Citation Nr: 21063559 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 16-07 103 DATE: October 14, 2021 ORDER Entitlement to service connection for erectile dysfunction is granted. Entitlement to a disability rating in excess of 30 percent for post-traumatic stress disorder (PTSD) prior to April 21, 2015 is denied. Entitlement to a disability rating in excess of 50 percent for post-traumatic stress disorder (PTSD) from April 21, 2015 to June 16, 2020 is denied. Entitlement to a compensable disability rating for bilateral hearing loss is denied. REMANDED Entitlement to a disability rating in excess of 10 percent for peripheral neuropathy of the left shoulder is remanded. Entitlement to a disability rating in excess of 10 percent for peripheral sensory neuropathy of the right low back is remanded. Entitlement to a total disability rating based on individual unemployability due to a service-connected disability (TDIU) prior to September 14, 2019 is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, his erectile dysfunction is at least as likely as not related to his service-connected cardiac condition or the medication used to treat the cardiac condition. 2. Prior to April 21, 2015 the severity, frequency, and duration of the Veteran's symptoms are most closely approximate to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 3. From April 21, 2015 to June 16, 2020 the severity, frequency, and duration of the Veteran's symptoms are most closely approximate to occupational and social impairment with reduced reliability and productivity. 4. The Veteran's bilateral hearing loss was manifested by hearing impairment no worse than Level II in the right ear and Level II in the left ear. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for erectile dysfunction have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to a disability rating in excess of 30 percent for post-traumatic stress disorder (PTSD) prior to April 21, 2015 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 3. The criteria for entitlement to a disability rating in excess of 50 percent for post-traumatic stress disorder (PTSD) from April 21, 2015 to June 16, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 4. The criteria for entitlement to a compensable disability rating for bilateral hearing loss have not been met. 38 U.S.C. § 1155; 38C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.27, 4.85, 4.86, Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1965 to July 1967, to include verified service the Republic of Vietnam from June 1966 to July 1967. This matter is before the Board of Veterans' Appeals (Board) on appeal of the March 2014 and May 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a March 2019 videoconference hearing before the undersigned Veterans Law Judge. A copy of that transcript is of record. In August 2019, the Board remanded this appeal for more development. The Board finds that the Regional Office (RO) substantially complied with the Board's remand instructions and an additional remand to comply with the Board's directives is not required. See Stegall v. West, 11 Vet. App. 268 (1998). Neither the Veteran nor his representative has raised any issues with regard to the duty to notify or duty to assist as they pertain to the issues considered in this decision. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show with respect to the issues denied in this decision. The Veteran should not assume that evidence that is not explicitly discussed in this decision has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). 1. Entitlement to service connection for erectile dysfunction In a December 2014 statement, the Veteran indicated he was seeking service connection for erectile dysfunction due to exposure to herbicide agents, such as Agent Orange. In a separate December 2014 statement, he indicated his erectile dysfunction was secondary to his service-connected PTSD, to include psychiatric medication for that condition. At his hearing before the Board, the Veteran testified that he had experienced erectile dysfunction for approximately 25 years and that it was getting worse rather than better. He implied his erectile dysfunction was secondary to medication he took for his service-connected disabilities (specifically pain medication for physical disabilities and psychiatric medication for his PTSD). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran has a current disability that is related to his active military service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The Veteran's June 2021 male reproductive VA examination shows that the Veteran has a current diagnosis of erectile dysfunction. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of and against the claim. The May 2015 VA male reproductive examination found the Veteran did not have a diagnosis of erectile dysfunction. However, the Veteran has reported at VA appointments and testified at his hearing before the Board that he experiences erectile dysfunction. The Board finds that the Veteran, as a lay person, is competent to report that he experiences erectile dysfunction. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In June 2021, the Veteran was afforded a male reproductive VA examination. The examiner indicated that the Veteran has been diagnosed with erectile dysfunction. The Veteran reported that he started to experience erectile dysfunction in 2017 and it became more problematic over the last 5 years. The Veteran reported that since he has received treatment for his diabetes his condition has improved slightly. The examiner indicated that the Veteran's erectile dysfunction does not require continuous medication. The examiner opined that the Veteran's erectile dysfunction (ED) was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As to the rationale, the examiner explained that the Veteran has multiple current medical conditions that are well-known to cause ED and these are the most likely cause. However, PTSD and exposure to herbicides in Vietnam are very unlikely to be contributing factors to the Veteran's ED that started in 2017. However, service connection may be also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current erectile dysfunction disability that is proximately due to or the result of or was aggravated beyond its natural progress by a service-connected disability. The Board concludes that, the Veteran has a current erectile dysfunction disability, and resolving reasonable doubt in the Veteran's favor, the preponderance of the evidence supports finding that the Veteran's erectile dysfunction is proximately due to or the result of or aggravated beyond its natural progression by the Veteran's service-connected disabilities. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). In the June 2021 male reproductive VA examination, the examiner opined that the Veteran's erectile dysfunction was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition or pain medications. As to the rationale, the examiner explained that the erectile dysfunction and pain medications for his service-connected disabilities are not medically related. Specifically, "the erectile dysfunction is a separate entity entirely from the pain medication for his service-connected disabilities and unrelated to it. A thorough review of medical literature failed to demonstrate a causal relationship." As to aggravation, the examiner opined that the Veteran's erectile dysfunction was not at least as likely as not aggravated beyond its natural progression by a service-connected condition. The examiner explained that there were many years that passed by between the herbicide exposure/PTSD, and the development of ED in 2017. The examiner was unable to conclude that herbicide exposure/PTSD could cause an aggravation of natural progression when 50 years have passed between exposure and disease onset. However, the examiner also explained that the etiology of the Veteran's erectile dysfunction had "multifactorial causes, most likely diabetes, obesity, smoking history, cardiac history with medication side effects from needed cardiac meds." Then, in the July 2021 rating decision, the Veteran was awarded service connection for his coronary artery disease with valve replacement surgery (valvular heart disease) associated with herbicide exposure. Thus, resolving reasonable doubt in the Veteran's favor the preponderance of the evidence shows that the Veteran's health conditions including the Veteran's service-connected cardiac condition, and the cardiac medications required to treat the Veteran are likely causes of the Veteran's erectile dysfunction. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current erectile dysfunction disability is related to service. Specifically, secondary to the Veteran's cardiac disability and the medications used to treat the disability. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for erectile dysfunction is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). 2. Entitlement to a disability rating in excess of 30 percent for post-traumatic stress disorder (PTSD) prior to April 21, 2015 is denied. 3. Entitlement to a disability rating in excess of 50 percent for post-traumatic stress disorder (PTSD) from April 21, 2015 to June 16, 2020 is denied. The Veteran seeks a higher rating for his PTSD disability. The Veteran stated that at least 50 percent is warranted as his condition has become progressively worse. See January 2015 Notice of Disagreement, July 2013 Statement in Support of Claim. The applicable rating period is from July 29, 2012, one year prior to the receipt of the claim, through the present. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994) (discussing the one-year "look-back" period for non-initial increased rating claims). In the January 2016 rating decision, the Veteran was awarded a 50 percent disability rating for his PTSD, effective April 21, 2015. In the July 2021 rating decision, the Veteran was awarded a 100 percent disability rating for his PTSD effective June 16, 2020. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. When determining the appropriate disability rating to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. Vazquez-Claudio, 713 F.3d at 118; Mauerhan, 16 Vet. App. at 442. Because the use of the term "such as" in the rating criteria demonstrates that the listed symptoms are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the General Rating Formula for Mental Disorders are also associated with objectively observable symptomatology, and the plain language of the regulation makes it clear that a Veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency and duration. Vazquez-Claudio, 713 F.3d at 118. The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 70 percent or higher. The Board concludes that the Veteran's symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher prior to June 16, 2020. Prior to April 21, 2015 the Veteran's symptoms more closely approximated the symptoms associated with a 30 percent rating. From April 21, 2015 to June 16, 2020, the Veteran's symptoms more closely approximated the symptoms associated with a 50 percent rating and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. The Veteran received ongoing treatment for his PTSD disability throughout the appeal period. In July 2013 and December 2013, the Veteran's spouse submitted statements in support of the Veteran's claim. She stated that they have been married for 46 years. She stated that the Veteran would not discuss what happened during the war. The Veteran has had trouble sleeping for years and the slightest noise wakes him up. He has night sweats and bad dreams. She had to take him to the emergency room while on a family trip because he had a panic attack. The Veteran's spouse has been affected by the Veteran's problems and has taken anti-anxiety medications. She stated that the Veteran always sits with his back against the wall and does not trust anyone. The Veteran does not go to movie theaters because he does not feel comfortable while in the dark and he is not in control of his surroundings. The Veteran also avoids malls due the crowds. In December 2013, the Veteran was afforded a VA examination for his PTSD disability. The examiner opined that the Veteran's symptoms manifest as an occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The Veteran reported getting frustrated more easily after watching war on TV. He reported not being able to sleep through the night. He lacks trust in people and prefers to be home alone. The Veteran retired working as a butcher and now works part time as a building and grounds attendant. The Veteran's symptoms include depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; and flattened affect. In April 2015, the Veteran was afforded a VA examination for his PTSD disability. The examiner opined that the Veteran's symptoms manifest as occupational and social impairment with reduced reliability and productivity. The Veteran reported that he has been married for 47 years and has good support from his family. The Veteran reported that he retired as a butcher at a supermarket and is now working part time for the Department of Public works. The examiner indicated that the Veteran's symptoms included hypervigilance; exaggerated startle response; problems with concentration; depressed mood; chronic sleep impairment; flattened affect; disturbances of motivation and mood; difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner concluded by stating that, "the Veteran has intrusive thoughts of military service. The Veteran also has feelings of isolation from significant others and often prefers to be alone. When the Veteran is not busy with an activity (such as work), his memories of military service are more intense and distressing." In a letter dated March 2017, the Veteran's counselor submitted a letter on his behalf. The counselor indicated that the Veteran has been attending therapy sessions to address his PTSD related symptoms from December 2014 to the present. The provider indicated that the Veteran was forced to cease working in August 2015. The Veteran's condition became too intensified to be around other people, making it impossible to execute his daily duties on the job. The Veteran's treatment notes from Vet Center demonstrate that the Veteran consistently reported intrusive memories, anxiety, anger, and depression. He denied suicidal or homicidal ideation. The Veteran reported that as he is getting older, he had more difficulty being around large crowds. Specifically, when his family came over for Christmas break it was just too much to handle. The Veteran reported having trust issues. In March 2019, the Veteran testified at a Board hearing. The Veteran testified that he still has anxiety, and he checks the perimeter, and no longer works. He testified that he felt on edge too much with people and he worked in a situation where that was not a good thing. He testified he tried various employment opportunities, but he had the same result. The Veteran testified that he does not like crowds and tries to stay to himself as much as possible. He testified that he makes sure he keeps his back to the wall, and not to the front door because of his insecurities. In June 2020, the Veteran was afforded a VA examination for his PTSD. The examiner noted that the Veteran is diagnosed with PTSD including anxiety, and that the Veteran has headaches that are considered a manifestation of his anxiety. The examiner indicated that the Veteran's PTSD and other service-connected conditions would preclude him from securing and maintaining employment. Thus, the examiner opined, that the Veteran's symptoms manifest as total occupational and social impairment. The examiner explained that the Veteran continues to have PTSD symptoms despite consistent treatment interventions for his PTSD. The examiner stated that there has been no work activity for over 7 years. The Veteran's symptoms include depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; and neglect of personal appearance and hygiene. Prior to April 21, 2015, the Veteran's PTSD manifested in symptoms associated with a 30 percent rating. The Veteran's symptoms included, chronic sleep impairment; suspiciousness; anxiety; depressed mood; mild memory loss, such as forgetting names, directions or recent events; and flattened affect. Beyond the flattened affect all of the Veteran's symptoms prior to April 21, 2015 are most closely approximate to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Board does not find the severity, frequency, and duration of the Veteran's flattened affect to rise to the level of an occupational and social impairment with reduced reliability and productivity. From April 21, 2015 to June 16, 2020 the Veteran's PTSD manifested in symptoms associated with a 50 percent rating. The Veteran's symptoms include hypervigilance; exaggerated startle response; problems with concentration; anxiety; depressed mood; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; disturbances of motivation and mood; and difficulty in adapting to stressful circumstances, including work or a worklike setting. The Board acknowledges that in July 2015 the Veteran resigned from his position with the Department of Public Works due to his disabilities. The Board also acknowledges that the Veteran's counselor indicated that the Veteran stopped working because the Veteran's condition became "too intensified to be around other people," around August 2015. However, a few months prior to that the April 2015 VA examiner indicated that when the Veteran is not busy with an activity (such as work), his memories of military service are more intense and distressing. This suggests that the Veteran does better when he is working than when he is not. The Board finds that although the Veteran may have had difficulties from time to time working, his occupational and social impairment do not rise to the level of having deficiencies in most areas. He has a good relationship with his wife and family. He has consistently denied having suicidal or homicidal ideation. His examiners have indicated that he is oriented with reality and his speech is congruent with speech content. There is no evidence that the Veteran has impulse control problems, near continuous panic attacks, or an inability to establish and maintain effective relationships. The Board carefully considered the Veteran's counselors statements from Vet Center, but the symptoms listed were not contemplated by a rating higher than 50 percent. The evidence in the record did not support the counselor's assertions. The only factor that could be considered under the 70 percent rating is the Veteran's potential problems in a work setting. The record does not demonstrate that the Veteran was fired from any position or was disciplined. The Veteran testified that he was on edge and he had disagreements. The Board acknowledges that the Veteran has had difficulties with working, but the severity, frequency, and duration of these difficulties does not rise to the level of having deficiencies in most areas. The Board also acknowledges that the Veteran's condition has progressively become worse. However, the evidence does not support a higher rating than 50 percent prior to June 16, 2020. The Board also acknowledges that the Veteran was awarded a TDIU effective September 14, 2019 for all of his service-connected disabilities. However, the Board does not find that there is evidence in the record that supports that the Veteran's PTSD symptoms manifest to a 70 percent or higher level prior to June 16, 2020. Therefore, the Board finds that the criteria for a disability rating in excess of 30 percent prior to April 21, 2015 is not warranted. The Board finds that a disability rating in excess of 50 percent prior to June 16, 2020 is not warranted. As the preponderance of the evidence is against the assignment of a higher rating, the benefit-of-the-doubt doctrine is not for application, and the appeal must be denied. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to a compensable disability rating for bilateral hearing loss The Veteran seeks a compensability disability rating for his bilateral hearing loss disability, as he contends his hearing loss has become progressively worse. See July 2013 Statement in Support of Claim. The applicable rating period is from July 29, 2012, one year prior to the receipt of the claim, through the present. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994) (discussing the one-year "look-back" period for non-initial increased rating claims). The VA rating scheme for the evaluation of hearing loss provides ratings from noncompensable to 100 percent based on the results of controlled speech discrimination tests together with the results of puretone audiometry tests which average puretone thresholds at 1000, 2000, 3000 and 4000 Hertz. 38 C.F.R. § 4.85. The evaluation of hearing impairment applies a formula which is essentially a mechanical application of the VA Schedule for Rating Disabilities to numeric designations after audiology evaluations are rendered. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. 38 C.F.R.§ 4.85(a). Using Table VI in 38 C.F.R. § 4.85, the puretone average and speech recognition score are combined to give each ear a numeric designation for use on Table VII to determine the correct disability level. Alternatively, Table VIA uses only the puretone averages to give each ear a numeric designation. The regulations have two provisions for evaluating veterans with certain patterns of hearing impairment that cannot always be accurately assessed under § 4.85 because the speech discrimination test may not reflect the severity of communicative functioning that veterans experience. 38 C.F.R. § 4.86(a) provides that if puretone thresholds in the specified frequencies of 1000, 2000, 3000, and 4000 Hertz are each 55 decibels or more, an evaluation can be based either on Table VI or Table VIA, whichever results in a higher evaluation. This provision corrects the fact that with a 55-decibel threshold level (the level at which speech becomes essentially inaudible) the high level of amplification needed to attempt to conduct a speech discrimination test would be painful to most people, and speech discrimination tests may therefore not be possible or reliable. See 64 Fed. Reg. 25209 (May 11, 1999). Additionally, 38 C.F.R. § 4.86(b) provides that if the puretone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz, an evaluation can be based on either Table VI or Table VIA, whichever results in a higher numeric designation, and that designation will then be elevated to the next higher Roman numeral. This provision compensates for a pattern of hearing impairment that is an extreme handicap in the presence of any environmental noise, and a speech discrimination test conducted in a quiet room with amplification of sound does not always reflect the extent of impairment experienced in the ordinary environment. If the use of the word recognition score is not appropriate for the Veteran because of language difficulties, cognitive problems, inconsistent word recognition scores, etc., that make combined use of puretone average and word recognition scores inappropriate, the use of Table VIa is warranted. In December 2013, the Veteran received a VA examination for his hearing impairment. The audiological evaluation revealed puretone thresholds, in decibels, as follows: HERTZ 1000 2000 3000 4000 AVG RIGHT 25 20 20 20 21 LEFT 25 20 30 45 30 The speech recognition score was 98 percent in the right ear and 98 in the left ear. Utilizing Table VI, the combination of the 21 dB puretone threshold average and the 99 percent speech discrimination for the right ear results in the designation of a Roman numeral I. The combination of the 30 dB puretone threshold average and the 98 percent speech discrimination for the left ear results in the designation of a Roman numeral I. When the Roman numerals I and I are applied to Table VII, the resulting percentage evaluation is zero percent. In January 2015, the Veteran's private treatment provider submitted a letter that indicated that the Veteran had significant permanent hearing loss in both ears. The examiner provided audiometric tests. Some of the results of the audiometric tests are in graphical form, but the Board may interpret graphical representations of audiometric data and convert them to numerical data in its role as a fact finder, as long as the graphical representations are clear. Kelly v. Brown, 7 Vet. App. 471 (1995). The Board finds that the graphical representations in this case are clear, and the Board will therefore interpret them. HERTZ 1000 2000 3000 4000 AVG RIGHT 35 40 45 45 41.25 LEFT 35 40 50 50 43.75 The speech recognition score was 92 percent in the right ear and 88 in the left ear. Utilizing Table VI, the combination of the 41.25 dB puretone threshold average and the 92 percent speech discrimination for the right ear results in the designation of a Roman numeral I. The combination of the 43.75 dB puretone threshold average and the 88 percent speech discrimination for the left ear results in the designation of a Roman numeral II. When the Roman numerals I and II are applied to Table VII, the resulting percentage evaluation is zero percent. In January 2016, the Veteran received a VA examination for his hearing impairment. The Audiological evaluation revealed puretone thresholds, in decibels, as follows: HERTZ 1000 2000 3000 4000 AVG RIGHT 25 20 25 20 23 LEFT 25 25 35 40 31 The speech recognition score was 96 percent in the right ear and 94 in the left ear. Utilizing Table VI, the combination of the 23 dB puretone threshold average and the 96 percent speech discrimination for the right ear results in the designation of a Roman numeral I. The combination of the 31 dB puretone threshold average and the 94 percent speech discrimination for the left ear results in the designation of a Roman numeral I. When the Roman numerals I and I are applied to Table VII, the resulting percentage evaluation is zero percent. In March 2019, the Veteran testified at a Board hearing. The Veteran testified that his hearing aids were working pretty well. The Veteran testified that his doctor told him his hearing has worsened. In March 2021, the Veteran received a VA examination for his hearing impairment. The audiological evaluation revealed puretone thresholds, in decibels, as follows: HERTZ 1000 2000 3000 4000 AVG RIGHT 45 55 60 60 55 LEFT 35 45 60 65 51 The speech recognition score was 88 percent in the right ear and 84 in the left ear. Utilizing Table VI, the combination of the 55 dB puretone threshold average and the 88 percent speech discrimination for the right ear results in the designation of a Roman numeral II. The combination of the 51 dB puretone threshold average and the 84 percent speech discrimination for the left ear results in the designation of a Roman numeral II. When the Roman numerals II and II are applied to Table VII, the resulting percentage evaluation is zero percent. The Veteran has argued that his hearing loss is more severe than was reflected by his assigned evaluations. Although the Veteran is competent to attest to his observations and laypeople may, in some circumstances, opine on questions of diagnosis and etiology, in this case, the Veteran is not competent to diagnose himself with a particular level of hearing impairment. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). Specifically, the Veteran is competent to describe observable symptoms and impairments he experiences (e.g., diminished hearing and the use of hearing aids). However, as a lay person, he is unable to provide competent evidence as to the audiometry or measured level of his hearing loss to support a higher disability rating. The Board acknowledges the Veteran's complaints regarding the impact of his service-connected bilateral hearing loss on his daily activities. However, the assignment of disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometry evaluations are made. The Board also notes that the rating criteria do not provide for a compensable rating based on the use of hearing aids. There is no doubt as to the proper evaluations to assign, and thus no doubt to resolve in favor of the claimant. Lendenmann, 3 Vet. App. 345; 38 C.F.R. § 4.85, Tables VI, VIA, VII, DC 6100. The Board is bound by applicable laws and regulations promulgated by the VA. 38 U.S.C. § 7104(c); 38 C.F.R. § 20.101(a). Consideration of factors wholly outside the schedular rating criteria would constitute error as a matter of law. Massey v. Brown, 7 Vet. App. 204 (1994); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). In conclusion, the preponderance of the most probative evidence weighs against entitlement to a compensable rating for bilateral hearing loss. In reaching this conclusion, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the claim, the doctrine does not apply, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to a disability rating in excess of 10 percent for peripheral neuropathy of the left shoulder is remanded. 2. Entitlement to a disability rating in excess of 10 percent for peripheral sensory neuropathy of the right back is remanded. The Veteran seeks a higher disability rating for his peripheral neuropathy of the left shoulder, and peripheral sensory neuropathy of the right back conditions. In June 2021 the Veteran was afforded a VA examination for his peripheral nerve conditions. The examiner noted that the onset of these conditions occurred in 2018-2019 and that the Veteran reported some mild numbness in his feet and in several fingers not severe in intensity. The symptoms included mild numbness in all extremities upper and lower. The examiner noted that EMG studies were not performed. The examiner stated that the physical examination was normal but that the Veteran has not had an EMG testing to help confirm the Veteran's peripheral nerve condition and its severity. Thus, the Board finds that a remand is necessary to allow the Veteran the opportunity to obtain EMG testing prior to adjudicating this matter. 3. Entitlement to a total disability rating based on individual unemployability due to a service-connected disability (TDIU) prior to September 14, 2019 is remanded A decision on the other remanded issues could significantly impact a decision on the issue of entitlement to a TDIU. Therefore, the issues are inextricably intertwined. A remand of the claim for entitlement to a TDIU is required. The matter is REMANDED for the following action: 1. Schedule to Veteran the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected peripheral nerve conditions in his left shoulder and back. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner should also perform an EMG to determine the severity of the Veteran's peripheral nerve conditions in his left shoulder and back. 2. Then, the Veteran's claims must be readjudicated. If any benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative must be provided a Supplemental Statement of the Case and be given an adequate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Quist 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.