Citation Nr: 21005285 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 18-41 098 DATE: February 1, 2021 ORDER Entitlement to a disability rating in excess of 20 percent for degenerative disc disease of the lumbar spine with compression fracture (hereinafter “lumbar spine disability”) is denied. Entitlement to a rating in excess of 20 percent for radiculopathy of the right lower extremity (sciatic nerve) is denied. Entitlement to an initial rating in excess of 20 percent for radiculopathy of the right lower extremity (femoral nerve) is denied. Entitlement to an initial rating in excess of 10 percent for radiculopathy of the left lower extremity (sciatic nerve) is denied. Entitlement to an initial rating in excess of 20 percent for bilateral hearing loss is denied. From December 8, 2017, entitlement to an increased 30 percent rating for bilateral hearing loss is granted. REMANDED Entitlement to service connection for a left knee disability, to include as secondary to a service-connected lumbar spine disability, is remanded. Entitlement to service connection for a right knee disability, to include as secondary to a service-connected lumbar spine disability, is remanded. FINDINGS OF FACT 1. The Veteran’s lumbar spine disability has not been shown to result in limitation of forward flexion of the thoracolumbar spine to 30 degrees or less, even considering functional limitation factors; ankylosis of the thoracolumbar spine; or incapacitating episodes having a total duration of at least four weeks during the past 12 months. 2. The Veteran’s radiculopathy of the right lower extremity (sciatic nerve) has been manifested by no more than moderate incomplete paralysis. 3. The Veteran’s radiculopathy of the right lower extremity (femoral nerve) has been manifested by no more than moderate incomplete paralysis. 4. The Veteran’s radiculopathy of the left lower extremity (sciatic nerve) has been manifested by no more than mild incomplete paralysis. 5. Prior to December 8, 2017, the Veteran’s bilateral hearing loss was not shown to be worse than Level V in the right ear and Level VI in the left ear. 6. From December 8, 2017, when resolving reasonable doubt in the Veteran’s favor, his bilateral hearing loss has not been shown to be worse than Level VI in the right ear and Level VII in the left ear. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71A, Diagnostic Code (DC) 5242-5236 (2019). 2. The criteria for a rating in excess of 20 percent for radiculopathy of the right lower extremity (sciatic nerve) have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71A, DC 8520 (2019). 3. The criteria for an initial rating in excess of 20 percent for radiculopathy of the right lower extremity (femoral nerve) have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71A, DC 8526 (2019). 4. The criteria for an initial rating in excess of 10 percent for radiculopathy of the left lower extremity (sciatic nerve) have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71A, DC 8520 (2019). 5. Prior to December 8, 2017, the criteria for an initial rating in excess of 20 percent for bilateral hearing loss was not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.85, 4.86, DC 6100 (2019). 6. From December 8, 2017, the criteria for an increased 30 percent rating for bilateral hearing loss have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.85, 4.86, DC 6100 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Army from January 1966 to February 1973. In March 2019, the Board of Veterans’ Appeals (Board) remanded the above matters for additional evidentiary development. During the pendency of the appeal, the Regional Office (RO) issued rating decisions on October 19, 2020 and October 27, 2020 that granted an increased 30 percent rating for bilateral hearing loss, effective September 30, 2020; an increased 20 percent rating for radiculopathy of the right lower extremity (sciatic nerve), effective December 29, 2015; and assigned a separate 20 percent rating for radiculopathy of the right lower extremity (femoral nerve), effective October 14, 2020. Because higher schedular ratings are available for these disabilities and because the Veteran is presumed to seek the maximum available benefit, the claims remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board notes that in granting an increased 20 percent rating for radiculopathy of the right lower extremity (sciatic nerve) in its October 27, 2020 rating decision, the RO appears to have changed the effective date of the award of service connection for that disability, thus prejudicing the Veteran. The RO initially granted service connection for radiculopathy of the right lower extremity (sciatic nerve) in an April 2013 rating decision, assigning an effective date of October 18, 2012. The most recent rating codesheet, however, indicates an effective date of December 29, 2015 for the award of service connection. This error should be rectified by the RO. Increased Rating Claims 1. Lumbar spine disability The Veteran contends that his lumbar spine disability is more severe than his current 20 percent disability rating reflects. Disabilities of the spine are evaluated under either the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), or under the formula for rating intervertebral disc syndrome (IVDS) based on incapacitating episodes (DC 5243), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. The Veteran’s symptoms have been rated under the General Rating Formula. The General Rating Formula provides that a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71A. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. Id. Alternatively, DC 5243 provides that a 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months; a 40 percent rating is assigned for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months; and a 60 percent rating is assigned in the event of incapacitating episodes having a total duration of at least six weeks during the past 12 months. Id. Note (1) under DC 5243 defines an incapacitating episode as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id. The Board notes that, when assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must, in addition to applying schedular criteria, also consider evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-207 (1995). This appeal dates from the Veteran’s December 2015 intent to file. In July 2016, the Veteran underwent a VA examination. The report notes the Veteran’s descriptions of worsening pain with flare-ups of sharp, burning pain resulting in limitations on standing, sitting, and walking for long periods of time. Range of motion testing revealed that the Veteran had forward flexion of the thoracolumbar spine limited to 60 degrees, extension limited to 20 degrees, right and left lateral flexion to 20 and 15 degrees, respectively, and right and left lateral rotation to 30 degrees bilaterally. Pain was noted to cause functional loss in all ranges of motion; there was evidence of pain with weight-bearing as well as localized tenderness or pain on palpation over the low lumbar spine region. The Veteran was able to perform repetitive-use testing with no additional functional loss; however, the examiner was unable to determine if pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time. Localized tenderness was observed, but such did not result in abnormal gait or abnormal spinal contour. No guarding was noted. In addition, the examiner noted that certain other factors contributed to disability, including instability of station, disturbance of locomotion, and interference with sitting and standing. Muscle strength and sensation were normal. There was no evidence of ankylosis of the spine. Apart from radiculopathy (addressed below), no neurological abnormalities were noted. The examiner indicated that the Veteran had IVDS, but that he had not had any episodes of acute signs and symptoms requiring bedrest in the past 12 months. The Veteran did not report the need for assistive devices. In terms of functional impact, the examiner noted pain, difficulty standing for extended periods, and difficulty bending and lifting. In April 2017, the Veteran was seen for a Spine Center Consult at a VA medical facility. He reported a history of chronic lower back pain with restricted movement and spasms. The Veteran described “lightning bolt” sensations from his back to both thighs when trying to get up from a laying position. It was noted that the Veteran was able to ambulate with assistive devices. On physical examination, there was tenderness on palpation and pain throughout the lumbar spine region. Decrease range of motion was noted. The examiner noted that 2013 X-rays had revealed lower lumbar osteoarthritis and lumbar lordosis; updated imaging performed in April 2017 was unchanged. In December 2017, a consult note reflects that the Veteran’s back pain affected his physical activity, including his ability to walk. The Veteran reported that he ambulated with a cane. Private clinical records dated in December 2019 and January 2020 reflect that the Veteran continued to seek treatment for back pain, described as “intermittent, sharp, shooting pain.” These records noted decreased range of motion in the lumbar spine area. The Veteran reported having difficulty carrying groceries and preparing meals. He was assessed with IVDS with radiculopathy, lumbar region. The Veteran was afforded another VA back examination in October 2020. The report reflects his concerns that his symptoms, which included pain, popping, weakness, and stiffness, were getting worse. The Veteran reported taking Aspirin as needed for his pain. He noted that his symptoms affected his daily activities by preventing him from sitting or standing for long periods of time. The Veteran reported flare-ups of aching, throbbing pain. Range of motion testing revealed forward flexion of the thoracolumbar spine limited to 50 degrees, extension limited to 15 degrees, right and left lateral flexion limited to 15 and 10 degrees, respectively, and right and left lateral rotation to 10 and 15 degrees, respectively. Pain was noted in all ranges of motion but was not observed to cause additional functional loss. Localized tenderness or pain on palpation, characterized as “moderate,” was noted. Repetitive-motion testing did not result in further functional limitation; however, the examiner estimated that fatigue, weakness, and lack of endurance resulted in an additional five degrees of motion lost in all ranges of motion (thus, forward flexion was limited to 45 degrees). Flare-ups were also noted to cause an additional five degrees of lost motion. Guarding and spasm were observed but did not result in abnormal gait or abnormal spine contour. Muscle strength was slightly reduced in bilateral hip flexion and knee extension; no muscle atrophy was noted. Reflexes were hypoactive, and sensation was decreased in both lower extremities. There was no evidence of ankylosis or other neurologic abnormalities. The examiner determined that the Veteran did not have IVDS. In terms of functional impact, the examiner noted that the Veteran’s symptoms limited prolonged sitting, driving, standing, walking, bending, and stair climbing. Pursuant to Correia v. McDonald, 28 Vet. App. 158 (2017), the examiner observed that there was pain in non-weight bearing situations and with passive range of motion, but that such did not contribute to additional functional loss. Based on the evidence of record, the Board finds that the Veteran’s lumbar spine disability symptoms do not warrant a rating in excess of 20 percent under the General Rating Formula. To reiterate, a 20 percent rating under the General Ratings Formula requires limitation of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. A 40 percent rating requires limitation of forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. See 38 C.F.R. § 4.71A. In short, the Board can find no probative evidence establishing that the Veteran’s symptoms more nearly approximated forward flexion of the thoracolumbar spine to 30 degrees or less, even when considering the types of functional impairment noted in 38 C.F.R. §§ 4.40 and 4.45 and DeLuca. The VA examination reports of record both demonstrate range of motion of the thoracolumbar spine exceeding the criteria for a rating in excess of 20 percent. The Veteran’s private and VA outpatient records likewise do not demonstrate forward flexion limited to 30 degrees or less nor combined range of motion of the thoracolumbar spine to 120 degrees or less. The Veteran has not called the VA examination results into question, and there is no evidence that they are inaccurate or that the Veteran’s symptoms have worsened since his most recent VA examination, in October 2020. The Board emphasizes that VA is obligated to consider evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, supra at 204-07. The Veteran has demonstrated many of these factors in the context of his lumbar spine disability; however, even when considering these factors, there is no evidentiary basis to support a finding that the criteria for a rating in excess of 20 percent have been met. The Veteran has credibly reported chronic pain and functional impairment, to include stiffness and difficulty sitting, standing, lifting, bending, and walking for prolonged periods. He is of course competent to report these symptoms. See Layno v. Brown, 6 Vet. App. 465 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). His current 20 percent rating contemplates limitation of motion with corresponding functional impairment. As noted above, the VA examination reports of record demonstrate range of motion in all planes; neither of the examination reports indicate any history of ankylosis. The Veteran has not alleged, and the record does not reflect, that his range of motion has been limited to a degree that would warrant an increased rating. The weight of the evidence is also against a finding that the Veteran has suffered incapacitating episodes of IVDS warranting an increased rating under DC 5243. The Board acknowledges that the Veteran reported chronic back pain with accompanying functional limitation. Again, he is competent to report these symptoms. See Layno, supra; Jandreau, supra. Moreover, there is evidence in the record of IVDS, as discussed above. Notwithstanding, none of the Veteran’s examination reports, lay statements, or private or VA treatment records reflect that he has experienced incapacitating episodes of such severity (i.e., requiring bedrest) or frequency as would warrant an increased rating under DC 5243. For these reasons, the weight of the evidence is against a finding of physician-prescribed bedrest specifically on account of IVDS for at least four weeks over a 12-month period. The Board is aware of the Court decision in Sharp v. Shulkin, 29 Vet. App. 26 (2017), holding that when flare-ups are an indicated part of a claimant’s service-connected disability, VA examiners are obligated to elicit information concerning the “severity, frequency, duration, or functional loss manifestations” of flare-ups. Here, although the Veteran has reported flare-ups of back pain, his most recent VA examination report reflects that the examiner was able to estimate range of motion during flare-ups; the examiner noted that the Veteran would likely have an additional five degrees of motion lost during flare-ups. Such impairment is consistent with the Veteran’s 20 percent rating. The Board thus finds that VA has complied with Sharp with respect to the Veteran’s lumbar spine disability, as VA has attempted to estimate the functional impairment of flare-ups and evaluate the Veteran’s disability accordingly. His symptoms are consistent with the Veteran’s current evaluation, which contemplates limitation of motion as well as accompanying functional impairment factors. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, supra at 204-07. Finally, the Board acknowledges that Note (1) to the General Rating Formula directs VA to evaluate any associated objective neurologic abnormalities separately, under an appropriate DC. 38 C.F.R. § 4.71A. In this case, the Veteran has been shown to have radiculopathy in his lower extremities; these symptoms are separately rated and are addressed below. There is no evidence of any other neurological impairment. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the record). In sum, for the reasons discussed above, the Board finds that the Veteran’s currently assigned 20 percent rating is appropriate for his lumbar spine disability. His claim for an increased rating must be denied. 2. Radiculopathy of the lower extremities The Veteran contends that his bilateral lower extremity radiculopathy is more severe than his current disability ratings reflect. The Veteran is in receipt of three separate ratings for his bilateral lower extremity radiculopathy. For the right lower extremity, he is in receipt of a 20 percent rating under DC 8520, which applies to impairment of the sciatic nerve, as well as a separate 20 percent rating under DC 8526, which applies to impairment of the femoral nerve; the rating under DC 8526 is in effect from October 14, 2020, the date of the Veteran’s most recent VA examination. As for the left lower extremity, he is in receipt of a single 10 percent rating under DC 8520. Under DC 8520, a 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve; a 20 percent rating is warranted for moderate incomplete paralysis; a 40 percent rating is warranted for moderately severe incomplete paralysis; a 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy; and a maximum 80 percent rating is warranted for complete paralysis, where the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124A, DC 8520. Under DC 8526, a 10 percent rating is warranted for mild incomplete paralysis of the femoral nerve; a 20 percent rating is warranted for moderate incomplete paralysis; a 30 percent rating is warranted for severe incomplete paralysis; and a maximum 40 percent rating is warranted for complete paralysis of the quadriceps extensor muscles. Id. at DC 8526. On review, the Board finds that the relevant evidence reflects that increased ratings are not warranted for the Veteran’s bilateral lower extremity radiculopathy symptoms. The Veteran underwent a VA peripheral nerves examination in July 2016. The report notes symptoms of moderate intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness in both lower extremities. Muscle strength was normal bilaterally. Reflexes were diminished in the knees and ankles; however, sensation was normal bilaterally. There were no trophic changes, and the Veteran’s gait was normal. The examiner determined that the Veteran had radiculopathy in both lower extremities involving the sciatic nerve roots only that was mild in severity. A July 2016 VA spine examination report also reflects mild symptoms.) The Veteran was afforded another VA examination, in October 2020. The report reflects decreased muscle strength, reflexes, and sensation in both lower extremities, although no atrophy was noted. The examiner determined that the Veteran had moderate intermittent pain, paresthesias and/or dysesthesias, and numbness on the right side, and mild paresthesias and/or dysesthesias and numbness on the left side. No other signs or symptoms of radiculopathy were observed. The examiner determined that the Veteran had bilateral radiculopathy involving the sciatic nerve roots that was moderate on the right side and mild on the left side. In addition (and for the first time) it was noted that there was femoral nerve root involvement in the right lower extremity only, which was noted to be moderate in severity. In addition to the VA examination reports described above, the Board has reviewed the Veteran’s private and VA treatment records pertaining to his lower extremity radiculopathy. These records demonstrate that the Veteran has been followed for neurological impairment of his lower extremities, manifested primarily by pain and numbness. For example, an April 2017 VA spine center consult note reflects the Veteran’s reports of a “lightning bolt” sensation from his back to both thighs when trying to get up from a standing position. The records do not contain any specific medical findings as to the nature or severity of the Veteran’s radiculopathy. Based on the above, the Board finds that the preponderance of the evidence does not establish entitlement to increased ratings for the Veteran’s lower extremity radiculopathy. As for the right lower extremity, the only definitive determination as to the overall severity of the Veteran’s symptoms appeared in the two VA examination reports discussed above. As reflect in those reports, there is no credible evidence of incomplete paralysis involving the nerves of the right lower extremity that is more than moderate in severity. (Indeed, the July 2016 VA examination report noted no more than mild symptoms in the right lower extremity.) The Board also finds no evidentiary or legal basis to award an earlier effective date for the grant of the separate 20 percent rating under DC 8526 for radiculopathy of the right lower extremity with femoral nerve involvement. As noted above, the October 14, 2020 VA examination report marks the first evidence in the record of femoral nerve involvement. The Veteran has not argued that he had radiculopathy with femoral nerve involvement before that examination. As such, the October 14, 2020 effective date for the grant of a separate 20 percent rating under DC 8526 is appropriate, as that reflects the date on which entitlement arose for that specific disability. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. Accordingly, the criteria for increased ratings for radiculopathy of the right lower extremity have not been met. The Board further finds no basis for awarding an initial rating in excess of 10 percent for the Veteran’s left lower extremity radiculopathy (sciatic nerve). Both VA examination reports of record demonstrate that the Veteran’s left lower extremity radiculopathy was no more than mild in severity. The Veteran has not contested these findings, and they constitute the most probative evidence of record. As illustrated above, the Veteran has credibly reported pain and decreased sensation in both lower extremities throughout the appeal period. He is of course competent to report these symptoms. However, his current evaluations fully contemplate these symptoms. The Board further finds that the determinations of medical professionals with respect to the overall level of severity of the Veteran’s radiculopathy is the most probative evidence of record. See Jandreau, supra at 1377. Here, both the VA examiners of record determined that the Veteran’s right lower extremity radiculopathy (including both sciatic and femoral nerve involvement) was no more than moderate in severity, and that his left lower extremity radiculopathy (sciatic nerve) was no more than mild in severity. These findings reflect expert evaluations as to the Veteran’s specific symptomatology. They have, moreover, not been called into question. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, supra at 369-70. Accordingly, the Board finds that the weight of the evidence is against entitlement to increased ratings for the Veteran’s bilateral lower extremity radiculopathy. The claims must be denied. 3. Bilateral hearing loss The Veteran contends that his bilateral hearing loss warrants an initial rating in excess of 20 percent, prior to September 30, 2020, and a rating in excess of 30 percent thereafter. Evaluations of bilateral defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests together with the average hearing threshold level measured by puretone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). To evaluate the degree of disability for bilateral service-connected defective hearing, 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, DC 6100. 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 evaluations derived from the schedule are intended to make allowance for improvement by hearing aids. 38 C.F.R. § 4.85, DC 6100. Exceptional patterns of hearing impairment are to be evaluated in accordance with the provisions of 38 C.F.R. § 4.86. That regulation states that: (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. (b) When the puretone 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. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 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). This appeal dates from the Veteran’s December 2015 intent to file. He was afforded a VA audiological examination in September 2016, which revealed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 65 65 60 75 75 LEFT 70 65 70 70 85 Based on the above, the average decibel loss was 68.75 decibels in the right ear and 72.5 decibels in the left ear. Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 92 percent in the left ear. The examiner noted that both the puretone test results and the speech discrimination scores were valid for rating purposes. The Board notes that the September 2016 VA study results reflected exceptional patterns of hearing impairment of the type contemplated by 38 C.F.R. § 4.86(a). As such, the Roman numeral determination for hearing impairment of each ear will be the higher of the value from Table VI and the value from Table VIA, evaluating each ear separately. See 38 C.F.R. § 4.86(a). Applying the September 2016 results to both Table VI and Table VIA in 38 C.F.R. § 4.85, the result most favorable to the Veteran reflects a finding of Level V hearing loss in the right ear and Level VI in the left ear. Under Table VII of 38 C.F.R. § 4.85, these findings warrant a 20 percent rating. The Veteran subsequently appealed that determination, though he did not provide any substantive argument in support of his claim. In November 2017, the Veteran reported to a VA hearing aid walk-in clinic and requested a hearing evaluation (the record does not reflect that he reported worsened hearing at that time). He was scheduled for an evaluation the following month. On December 8, 2017, the Veteran was assessed by an audiologist and was prescribed hearing aids following his reports of “increasing difficulty comprehending speech.” On September 30, 2020, he was afforded another VA audiological evaluation. The study results revealed puretone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 60 65 70 75 85 LEFT 65 65 75 80 85 The average decibel loss was 73.75 decibels in the right ear and 76.25 decibels in the left ear. Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 100 percent in the left ear. The examiner noted that the test results were valid for rating purposes. Applying the results of the September 2020 VA study (which again reflected exceptional patterns of hearing impairment) to the tables provided in 38 C.F.R. § 4.85, the result most favorable to the Veteran reflects a finding of Level VI hearing loss in the right ear and, at most, Level VII hearing loss in the left ear. Under Table VII of 38 C.F.R. § 4.85, these findings warrant a 30 percent rating. Consequently, the RO increased the Veteran’s rating to 30 percent, effective September 30, 2020, the date of the VA audiological evaluation. After carefully reviewing the evidence, the Board first finds that the Veteran is entitled to an increased 30 percent rating effective December 8, 2017, the date of his VA audiological assessment in which he reported worsening hearing and was prescribed hearings aids. This date marks the first evidence of worsened hearing since the September 2016 VA audiometric study. Moreover, the reports of worsening appear to have been confirmed by objective audiological testing, as the Veteran was prescribed new hearing aids. Although a Compensation and Pension (C&P) study was not performed until September 2020, the Board will not penalize the Veteran for the almost three-year delay between his seeking treatment—and reporting worsened hearing loss—and VA’s provision of an examination. In light of the facts of this case, the Board finds that, when resolving reasonable doubt in the Veteran’s favor, the criteria for a 30 percent rating were met as of December 8, 2017. Prior to the December 2017 audiological assessment, however, the sole audiometric study of record, the September 2016 VA study, demonstrates objective hearing loss that corresponds to a 20 percent rating. See 38 C.F.R. §§ 4.85, 4.86. The record includes no other audiograms or lay evidence that calls the September 2016 VA study’s findings into question. In other words, there is no evidentiary basis that suggests an initial rating in excess of 20 percent is warranted prior to the Veteran’s reports of worsening symptomatology and subsequent audiological assessment in December 2017. See Hart v. Mansfield, 21 Vet. App. 505, 510 (2007) (staged ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings). For the period beginning on December 8, 2017, the sole audiometric study of record, the September 2020 VA study, is consistent with the Veteran’s current 30 percent rating. See 38 C.F.R. §§ 4.85, 4.86. As noted above, the Board has granted an increased 30 percent rating as of December 8, 2017, the date the evidence of record establishes worsening hearing loss. The subsequent C&P study demonstrated that such hearing loss was at a level contemplated by a 30 percent schedular rating. The Veteran has not indicated that his hearing loss has worsened since the September 2020 VA study. As such, the weight of the evidence does not support a finding that the criteria for a schedular rating in excess of 30 percent have been met at any time during the appeal. The Board has considered the Veteran’s lay contentions regarding his hearing loss throughout the appeal period. Indeed, the Board has afforded his lay statements considerable probative weight in granting an increased 30 percent rating as of the date of his December 2017 VA audiological assessment. To the extent the Veteran contends he is entitled to further increases, the Board finds that his statements are outweighed by the objective audiological findings In short, although laypersons are competent to report general symptoms such as hearing loss—and, again, the Board has based the Veteran’s award of an increased 30 percent rating in large part on such statements—the specific audiological findings from the September 2016 and September 2020 VA studies are more probative as to the severity of the Veteran’s hearing loss disability for VA purposes. See Jandreau, supra at 1376-77. The Board acknowledges the Veteran’s arguments of worsening hearing loss; however, these allegations have been considered in the Board’s evaluation. The Veteran has not alleged that any errors were made in either of the VA studies of record that would compromise the validity of the results. See Francway v. Wilkie, 930 F.3d 1377, 1381 (Fed. Cir. 2019); Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011); Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009). The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, supra at 369-70. The Board observes that the proposed rule for the current version of DC 6100 explains that the criteria of DC 6100 were revised in 1987 with the goal of recognizing the impact of hearing loss in higher frequencies, and to provide a more accurate picture of true hearing impairment. See 52 Fed. Reg. 17607 (May 11, 1987). As a result, VA changed its testing methods and, in conjunction with the Department of Medicine and Surgery, developed amendments to 38 C.F.R. § 4.85, 4.86(a), 4.87(a), and Tables VI and VII. In particular, puretone averaging was to be accomplished using tone bursts at 1000, 2000, 3000 and 4000 Hertz, and speech recognition was to be measured using the Maryland CNC word lists which contained words with sounds in the 3000 and 4000 Hertz range. Overall, the new schedule was intended to evaluate hearing loss based on a combination of puretone averages and speech discrimination, which was thought to provide for a more accurate representation of actual hearing impairment by recognizing that individuals with slight to moderate decibel loss as determined by puretone averaging may have significant impairment of speech and vice versa. Additionally, the rating schedule was revised to accommodate language difficulties and other factors which produced inconsistent speech audiometry scores, and to recognize exceptional patterns of hearing impairment. Notably, VA determined that “Table VII was developed during months of consultations with our Department of Medicine and represents the best judgment of experts in this field.” Here, the Veteran’s hearing loss disability has been evaluated based upon the exceptional pattern of hearing loss. Thus, the Board defers to VA’s expertise in determining the most appropriate measure of hearing loss impairment in terms of functioning under the ordinary conditions of life, including employment. 38 U.S.C. § 1155. As discussed above, the Veteran has not forth clear evidence that the VA examiners did not properly discharge their examination duties. In sum, the evidence deemed most probative by the Board demonstrates that, pursuant to the criteria provided in 38 C.F.R. §§ 4.85 and 4.86, an initial rating in excess of 20 percent for the Veteran’s bilateral hearing loss is not warranted. However, for the reasons discussed above, an increased 30 percent rating is warranted as of December 8, 2017, the date VA received notice that the Veteran’s hearing loss had worsened. The Board is grateful for the Veteran’s honorable service. The adverse decisions contained herein are in no way meant to detract from that service. REASONS FOR REMAND 4. Entitlement to service connection for bilateral knee disabilities, to include as secondary to a service-connected lumbar spine disability The Veteran asserts that his bilateral knee disabilities are secondary to his service-connected lumbar spine disability. He has also asserted (according to an October 2020 VA examination report) that he injured his right knee in a helicopter crash while serving in Vietnam. Notably, the Veteran’s service treatment records confirm that he was involved in a helicopter accident in August 1970 in Vietnam. He has since been service-connected for a lumbar spine disability stemming from that accident. Following the Veteran’s VA knee examination in October 2020, an examiner opined that it was not at least as likely as not that the Veteran’s bilateral knee problems were related to his lumbar spine disability. By way of rationale, the examiner noted that a review of the record did not show any evidence of a limp or altered gait; that the Veteran had a right knee meniscal repair in 2012; and that he was later shown to have osteoarthritis in both knees, which was likely due to aging. On review, the Board finds that the October 2020 negative nexus opinion is inadequate, for several reasons. First, the examiner failed to discuss the Veteran’s assertions regarding his in-service right knee injury as a possible cause of his current symptoms. Second, the examiner did not opine as to whether the Veteran’s bilateral knee disabilities were aggravated by his service-connected lumbar spine disability. See 38 C.F.R. § 3.310. Finally, the examiner’s rationale did not spell out precisely why the absence of an altered gait weighs against the Veteran’s claim, or the significance of the 2012 meniscal repair. For these reasons, an updated examination and opinion is needed to address these issues. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The matters are REMANDED for the following action: 1. Obtain and associate with the record any outstanding VA medical records pertaining to the Veteran, to include from July 2020 to the present. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his bilateral knee disabilities, to include osteoarthritis. The clinician must opine as to whether it is at least as likely as not that the Veteran’s current knee disabilities developed in service; within one year of separation from service; or are otherwise related to service, to include as due to injuries from an August 1970 helicopter accident. The clinician should specifically discuss the Veteran’s lay contentions regarding his symptoms. (Continued on the next page)   The clinician must also opine as to whether it is at least as likely as not that the Veteran’s current knee disabilities are caused or aggravated by his service-connected lumbar spine disability. A complete and detailed rationale should be included in support of all opinions rendered. The clinician should not base his or her opinion solely on the lack of documented medical evidence of knee symptoms/diagnoses. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Minot, 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.