applying the results of the July 2013 VA examination to Table VI showed that the Veteran had Level I hearing acuity in each ear. Under Table VII, such hearing acuity warrants a 0 percent rating. The findings do not reflect an exceptional pattern of hearing loss, nor did the examiner indicate that speech recognition scores were unreliable; therefore, Table VIa is not for application. Applying the results of the October 2019 private evaluation to Table VI showed that the Veteran had Level I hearing acuity in each ear. Under Table VII, such acuity warrants a 0 percent rating. The findings do not reflect an exceptional pattern of hearing loss, nor did the examiner indicate that speech recognition scores were unreliable; therefore, Table VIa is not for application. Applying the results of the December 2019 VA examination to Table VI showed that the Veteran had Level I hearing acuity in each ear. Under Table VII, these hearing acuity warrants a 0 percent rating. The findings do not reflect an exceptional pattern of hearing loss, nor did the examiner indicate that speech recognition scores were unreliable; therefore, Table VIa is not for application. The Board finds no reason to question that the Veteran has some functional impairment due to hearing loss, but such impairment is contemplated by the 0 percent rating that has been assigned. There is no other medical record that provides a basis for rating the Veteran's hearing loss disability. Consequently, a compensable rating for the left ear hearing loss is not warranted. The preponderance of the evidence is against this claim; therefore, the appeal in the matter must be denied. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Schechner, 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.