Citation Nr: 21069872 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 15-42 777A DATE: November 22, 2021 ORDER 1. Entitlement to service connection for left lower extremity radiculopathy, to include as secondary to service-connected bilateral pes planus is denied. 2. Entitlement to initial compensable rating for bilateral sensorineural hearing loss, to include on an extraschedular basis is denied. FINDINGS OF FACT 1. Left lower extremity radiculopathy did not have its onset in service, was not manifested to a compensable degree within one year of service discharge, and is not otherwise related to service. Left lower extremity radiculopathy is not proximately due to or aggravated by service-connected bilateral pes planus. 2. For the entire period on appeal, the Veteran's bilateral hearing loss disability has been manifested by no worse than Level I hearing loss in the right ear and Level I hearing loss in the left ear. The Veteran's hearing loss symptoms are contemplated by the rating criteria. CONCLUSIONS OF LAW 1. The criteria for service connection for left lower extremity radiculopathy, to include as secondary to service-connected bilateral pes planus, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a), 3.310. 2. The criteria for an initial compensable rating for bilateral sensorineural hearing loss, to include on an extraschedular basis, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.85, 4.86, DC 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1980 to August 1983. The Veteran also had a subsequent period of ACDUTRA from August 9, 1984 to August 22, 1984. In a June 2019 decision, the Board denied service connection for left leg pain with muscle spasms and an initial compensable rating for bilateral hearing loss. Thereafter, the Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2020 Joint Motion for Partial Remand (JMPR), the Veteran and the Secretary of VA agreed to vacate portions of the Board's decision regarding the denial of service connection for left leg pain and muscle spasms and the denial for a compensable rating for hearing loss. The case was remanded to the Board for additional development in compliance with the instructions in the JMPR. The issue of entitlement to service connection for left leg pain and muscle spasms has been recharacterized as listed above. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as radiculopathy, which is an organic disease of the nervous system, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. Id. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. 1. Entitlement to service connection for left lower extremity radiculopathy, to include as secondary to service-connected bilateral pes planus In an October 2021 statement, the Veteran contended that the June 2021 VA opinion was inadequate for failing to sufficiently discuss causation and aggravation as separate concepts. The June 2021 VA opinion includes a discussion of whether the Veteran's left lower extremity radiculopathy is directly or indirectly aggravated by service-connected bilateral pes planus, and notes the examiner's review of the Veteran's treatment records, which the examiner delineated by date of upload into the Veteran's claims folder. The June 2021 VA examiner's opinion also includes an analysis as to whether the Veteran's claimed disability was caused by his service-connected disability. Specifically, the examiner concluded there was no "pathophysiologic mechanism" in the medical literature and known medical principles that would explain a causal relationship between the two conditions. This conclusion would not require the examiner to treat causation and aggravation as separate concepts. For example, in El-Amin v. Shinseki, 26 Vet. App. 136 (2013), which was cited to by the Veteran's representative in the October 2021 submission, the Court found that the examiner's opinion that it was "more likely than not that the veteran's alcohol abuse was related to factors other than the veteran's post-traumatic stress disorder" (PTSD) did not rule out the possibility that the veteran's service-connected PTSD aggravated his alcohol abuse to some degree. Id. In contrast, here, the June 2021 examiner opined that there was no "pathophysiologic mechanism" in the medical literature and known medical principles that would explain a causal relationship between the two conditions. Because the examiner clearly opined that there was no medical relationship between the service-connected bilateral pes planus and left lower extremity radiculopathy, the examiner's statement, unlike that of the examiner in El-Amin, rules out the possibility that the service-connected disability may aggravate to some degree the non-service-connected disability. Thus, the Board finds that the examiner's opinion addressed both causation and aggravation and is, therefore, probative regarding whether the service-connected disability caused or aggravated the left lower extremity radiculopathy. The June 2021 VA opinion is adequate, and VA has fulfilled the duty to assist. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of service connection for left lower extremity radiculopathy on a direct or secondary basis. The reasons follow. The Veteran has been diagnosed with left lower extremity radiculopathy, and thus there is evidence of a current disability. For example, in the April 2021 VA examination the Veteran was diagnosed with left lower extremity radiculopathy. Thus, the facts establish that the first element of a service-connection claim is met. As to an in-service disease or injury, the evidence does not support a finding of a disease or injury in service indicative of left lower extremity radiculopathy. The service treatment records (STRs) show that the Veteran was found to have normal clinical evaluations of the lower extremities and neurological system in a Report of Medical Examination from August 1983 at service separation. This record also noted abnormal findings in the Veteran's feet and documented the Veteran's pes planus only. In a May 1984 Report of Medical Examination at enlistment into reserve duty, it was noted that the Veteran again had normal clinical evaluations of the lower extremities and neurological system. The examiner had checked an "abnormal" finding for the lower extremities, but then it was crossed out and initialed by the examiner, and the examiner documented a normal clinical evaluation of the lower extremities. Like the August 1983 Report of Medical Examination, the examiner again found that clinical evaluation of the feet was abnormal and documented pes planus. The fact that these two examinations, one performed at service discharge and one performed the following year, showed normal clinical evaluations of the lower extremities and the neurological system is evidence against a finding of left lower extremity radiculopathy during service. In PULHES evaluations from February 1983 and October 1983, the Veteran was found to have scores of T3 for "L." The "L" stands for "Lower Extremities." This factor concerns the feet, legs, pelvic girdle, lower back musculature and lower spine (lower lumbar and sacral) in regard to strength, range of motion, and general efficiency. An individual having a numerical designation of "3" under "L" is considered to possess a defect(s) causing moderate interference with function, yet capable of strong effort for short periods, and is capable of all basic work commensurate with grade and position. The "T" represents a temporary score. However, in both records, the score was directly attributed to the Veteran's painful feet and pes planus, but not to a problem with the Veteran's legs. Accordingly, these records do not support a finding of left lower extremity radiculopathy during service. In the Report of Medical History from May 1984 at enlistment into reserve duty, the Veteran denied a history of cramps in legs, lameness, neuritis, and paralysis, which further supports the finding that he was not experiencing radiculopathy in the left lower extremity during service or soon after service. Further, when reporting his symptoms related to the left lower extremity, the Veteran has not alleged that the symptoms began during service. Accordingly, for all of these reasons, the Board finds the preponderance of the evidence is against a finding of complaints or symptoms related to left lower extremity radiculopathy during service, and the in-service disease or injury element is not met. The preponderance of the evidence is also against a nexus between left lower extremity radiculopathy and service. For example, in the April 2021 VA examination report, the examiner opined that the Veteran's left lower extremity radiculopathy is less likely than not incurred in or otherwise related to service. The examiner explained that the Veteran's service records do not support problems with the Veteran's left lower extremity or radiculopathy. The examiner noted that the service records are absent for complaints of radicular pain. The examiner discussed that the Veteran's August 1980 and May 1984 Reports of Medical Examination showed normal findings for the Veteran's spine, lower extremities, and neurological evaluations. The examiner also noted that the Veteran denied a history of bone joint or deformity and denied a history trick or locked knee in a Report of Medical History from May 1984. The examiner noted that the Veteran had no findings of radiculopathy in an October 2017 VA diagnostic record. The examiner opined that the Veteran's lower left extremity radiculopathy is most likely due to the degenerative changes in the lumbar spine as shown in x-rays from October 2017. The Board notes the Veteran is not service connected for a lumbar spine disability. In light of the VA examiner's discussion of the Veteran's service records, including the Veteran's denial of a history of symptoms in close proximity to service, the analysis of the post-service medical history, and the discussion of the likely etiology of the Veteran's disability, the Board affords this opinion high probative value and finds that it establishes that left lower extremity radiculopathy did not have its onset in service and is not otherwise related to service. At the present time, there is no competent evidence of a nexus between the post-service diagnosis of radiculopathy in the left lower extremity and service to weigh against this opinion. As to secondary service connection, the preponderance of the evidence is also against a finding that the Veteran's left lower extremity radiculopathy is caused or aggravated by the service-connected bilateral pes planus. In the June 2021 VA opinion, the examiner opined that the Veteran's left lower extremity radiculopathy is not directly or indirectly aggravated by the service-connected bilateral pes planus. The examiner provided the rationale that there is no plausible pathophysiologic mechanism discussed in the medical literature and known medical principles that would explain a causal relationship between these conditions. The examiner noted that the Veteran has documented lumbar degenerative disc disease and opined that it is the cause of the left leg radiculopathy. The examiner provided the rationale that the Veteran's treatment records between 2013 and 2021, spanning an eight-year period, do not support that bilateral pes planus directly or indirectly aggravated the Veteran's left leg radiculopathy. The Board has already explained above why the June 2021 examiner's opinion is sufficient to address both causation and aggravation. As the June 2021 VA opinion is based upon a review of the Veteran's treatment records, the specific facts in the Veteran's case, medical principles, and a review of medical literature, and provides the likely etiology for the Veteran's disability, the Board affords this opinion high probative value and finds that it establishes that left lower extremity radiculopathy is not caused or aggravated by the service-connected bilateral pes planus. At the present time, there is no competent evidence of a nexus between the post-service diagnosis of radiculopathy in the left lower extremity and the service-connected disability to weigh against this opinion. As to presumptive service connection for a chronic disease, the Board finds that the Veteran did not incur a disease or injury related to his current left lower extremity radiculopathy in service and that his left lower extremity radiculopathy did not manifest during service or within one year of separation from service. Furthermore, the evidence of record does not demonstrate that the Veteran's symptoms have been continuous since separation from service. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). There were no complaints, diagnosis, or treatment for this disorder for more than 20 years following service discharge until the Veteran first sought service connection for this disability in August 2012. Even though the Veteran sought treatment for right lower extremity symptoms in 2010, he was not reporting left lower extremity symptoms. For example, an August 12, 2010 VA treatment record shows that the Veteran complained of right sciatica. A November 2010 VA treatment record confirms this fact, as the examiner wrote, "Symptoms: Pain is increasing to the right leg having difficulty walking and sitting for long period of time. Vet[eran] has history of Sciatica (See note August 12, 2010)." (Italics added.) Thus, in 2010, the Veteran was reporting sciatica in his right lower extremity but not his left lower extremity, which the Board finds is evidence against left sciatica manifesting at that time, which would be evidence against ongoing symptoms since service discharge. The Veteran was not diagnosed with left lower extremity radiculopathy until April 2021, which is more than 35 years following service discharge. The absence of post-service complaints, findings, diagnosis, or treatment for decades after service discharge is one factor that tends to weigh against a finding of continuous symptoms since separation from service. The Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence. A prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. While the Veteran alleges that the left lower extremity radiculopathy is related to service or his service-connected bilateral pes planus, he is not competent to attribute the left lower extremity radiculopathy to service or to a service-connected disability, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's opinion is nonprobative evidence. At the present time, there is no competent evidence of a nexus between the left lower extremity radiculopathy and service and the service-connected disability to weigh against the April 2021 and June 2021 negative opinions , and the nexus element of a service-connection claim based on direct, presumptive, and secondary theories of entitlement is not met. In sum, for all the reasons laid out above, the Board concludes that the preponderance of the evidence of record is against the Veteran's claim for service connection for left lower extremity radiculopathy on direct, presumptive, and secondary bases. The benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107(b) is not applicable, as there is no approximate balance of evidence. Increased Rating In evaluating service-connected hearing loss, disability ratings are derived from mechanical application of the rating schedule to numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity, as measured by a controlled speech discrimination test (Maryland CNC) and the average hearing threshold, as measured by puretone audiometric tests at the frequencies of 1000, 2000, 3000 and 4000 Hertz. The rating schedule establishes eleven auditory acuity levels designated from Level I, for essentially normal hearing acuity, through level XI for profound deafness. 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. Examinations will be conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). Under 38 C.F.R. § 4.85, Table VI (Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination) is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination (horizontal rows) and the puretone threshold average (vertical columns). The Roman numeral designation is located at the point where the percentage of speech discrimination and puretone average intersect. 38 C.F.R. § 4.85(b). The puretone threshold average is the sum of the puretone thresholds at 1000, 2000, 3000 and 4000 Hertz, divided by 4. This average is used in all cases to determine the Roman numeral designation for hearing impairment. 38 C.F.R. § 4.85(d). Under 38 C.F.R. § 4.86(a), 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, whichever results in the higher numeral. Each ear will be evaluated separately. 2. Entitlement to initial compensable rating for bilateral sensorineural hearing loss In the June 2013 rating decision currently on appeal, the Veteran was granted service connection for hearing loss and assigned a noncompensable rating effective August 21, 2012. In a June 2019 decision, the Board denied an initial compensable rating for bilateral hearing loss. In the June 2020 JMPR, the parties agreed to have the denial for a compensable rating for hearing loss vacated and remanded to the Board. In a January 2021 Board decision, the claim was remanded to afford the Veteran a new VA examination. In an August 2021 rating decision, the issue was recharacterized as bilateral sensorineural hearing loss, and the noncompensable rating was continued. (Previously, the AOJ had characterized the service-connected disability as "hearing loss" without specifying whether it was unilateral or bilateral. The August 2021 rating decision made it clear that the Veteran's service-connected disability involved bilateral hearing loss.) The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of an initial compensable rating for bilateral sensorineural hearing loss. The reasons follow. On the audiological evaluation in May 2013, pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average Maryland CNC RIGHT 25 45 60 60 47.5 96% LEFT 30 55 55 60 50 96% As noted above, Table VI in 38 C.F.R. § 4.85 combines the puretone average and the speech recognition scores to produce a numeric designation for each ear, which is inserted into Table VII in 38 C.F.R. § 4.85 to determine the correct disability level. Because the Veteran's right ear had a puretone average of 47.5 dB and a speech discrimination score of 96 percent, and no worse, the Veteran's right ear hearing loss receives a designation of I. Because the Veteran's left ear had a puretone average of 50 dB and a speech discrimination score of 96 percent, and no worse, the Veteran's left ear hearing loss receives a designation of I. The intersection of designations I and I on Table VII establishes that the Veteran's hearing loss disability is entitled to a noncompensable rating. See 38 C.F.R. § 4.85, DC 6100. In a December 2020 VA treatment record, the audiologist documented the Veteran had a Speech Recognition Threshold (SRT) of 60 decibels (dB) in the right ear, and 55 dB in the left ear. However, the examiner reported that the Veteran required reinstruction and retesting as the initial SRT for the right ear was 75 dB. The examiner wrote the Veteran demonstrated significant difficulty hearing the clinician during the case history portion of the appointment, even with increased speech volume. The examiner noted, "After hearing test was complete, however, the clinician spoke at a normal conversational volume and the Vet[eran] appeared to experience less difficulty hearing the clinician." The examiner concluded that word recognition performance was not accepted or believed to be accurate due to nature of errors in word recognition that were not consistent with the Veteran's degree of hearing loss. On the audiological evaluation in April 2021, pure tone thresholds, in decibels (dB), were as follows: HERTZ 1000 2000 3000 4000 Maryland CNC RIGHT CNT CNT CNT CNT 96% LEFT CNT CNT CNT CNT 96% A finding denoted by the letters "CNT" means that this frequency could not be tested. The examiner documented that there were one or more frequencies that could not be tested, and explained that the Veteran was reinstructed multiple times on testing protocol, but was unable to provide reliable results on today's evaluation. The examiner documented the Veteran's hearing thresholds were inconsistent with his speech reception threshold. The examiner stated that the test results were not valid for rating purposes (not indicative of organic hearing loss). Specifically, the examiner stated that the Veteran's puretone test results during the examination were unreliable and inconsistent and were of poor reliability when compared with speech testing. Accordingly, the examiner concluded that they are not valid for rating purposes. The examiner also reported that word discrimination scores were available and the use of speech discrimination scores for the Veteran is appropriate. As the pure tone threshold scores from this examination are unreliable, this examination is not adequate for rating purposes. See 38 C.F.R. § 4.85 (a hearing examination for VA purposes must include a pure tone audiometry test and Maryland CNC test). The Board determines that another remand for a new examination is unnecessary for two reasons. One, the April 2021 VA examiner attempted to test the Veteran's hearing loss and was unable to do so. This is consistent with what a different audiologist documented in the December 2020 VA treatment record described above. Two, as two audiologists concluded that the hearing test results are not valid, the Board finds that this is sufficient evidence to conclude that the Veteran is not cooperating during hearing testing, and that a new hearing examination would not result in anything but the same conclusion. After applying the formula located in 38 C.F.R. § 4.85, DC 6100 for the May 2013 VA audiological examination, the Board concludes that the Veteran's bilateral sensorineural hearing loss does not warrant a compensable rating. The preponderance of the evidence, including the VA examination reports, is against a compensable disability rating for bilateral sensorineural hearing loss for the entire period on appeal. The impairment associated with the Veteran's disability is contemplated by the rating criteria, which consider the average impairment resulting from a service-connected disability. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Absent audiometric and speech discrimination scores showing that the Veteran's bilateral ear hearing loss disability meets the schedular criteria in excess of the disability rating already assigned, his hearing loss does not warrant a higher rating. See 38 C.F.R. § 4.85. Extraschedular Consideration Disability ratings are determined by applying criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate DCs. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In this case, however, the Board will not address schedular entitlement as that issue is not before it. In a March 2019 statement, the Veteran's representative contended that the Veteran is entitled to an increased rating on an extraschedular basis. The Board will proceed to consider whether the Veteran is entitled to an extraschedular rating for the service-connected bilateral sensorineural hearing loss. In Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom., Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009), the Court outlined the framework for determining entitlement to an extraschedular evaluation. First, the Board must determine whether the evidence "presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate." Id. This obliges the Board to compare "the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability." Id. When this requirement is satisfied, the Board must determine whether the veteran's exceptional disability picture exhibits other related factors such as "marked interference with employment or "frequent periods of hospitalization." Id. at 116 (quoting 38 C.F.R. § 3.321(b)(1)). If both these inquiries are answered in the affirmative, the Board must refer the matter to the Under Secretary for Benefits or the Compensation Service Director for the third inquiry-a determination of whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular evaluation. Id.; see generally Todd v. McDonald, 27 Vet. App. 79, 89-90 (2014); Anderson v. Shinseki, 22 Vet. App. 423, 427 (2009) (outlining the "elements that must be established before an extraschedular rating can be awarded"). The Board finds that an initial compensable extraschedular rating Veteran's bilateral sensorineural hearing loss is not warranted, as the Veteran's symptoms are contemplated by the schedular rating criteria, which is explained below. With respect to the first prong of Thun, the Board finds that the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's bilateral sensorineural hearing loss is inadequate. A comparison between the level of severity and symptomatology of the Veteran's bilateral sensorineural hearing loss with the established criteria shows that the rating criteria reasonably contemplate the Veteran's disability level. For instance, the schedular rating criteria for rating hearing loss provide for disability ratings based on testing during audiological evaluations, to include speech discrimination and pure tone testing. Here, all hearing impairment associated with the Veteran's hearing loss is contemplated by the schedular rating criteria. The Board points out that the applicable schedular rating criteria (38 C.F.R. §§ 4.85, 4.86) provide for ratings based on all levels of hearing loss in various contexts, as measured by both audiometric testing and speech recognition testing. The ability of the Veteran to hear sounds and voices is measured and rated by an audiometric test, as this test measures different frequencies and captures high frequency hearing loss from sources including voices, music, sirens, and certain high-pitched sounds. The ability of the Veteran to understand people is rated by a speech recognition test, as this test measures conversation comprehension, words, and missed conversations. The schedular rating criteria specifically provide for ratings based on all levels of hearing loss, including exceptional hearing patterns, as measured by both audiometric testing and speech recognition testing. See Doucette v. Shulkin, 28 Vet. App. 366. The decibel loss and speech discrimination ranges designated for each level of hearing impairment in Tables VI and VIa of the rating schedule were chosen in relation to clinical findings of the impairment experienced by veterans with certain degrees and types of hearing disability. The regulatory history of 38 C.F.R. §§ 4.85 and 4.86 includes revisions, effective June 10, 1999. See 64 Fed. Reg. 25,202 (May 11, 1999). In forming these revisions, VA sought the assistance of the Veteran's Health Administration (VHA) in developing criteria that contemplated situations in which a veteran's hearing loss was of such a type that speech discrimination tests may not reflect the severity of communicative functioning these veterans experienced or that was otherwise an extreme handicap in the presence of any environmental noise, even with the use of hearing aids. VHA had found through clinical studies of veterans with hearing loss that, when certain patterns of impairment are present, a speech discrimination test conducted in a quiet room with amplification of the sounds does not always reflect the extent of With regard to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. In this case, the Veteran has been assigned the noncompensable rating for his disability, which contemplates the Veteran's audiometric findings and speech recognition test scores. Altogether, the noncompensable rating adequately contemplates the severity and frequency of the Veteran's bilateral sensorineural hearing loss, as well as the impact of his other disabilities. The Veteran's representative concedes that the Veteran's inability to hear or understand speech or other sounds are effects contemplated by the schedular rating, but contends that the rating criteria do not account for other functional effects, such as dizziness, vertigo, ear pain, etc. First, the Board notes that the record does not support complaints of these symptoms. For example, the Veteran denied experiencing vertigo, which is documented in VA treatment records from January 2010, April 2011, November 2015, December 2017, and March 2019. The Veteran denied experiencing dizziness, which is documented in VA treatment records from January 2010, April 2010, March 2019, and December 2020. The Veteran also denied experiencing ear pain, which is documented in VA treatment records from August 2010, November 2010, January 2011, August 2011, November 2011, August 2012, April 2013, April 2014, January 2015, and December 2020. In VA treatment records from June 2018, February 2019, and January 2021, the Veteran stated his ear pain level was zero. The Board affords these records high probative value, as they represent consistent presentation of symptoms over an 11-year period and were made in the context of seeking treatment. The Board finds that the Veteran would have been motivated to provide accurate reporting of medical symptoms when seeking treatment or speaking to treatment providers. Accordingly, the Board finds that the Veteran's representative's contention of vertigo, dizziness, and ear pain is outweighed by the Veteran's denial of these same symptoms at VA treatment facilities. Second, while these symptoms are not contemplated in the rating schedule to be symptoms associated with hearing loss, the symptoms of dizziness and vertigo are specifically shown by the rating schedule to be symptoms of a separately ratable disability under DC 6204 for "peripheral vestibular disorders," which is a separate and distinct disability from hearing impairment (DC 6100). Thus, the Board finds that dizziness and vertigo not extraschedular symptoms related to hearing impairment and are separately ratable under the schedular code. Even if the first prong of the Thun criteria were not met, and the Board finds that the schedular criteria do not contemplate the Veteran's disability picture concerning the bilateral sensorineural hearing loss, the record does not support the second prong of Thun, as the Veteran's bilateral sensorineural hearing loss do not exhibit other related factors such as marked interference with employment or frequent periods of hospitalization. For example, the record does not support that the Veteran has been frequently hospitalized due to bilateral hearing loss. The Veteran also has not alleged marked interference with employment. The facts before the Board do not reveal evidence of frequent hospitalizations or sufficient evidence to indicate that the Veteran's bilateral sensorineural hearing loss caused marked impairment with employment over and above that which is already contemplated in the assigned schedular rating. See 38 C.F.R. § 4.1; 38 C.F.R. § 3.321(a). The Board finds that taking into account the symptoms reported by the Veteran, including vertigo, dizziness, and ear pain; the preponderance of the evidence does not support that the Veteran's bilateral sensorineural hearing loss is manifested by marked interference with work or frequent hospitalizations; and the second prong of Thun is not met. In sum, the Board concludes that the facts here do not show an exceptional or unusual disability picture. The preponderance of the evidence of record is against the Veteran's claim for a disability evaluation in excess of noncompensable for service-connected bilateral sensorineural hearing loss on an extraschedular basis. Separate Rating In a June 2020 statement, the Veteran's representative contended that the Veteran is entitled to ratings as secondary to service-connected bilateral sensorineural hearing loss because of his vertigo, dizziness and ear pain. However, as discussed above, the Board finds that the Veteran's contentions of these symptoms are outweighed by his regular and consistent denial of these symptoms to his VA treatment providers. Accordingly, the evidence does not support a separate rating or the grant of secondary service connection for vertigo, dizziness, or ear pain. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Husain, 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.