Citation Nr: 21071936 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 16-57 116 DATE: December 1, 2021 ORDER Entitlement to a disability rating greater than 50 percent before June 9, 2020, and greater than 70 percent thereafter, for posttraumatic stress disorder, is denied. Entitlement to a compensable disability rating before September 16, 2020, and greater than 60 percent thereafter, for bilateral hearing loss, is denied. A disability rating of 10 percent, effective July 11, 2019, for surgical scar associated with left spermatocelectomy, is granted. Entitlement to a compensable disability rating before July 11, 2019, and to a rating greater than 10 percent thereafter, for surgical scar associated with left spermatocelectomy, is denied. REMANDED Entitlement to a compensable disability rating for residuals of a left spermatocelectomy is remanded. FINDINGS OF FACT 1. Before June 9, 2020, the severity, frequency, and duration of the Veteran's posttraumatic stress disorder symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. 2. From June 9, 2020, onward, the severity, frequency, and duration of the Veteran's posttraumatic stress disorder symptoms did not more closely approximate total occupational and social impairment. 3. Before September 16, 2020, the Veteran's bilateral hearing has been manifested by hearing acuity of no worse than Level I in the right ear and no worse than Level I in the left ear. 4. From September 16, 2020, the Veteran's bilateral hearing has been manifested by hearing acuity of no worse than Level VIII in the right ear and no worse than Level IX in the left ear. 5. Before July 11, 2019, the Veteran had one scar that was not unstable or painful. 6. From July 11, 2019, the Veteran has one scar that is painful but not unstable. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for posttraumatic stress disorder before June 9, 2020, and in excess of 70 percent thereafter, 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 9411. 2. The criteria for a compensable disability rating for bilateral hearing loss before September 16, 2020, and a rating in excess of 60 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. 3. The criteria for a 10 percent disability rating, but not more, for surgical scar, have been met effective July 11, 2019, but not earlier. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from September 1977 to July 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision by the Department of Veterans Affairs (VA); this case is in VA's legacy appeals system. In July 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge; a transcript of that hearing is of record. Increased Rating 1. Entitlement to a disability rating greater than 50 percent before June 9, 2020, and greater than 70 percent thereafter, for posttraumatic stress disorder The Veteran asserts that his current staged disability rating for posttraumatic stress disorder (PTSD), at 50 percent before June 9, 2020 and 70 percent thereafter, does not adequately recognize or compensate for the severity of his PTSD symptoms. 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). 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 before June 9, 2020, or total occupational and social impairment thereafter. The Board concludes that before June 9, 2020, the Veteran's symptoms did not cause the level of impairment required for a disability rating of 70 percent or higher, and from June 9, 2020, it did not cause total occupational and social impairment. Before June 9, 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. From June 9, 2020 onward, the Veteran's symptoms more closely approximated the symptoms associated with a 70 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating. A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. 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 for total occupational and social impairment, due to such symptoms 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. Evidence In February 2013, the Veteran submitted a private psychiatric examination. The examiner noted symptoms including suspiciousness, chronic sleep disturbance, nightmares, night sweats, making noise during sleep, hypervigilance, hyperalertness, alternating anxiety and depression, anger and impulse control trouble, and trouble remembering important information unless he writes it down. The Veteran mentioned that he often says what he thinks without considering social effects, which leads to lack of friends and social support system. The examiner opined that the Veteran's PTSD was severe but did not specifically opine as to the effect PTSD had on the Veteran's employment. In December 2013, VA provided an examination to determine the nature and etiology of the Veteran's PTSD. The Veteran reported he was working as a diesel mechanic. He was married with two children but experiencing relationship conflict. The VA examiner noted symptoms including recurrent distressing thoughts, recollections, dreams. markedly diminished interest in significant activities, feelings of detachment or estrangement from others, irritability or outbursts of anger, difficulty concentrating, hypervigilance, exaggerated startle response, depressed mood, anxiety, suspiciousness, panic attacks more than once per week, chronic sleep impairment, impairment of short and long term memory (retention of only highly learned material while forgetting to complete tasks), flattened affect, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and obsessional rituals which interfere with routine activities. The examiner opined that the Veteran's PTSD caused occupational and social impairment with reduced reliability and productivity. In March 2014, the Veteran's treating psychologist wrote a letter stating that the Veteran's PTSD was worsening but provided no further details. In October 2014, VA provided an examination to determine the severity of the Veteran's PTSD. The VA examiner diagnosed both PTSD and an unspecified depressive disorder but opined that the symptoms of each could not be differentiated from the other and that PTSD should be considered the primary diagnosis. The Veteran reported living with his wife of 16 years but experiencing significant relationship conflict. He had attended only three mental health related appointments since his last VA exam in December 2013 and stated that his current schedule made it difficult to schedule appointments. The examiner notes symptoms including distressing memories and dreams of his stressor, psychological distress and physiological reaction to triggers related to his stressor, avoidance of thoughts and outside triggers related to his stressor, persistent negative beliefs about self, others, the world, persistent negative emotional state, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement, persistent inability to experience positive emotions, irritable behavior and angry outbursts, hypervigilance, exaggerated startle response, problems with concentration, depressed mood, anxiety, suspiciousness, chronic sleep impairment, impairment of short- and long-term memory (for example, retention of only highly learned material, while forgetting to complete tasks), flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships. The examiner opined that the Veteran's PTSD caused occupational and social impairment with reduced reliability and productivity. Around August 2015, the Veteran submitted Family and Medical Leave Act (FMLA) paperwork showing that he was approved to take FMLA leave up to twice per week for up to three hours each, or one full day, per episode. The paperwork did not specify what type of episode, but the Veteran has stated that this was related to his PTSD. A treatment record from May 2018 shows the Veteran complained of memory problems and was not sure if this was related to his CPAP or medication. He also complained of nightmares and flashbacks three times per week. He denied any other psychiatric symptoms including suicidal and/or homicidal ideas, intentions, or plans. A treatment record from January 2019 shows the Veteran's complaints of nightmares, flashbacks, depression, and mood issues, all under control with current treatment. He again denied any other psychiatric symptoms including suicidal and/or homicidal ideas, intentions, or plans. In July 2019, the Veteran testified at a hearing before the undersigned. He stated that he works but sometimes something sets him off and he just leaves, and he has used all of his FMLA some years. He reported getting into physical altercations and having been angry to the point of wanting to hurt someone badly. His representative described habits such as always waiting to be seated where he can see exits, and always sitting on the left side in church. The representative described these as "mild but clearly obsessive." The Veteran also reported getting about four to five hours of sleep per night, with frequent nightmare and broken fitful sleep. A treatment record from February 2020 shows the Veteran's complaint of mood issues, concentration issues, anxiety, and nightmares, all affected by his chronic pain. He again denied any other psychiatric symptoms including suicidal and/or homicidal ideas, intentions, or plans. The Veteran was still working 32-40 hours per week. The provider encouraged him to cut this back to 10-15 hours per week to concentrate on mind/body recovery. In June 2020, the Veteran submitted a private psychiatric examination. The Veteran reported his symptoms getting intermittently worse over the previous year. He was still married to his wife of 20 years and working as a diesel mechanic. However, he reported increased irritability, anxiety, depression, panic attacks, and suspicion causing him to withdraw from other people. He was also having nightmares up to four times per week and seeing dead people. The examiner also noted trouble with concentration and memory, insomnia from racing thoughts, circumstantial speech, and homicidal ideation without a plan ("just thoughts, no plan"), difficulty understanding complex commands, near continuous panic or depression affecting ability to function independently appropriately and effectively, impaired impulse control, difficulty adapting to stressful circumstances, persistent danger of hurting self or others, inability to establish and maintain effective relationships, (difficulty with same), disturbance of motivation and mood, and impaired judgement. In June 2020, the Veteran stated that his PTSD is much worse. He reported chronic depression to the point he has no life, no motivation or interest in anything. He reported daily anxiety and panic attacks and couldn't stand noise or commotion of any kind. In August 2020, VA provided an examination to determine the severity of the Veteran's PTSD. The VA examiner noted symptoms including distressing memories and dreams of his stressor, psychological distress and physiological reaction to triggers related to his stressor, avoidance of thoughts and outside triggers related to his stressor, persistent negative beliefs about self, others, the word, persistent negative emotional state, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement, persistent inability to experience positive emotions, irritable behavior and angry outbursts, hypervigilance, exaggerated startle response, problems with concentration, depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss (such as forgetting names, directions or recent events), impairment of short and long term memory (for example, retention of only highly learned material, while forgetting to complete tasks), 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, inability to establish and maintain effective relationships, and obsessional rituals which interfere with routine activities. The Veteran reported minimal social relationships and reported spending most of his time alone. The VA examiner opined that the Veteran's PTSD caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Analysis Before June 9, 2020 VA and private treatment records, VA examinations, private examinations and the Veteran's lay statements show that before June 9, 2020 the Veteran's PTSD was manifested by symptoms associated with a 50 percent rating and symptoms associated with a 70 percent rating. He also had symptoms that are not listed with a specific rating, such as nightmares, night sweats, making noise during sleep, hypervigilance, hyperalertness, lack of friends and social support system, recurrent distressing thoughts, recollections, dreams. markedly diminished interest in significant activities, feelings of detachment or estrangement from others, psychological distress and physiological reaction to triggers related to his stressor, avoidance of thoughts and outside triggers related to his stressor, persistent negative beliefs about self, others, the world, persistent negative emotional state, persistent inability to experience positive emotions. The Board finds that before June 9, 2020, the severity, frequency, and duration of the Veteran's unlisted symptoms more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. See 38 C.F.R. § 4.126. These symptoms are similar to listed symptoms which are contemplated by the assigned 50 percent rating. Nightmares, night sweats, and making noise during sleep are all similar to or a part of chronic sleep impairment. hypervigilance, hyperalertness, recurrent distressing thoughts, recollections, dreams. markedly diminished interest in significant activities, feelings of detachment or estrangement from others, avoidance of thoughts and outside triggers related to his stressor, persistent negative beliefs about self, others, the world, persistent negative emotional state, and persistent inability to experience positive emotions are all similar to or a part of anxiety and depression with suspiciousness. Psychological distress and physiological reaction to triggers related to his stressor are similar to or a part of panic attacks. Finally, lack of friends and a support network are similar to or part of difficulty in establishing and maintaining effective work and social relationships. The February 2013 private examiner did note impaired impulse control, which can be associated with a 70 percent rating. But contemporaneous statements by the Veteran imply that he had trouble controlling his impulse to speak his mind regardless of social consequences, not trouble with violent outbursts. This is more consistent with the level of impairment associated with a 50 percent rating than a 70 percent rating. While the December 2013 VA examiner also checked the box for obsessional rituals, the only such rituals identified in the record are a desire to sit on the left side of church and always sit knowing where the exits are. These habits do not appear to rise to the level of interfering with routine activities and the record does not show that they have done so. The October 2014 VA examiner noted nothing more serious than the previous examiners and noted that the Veteran was still married and working at the same job, although experiencing some conflict in each area. Treatment records after this examination and the Veteran's testimony at his July 2019 Board hearing show him experiencing approximately the same level of symptoms. While he was granted FMLA leave to accommodate his PTSD symptoms, he was also then able to maintain both his employment and family relationships, however strained. While the Veteran did experience symptoms contemplated by a 70 percent rating - obsessional rituals and impaired impulse control - the evidence overall does not demonstrate the level of impairment associated with a 70 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 50 percent rating. Specifically, the Veteran was able, with difficulty, to maintain both his employment and marital status over a period of approximately eight years. This is more consistent with the level of impairment associated with a 50 percent rating than with a 70 percent rating. From June 9, 2020 VA and private treatment records, the June 9, 2020 private exanimation, August 2020 VA examination, and the Veteran's lay statements show that the Veteran's PTSD was manifested by symptoms associated with a 70 percent rating such as increased irritability, near continuous panic or depression affecting ability to function independently appropriately and effectively, anxiety with daily panic attacks, suspiciousness, trouble with concentration and memory, and difficulty understanding complex commands, impaired impulse control, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, (difficulty with same), disturbance of motivation and mood, obsessional rituals, and impaired judgement. He also had symptoms associated with a 100 percent rating such as a persistent danger of hurting self or others. Finally, he had symptoms that are not listed with a specific rating, such as insomnia from racing thoughts, nightmares up to four times per week and seeing dead people, circumstantial speech, and homicidal ideation without a plan ("just thoughts, no plan"). The Board finds the severity, frequency, and duration of the Veteran's unlisted symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. See 38 C.F.R. § 4.126. The majority of these symptoms are similar to listed symptoms which are contemplated by the assigned 70 percent rating. Insomnia from racing thoughts and nightmares up to four times per week are similar to chronic sleep impairment. Circumstantial speech is similar to intermittently illogical, obscure, or irrelevant speech. All of these are contemplated by the assigned 70 percent rating. Seeing dead people and homicidal ideation are more similar to persistent delusions or hallucinations and persistent danger of hurting self or others. However, the Veteran's statements associated seeing dead people with his nightmares and he consistently denied any plan or intent to act on any homicidal ideation. Each of these symptoms is therefore less persistent than is required by the criteria for a 100 percent rating. The Board also finds the level of impairment caused by the Veteran's symptoms more closely approximates the level associated with a 70 percent rating. The Veteran experienced occupational and social impairment with reduced reliability and productivity with deficiencies in most areas. Mental status examinations in VA and private treatment records and the August 2020 VA examination indicate that the Veteran was oriented to time, place, and person, appropriately dressed, not responding to internal stimuli, and generally able to maintain a normal conversation. The Veteran was also still able to maintain his employment and marital status, although it is clear that he was experiencing significant difficulty with each and had withdrawn from other people wherever possible. While the Veteran did experience symptoms contemplated by a 100 percent ratingdelusions or hallucinations and danger of hurting othersthe evidence overall does not demonstrate the level of impairment associated with a 100 percent rating. Specifically, these symptoms were limited in time and intensity and did not rise to the level of persistence required for a 100 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 70 percent rating. Conclusion In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in the level of impairment required for a 70 percent rating before June 9, 2020, or for a 100 percent rating thereafter. The Veteran's appeal on this issue is therefore denied. 2. Entitlement to a compensable disability rating before September 16, 2020, and greater than 60 percent thereafter, for bilateral hearing loss The Veteran contends that he is entitled to a higher rating because his staged ratings of 0 percent before September 16, 2020 and 60 percent thereafter does not sufficiently recognize and compensate for the severity of his hearing loss disability. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, Diagnostic Code 6100. To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). If impaired hearing is service-connected in only one ear, the law allows for compensation for hearing loss as if both ears were service-connected if the service-connected hearing loss is ratable as at least 10 percent disabling and the non-service-connected hearing loss meets the standard for a hearing loss disability for VA purposes under 38 C.F.R. § 3.385, unless the non-service-connected hearing loss is the result of the Veteran's willful misconduct. See 38 C.F.R. § 3.383. To determine the percentage evaluation from Table VII, the non-service-connected ear will be assigned a Roman Numeral designation for hearing impairment of I, subject to the provisions of 38 C.F.R. § 3.383. 38 C.F.R. § 4.85(f). Evidence A rating decision of November 2002 granted service connection for left ear hearing loss with a noncompensable rating. The rating decision denied service connection for right ear hearing loss because this condition had not been shown to a level of severity that qualified as a disability for VA purposes. The Veteran did not appeal this decision and it became final. A treatment report from September 2012 shows the Veteran's complaint of gradually declining hearing, worse on the left. Audiometric testing at the time was invalid, showing inconsistent results, and no hearing aids were issued. A December 2013 VA examination reveals that the Veteran reported trouble hearing. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds could not be validly tested. The examiner reported intertest inconsistencies. However, the examiner noted that right ear threshold shift during service would make it at least as likely as not that right ear hearing loss, if present, was related to active service. An October 2014 VA examination reveals that the Veteran reported difficulty understanding speech, especially in environments with background noise. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: October 01, 2014 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 20 40 40 40 35 96% LEFT 30 45 45 50 43 96% Applying the results to Table VI, the findings yield a numeric designation of Level I in the right ear and Level I in the left ear. Entering the resulting bilateral numeric designation of Level I for the right ear and Level I for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a 0 percent disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. This examiner also opined that the Veteran's right ear hearing loss, now a confirmed diagnosis, was at least as likely as not related to his active service. A January 2015 rating decision granted service connection for right ear hearing loss effective October 1, 2014, the date of the exam confirming his diagnosis. A September 2020 VA examination reveals that the Veteran reported being able to converse one on one so long as there was no other noise but needing to ask for repetitions if there was background noise or a speaker faced away from him while speaking. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: September 16, 2020 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 40 30 40 40 38 24% LEFT 40 35 40 45 40 32% Applying the results to Table VI, the findings yield a numeric designation of Level VIII in the right ear and Level IX in the left ear. Entering the resulting bilateral numeric designation of Level VIII for the right ear and Level IX for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a 60 percent disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. Analysis Before October 1, 2014, the Veteran was only service connected for left ear hearing loss. The Veteran's left ear must be rated on its own for this period because the right ear had not been diagnosed with hearing loss for VA purposes. A compensable rating for single ear hearing loss requires a numeric designation of at least Level X in the service-connected ear. The evidence does not show this level of severe hearing loss in the Veteran's left ear before October 1, 2014. As noted above, the results of the October 2014 VA examination showed a numeric designation of Level I in each ear, which does not warrant a compensable rating. The September 2020 VA examination showed a numeric designation of Level VIII in the right ear and Level XI in the left ear. This supports a 60 percent disability rating, but not higher. The Board expressly acknowledges its consideration of the lay evidence of record when adjudicating this claim, including the Veteran's reports of difficulty hearing during conversation, especially in noisy environment or when the speaker is not facing him. The Veteran is competent to report difficulty with his hearing; however, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes, is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran's main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). Conclusion Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a compensable rating before September 16, 2020 or a rating in excess of 60 percent thereafter for hearing loss. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to a compensable disability rating before September 10, 2020, and to a rating greater than 10 percent thereafter for surgical scar associated with left spermatocelectomy The Veteran contends that he is entitled to a higher rating because his current ratings of 0 percent before September 10, 2020, and 10 percent thereafter, do not sufficiently recognize and compensate for the severity of his symptoms. The Veteran's surgical scar associated with left spermatocelectomy (surgical scar) is rated 0 percent before September 10, 2020 and 10 percent thereafter, under Diagnostic Code 7804 for unstable or painful scars. A January 2014 rating decision granted service connection for a surgical scar on the Veteran's anterior trunk, neither painful nor unstable, and measuring 0.01 square centimeters. In October 2014, VA provided an examination to determine the severity of the Veteran's surgical scar symptoms. The examiner identified a single scar on the Veteran's anterior trunk. The scar was superficial and linear, measuring 8.5 cm by 0.2 cm and was neither painful nor unstable. The Veteran reported having two other scars on his scrotum, but the examiner was unable to discern them within the scrotal folds. At his July 2019 Board hearing the Veteran reported that his surgical scar was painful. He did not mention any other scar-related symptoms. In September 2020, VA provided an examination to determine the severity of the Veteran's surgical scar symptoms. The examiner identified a single scar on the Veteran's anterior trunk. The scar was superficial and linear, measuring 5.0 cm by 0.1 cm and was painful but not unstable. The Veteran reported tenderness on the back of his scrotum where a previous incision was made but the examiner was unable to locate a scar in this area. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Code 7804 was not changed by the August 13, 2018, amendments. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent rating. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. The Board finds that the Veteran first reported his surgical scar being painful at his Board hearing on July 11, 2019, and he has consistently reported this since then. He has also reported having multiple surgical scars, but no examiner has been able to identify more than one scar. The Board finds that the independent observations of two VA examiners is more probative than the Veteran's report because, while the Veteran was certainly present to experience his surgery, his reported scars are not in an area that is easy to observe on his own body and the examiners would have a better chance to observe whether more than one scar was present. The preponderance of the evidence shows that the Veteran had a single scar that was stable and not painful before July 11, 2019. From July 11, 2019, onward, the preponderance of the evidence shows that the Veteran has a single scar that is painful but not unstable. Under diagnostic code 7804 a compensable rating is not warranted before July 11, 2019 and a rating greater than 10 percent is not warranted at any time. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran's surgical scar is not of the head, face, or neck, is not deep and nonlinear, and is not associated with underlying soft tissue damage. Although it is superficial and not associated with underlying soft tissue damage, it does not cover an area or areas of 144 square inches or greater. Therefore, Diagnostic Codes 7800 through 7802, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effects not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. The only symptom is pain, and this is contemplated by the current rating under 7804. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms, to include pain on different areas, and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Veteran's medical records do not show, and two VA examinations could not identify, three or four scars that are unstable or painful. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a compensable disability rating before July 11, 2019, or in excess of 10 percent from July 11, 2019, for a surgical scar. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to a compensable disability rating for residuals of a left spermatocelectomy The Veteran contends that he is entitled to a compensable rating for residuals of a left spermatocelectomy because his symptoms have increased to include unpredictable intermittent severe pain, especially after activity. The Veteran's residuals of spermatocelectomy, which is not specifically addressed under any diagnostic code, have been rated by analogy under diagnostic codes 7599-7523 for atrophy of one testicle. When assigning a code by analogy, VA must choose a code which closely relates to the disease or injury -- one in which "not only the functions affected [are analogous], but the anatomical localization and symptomatology are closely analogous." 38 C.F.R. § 4.20 (1995); Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992); Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). VA must provide adequate reasons and bases for its choice of an analogous code. See Arnesen v. Brown, 8 Vet. App. 432 (1995). A spermatocele is a cyst on the epididymis. Stedman's Medical Dictionary at 1645 (26th ed. 1995). The epididymis is the channel which transports and stores spermatozoa between the testes and testicular ducts. Stedman's at 583. Atrophy is a diminishing of cellular proliferation, volume, pressure or lessened function. Stedman's at 165. Epididymitis is inflammation of the epididymis, occasionally accompanied by inflammation of the testis (epididymo-orchitis). Merck Manual Professional Version, https://www.merckmanuals.com/professional/genitourinary-disorders/penile-and-scrotal-disorders/epididymitis (last accessed November 29, 2021). To date, the record contains no explanation as to why DC 7523 is the appropriate code to use for rating residuals of spermatocelectomy. Because spermatocele is a condition of the epididymis, and the surgery to remove it would have been surgery of the epididymis, it seems at least as appropriate to use diagnostic code 7599-7525 as 7599-7523. Under diagnostic code 7523, atrophy of one testicle is rated 0% compensable. Atrophy of both testicles is rated 20% compensable. There are no other criteria under this code. 38 C.F.R. § 4.115b, Diagnostic Code 7523 (2021). Diagnostic code 7525 covers chronic prostatitis, urethritis, epididymitis, orchitis (unilateral or bilateral), and directs that these conditions be rated as urinary tract infections. 38 C.F.R. § 4.115b, Diagnostic Code 7525 (2021). Urinary tract infections should be rated as renal dysfunction when they cause poor renal function. Otherwise, a noncompensable rating is assigned for recurrent symptomatic infection not requiring hospitalization but requiring suppressive drug therapy for less than 6 months. A 10 percent rating is assigned for recurrent symptomatic infection requiring 1-2 hospitalizations per year or suppressive drug therapy lasting six months or longer. A maximum 30 percent rating is assigned for recurrent symptomatic infection requiring drainage by stent or nephrostomy tube; or requiring greater than 2 hospitalizations per year; or requiring continuous intensive management. 38 C.F.R. § 4.115a (2021). The criteria for rating disabilities of the genitourinary system were updated effective November 14, 2021. Diagnostic code 7523 was not changed. 38 C.F.R. § 4.115b, Diagnostic Code 7523 (2020). The previous version of Diagnostic code 7525 addressed only chronic epididymo-orchitis, but still directed that it be rated as a urinary tract infection. 38 C.F.R. § 4.115b, Diagnostic code 7525 (2020). Under the previous version of the criteria for rating urinary tract infections, a 10 percent rating was assigned for long-term drug therapy, 1-2 hospitalizations per year and/or requiring intermittent intensive management. A 30 percent rating was assigned for recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. Poor renal function was still evaluated as renal dysfunction. 38 C.F.R. § 4.115a (2020). The Veteran's residuals of spermatocelectomy do not meet the schedular requirements for a higher rating under either of the relevant diagnostic codes. However, at his July 2019 Board hearing the Veteran reported symptomatology of intense scrotal pain, sometimes spreading to his abdomen. The Veteran reported this has a significant effect on both his personal life and his ability to work, as the pain is exacerbated by activity. A September 2020 VA examiner confirmed that scrotal pain was severe enough to make the Veteran slow down and take breaks at work. The Veteran's scrotal pain, which is the primary residual of his left spermatocelectomy, is not reasonably contemplated by any relevant diagnostic code, and his testimony and the September 2020 VA examination suggest that he may have experienced marked interference with employment due to this service-connected disability. The Veteran's claim for an increased rating for residuals of left spermatocelectomy is therefore being remanded and referred to VA's Director of Compensation Service for extraschedular consideration. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). The matters are REMANDED for the following action: 1. Refer the Veteran's claim for an increased rating for residuals of left spermatocelectomy to VA's Director of Compensation Service for extraschedular consideration. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. If any benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zimmerman, Micah 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.