Citation Nr: 21007336 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 18-17 238 DATE: February 9, 2021 ORDER Entitlement to service connection for cervical spine condition is denied. Entitlement to service connection for lumbar spine condition is denied. Entitlement to service connection for left shoulder condition is denied. Entitlement to service connection for right shoulder condition is denied. Entitlement to service connection for right hand condition is denied. Entitlement to service connection for left hip condition is denied. Entitlement to service connection for right hip condition is denied. Entitlement to service connection for left knee condition is denied. Entitlement to service connection for right knee condition is denied Entitlement to service connection for left ankle condition is denied. Entitlement to service connection for right ankle condition is denied. Entitlement to service connection for left foot condition is denied. Entitlement to service connection for right foot condition is denied. Entitlement to service connection for generalized osteoporosis is denied. Entitlement to service connection for a stomach condition is denied. Entitlement to service connection for hypothyroidism is denied. Entitlement to service connection for an acquired psychiatric disorder is denied. Entitlement to a compensable rating for bilateral hearing loss is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. REMANDED Entitlement to service connection for left hand condition, to include carpal tunnel syndrome, is remanded. FINDINGS OF FACT 1. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s cervical spine condition is attributable to service. 2. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s lumbar spine condition is attributable to service. 3. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s left shoulder condition is attributable to service. 4. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s right shoulder condition is attributable to service. 5. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s right hand condition is attributable to service. 6. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s left hip condition is attributable to service. 7. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s right hip condition is attributable to service. 8. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s left knee condition is attributable to service. 9. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s right knee condition is attributable to service. 10. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s left ankle condition is attributable to service. 11. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s right ankle condition is attributable to service. 12. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s left foot condition is attributable to service. 13. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s right foot condition is attributable to service. 14. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s generalized osteoporosis is attributable to service. 15. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s stomach condition is attributable to service. 16. The preponderance of the competent and credible evidence weighs against a finding that the Veteran’s hypothyroidism is attributable to service. 17. The preponderance of the competent and credible evidence weighs against a finding that any acquired psychiatric disorder is attributable to service. 18. The Veteran’s hearing loss manifested by no more than Level I hearing loss in his right ear and Level I hearing loss in his left ear. 19. The competent and probative evidence of record does not demonstrate that the Veteran was unable to obtain or maintain employment solely due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 2. The criteria for service connection for a lumbar spine condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 3. The criteria for service connection for a left shoulder condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 4. The criteria for service connection for a right shoulder condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 5. The criteria for service connection for a right hand condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 6. The criteria for service connection for a left hip condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 7. The criteria for service connection for a right hip condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 8. The criteria for service connection for a left knee condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 9. The criteria for service connection for a right knee condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 10. The criteria for service connection for a left ankle condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 11. The criteria for service connection for a right ankle condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 12. The criteria for service connection for a left foot condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 13. The criteria for service connection for a right foot condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 14. The criteria for service connection for generalized osteoporosis have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 15. The criteria for service connection for a stomach condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). 16. The criteria for service connection for hypothyroidism have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). 17. The criteria for service connection for an acquired psychiatric condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). 18. The criteria for a compensable disability rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2018); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.85, Diagnostic Code 6100 (2020). 19. The criteria for entitlement to TDIU have not been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1979 to January 1983. He also served in the Army National Guard of Puerto Rico from January 1983 to March 2000 with a period of active duty from January 1991 to June 1991. He appeals a February 2017 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) denying entitlement to a compensable rating for his service-connected bilateral hearing loss, entitlement to TDIU, and numerous claims for service connection. In October 2018, the Board of Veterans’ Appeals (Board) remanded these claims for further development. The appeal is now back before the Board. VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). In October 2016, the AOJ requested the Veteran submit further details regarding his claim for service connection for an acquired psychiatric disorder and included the proper VA forms for the Veteran to submit this information. See October 2016 correspondence. The Veteran did not respond. In the October 2018 Board remand, the Board requested the AOJ obtain any private treatment records, to include private psychiatric treatment records. The AOJ requested the Veteran fill out the proper VA Form 21-4142 and 21-4142a, “to include any private psychiatric and/or psychological therapy” and any other private treatment records. See February 2020 subsequent development letter. The Veteran completed and submitted the requested forms and the private treatment records listed by the Veteran were obtained. Additionally, the AOJ obtained all outstanding VA treatment records, inquired on potential records with the Social Security Administration, and further developed the Veteran’s National Guard service. As such, the Board finds the duty to notify and assist have been satisfied in this case as the AOJ has associated the Veteran’s pertinent service and post-service records with the claims file. No other relevant records have been identified or are outstanding. Further, the Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (2016). Service Connection The Veteran contends he is entitled to VA examinations to assess the nature and etiology of his claimed conditions as he was not provided one for the service-connection claims noted above. See March 2018 VA Form 9. The Board recognizes the Veteran was never provided VA examinations or opinions for these issues. However, VA need not conduct examinations with respect to the claims on appeal, as information and evidence of record contains sufficient competent medical evidence to decide the claim. See 38 C.F.R. § 3.159(c)(4). In disability compensation claims, VA must provide a VA medical examination or medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The standards of McLendon are not met in this case. The Veteran’s current records provide evidence of musculoskeletal conditions, stomach conditions, hypothyroidism, and an acquired psychiatric condition. See April 2015 VA treatment records (“chronic arthralgias for four years (shoulder, hands, knees); neck pain started 7 months ago”); June 2016 Dr. C.E.M.Q. medical opinion (“tingling, sensorial loss, cramps, weakness, and instability radiating to hips, knees, and ankles”); January 2016 VA treatment records (hypothyroidism; lumbar spine osteoporosis; cervical spine degenerative disc disease; bilateral carpal tunnel syndrome; GERD; bilateral foot pain; plantar fasciitis;); December 2019 VA treatment records (“left shoulder pain: MRI with evidence of rotator cuff tear and bursitis”); December 2019 Dr. E.H.V. treatment records (“irradiation is to the shoulders”). However, as discussed in greater detail below, the evidence does not support a finding or an indication that the conditions were incurred in service or are associated with his service or any service-connected disability. Thus, a remand for VA opinions regarding the above claims is not necessary. A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. See 38 U.S.C. § 1110. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. See Shedden v. Principi, 381 F.3d 1163, 1167 (2004). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). Under 38 C.F.R. § 3.303(b), claims for chronic diseases enumerated in 38 C.F.R. § 3.309(a) benefit from a relaxed evidentiary standard. See Walker v. Shinseki, 708 F.3d 1331, 1339 (2013). Arthritis is such a chronic disease. To show a chronic disease in service, the record must contain a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The determination of whether the requirements of service connection have been met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). An appellant need only demonstrate an approximate balance of positive and negative evidence in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For a claim to be denied on the merits, a preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). While the evidence of record reflects numerous current disabilities, the first element for service connection, the preponderance of the evidence does not support a finding for the second and third elements required for service connection. The Board notes the Veteran submitted a private medical opinion that stated all of the Veteran’s current conditions, listed above, are “more probable than not, secondary to his military service performance.” See June 2016 Dr. C.E.M.Q. medical opinion. Dr. C.E.M.Q. did not provide a rationale for his opinion or indicate any specific relationship between a noted disability and an in-service injury or event. Id. A medical opinion is adequate when it is based on consideration of the Veteran’s prior medical history, examinations, and also describes the disability in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, the Board finds this medical opinion not probative. Musculoskeletal conditions, to include radiculopathy As noted above, the record indicates the Veteran has osteoporosis, chronic arthralgias of the shoulder, right hand, and knees, lumbar spine osteoporosis, and cervical spine degenerative disc disease. See April 2015 VA treatment records; January 2016 VA treatment records. He also has right hand carpal tunnel syndrome and bilateral foot pain with plantar fasciitis. Id. The June 2016 Dr. C.E.M.Q. medical opinion found the Veteran had “tingling, sensorial loss, cramps, weakness, and instability radiating to hips, knees, and ankles” and December 2019 Dr. E.H.V. treatment records note “irradiation to the shoulders.” Finally, the record reflects the Veteran has left shoulder pain with a rotator cuff tear and bursitis. See December 2019 VA treatment records. The record does not refect, and the Veteran does not contend, any chronic symptomatology starting in service or within one year of separation from service. As such, 38 C.F.R. § 3.309(a) does not apply. See Walker, 708 F.3d at 1339. The Board must still analyze the other two elements of direct service connection. Here, the preponderance of the evidence does not support a finding that the second and third elements required for service connection have been met. Service treatment records do not contain any complaints or notations of any musculoskeletal injury or radicular symptoms, with the exception of two left hand injuries. In November 1982, the Veteran broke his left index finger in service and was treated with a short arm cast. See November 1982 STRs. The Veteran is already service connected for the residuals of his left index finger fracture. See February 2017 rating decision codesheet. The record also reflects the Veteran was treated for left wrist tendonitis in service, which is addressed in the remand section below. The Veteran’s separation examination was also absent of any complaints or relevant history, except for his left index finger fracture. See January 1993 separation examination report. Additionally, his periodic National Guard examinations contain no notation of any musculoskeletal condition other than his left index finger fracture. See, e.g., May 1991 examination report. Additionally, the Veteran is not currently service connected for a spinal condition or any disability that could have caused or aggravated his radicular symptoms. See February 2017 rating decision codesheet. Medical records reflect the Veteran noted his low back and neck pain “started with symptoms over 20 years ago [and were] not related to any specific accidents.” See December 2019 Dr. E.H.V. treatment records. They further note the Veteran was “diagnosed with osteoporosis in 2014.” Id. In April 2015, the Veteran stated his “neck pain started 7 months ago” and his chronic shoulder, hands, and knee arthralgias began 4 years ago. See April 2015 VA treatment records. The Veteran’s most recent active duty service ended in June 1991; these reports of symptoms and subsequent diagnoses began many years after his separation from active duty and time with the National Guard. Overall, the medical treatment records in the Veteran’s file do not indicate any relationship between the Veteran’s military service and his musculoskeletal conditions or radiculopathy. Moreover, as noted above, the June 2016 opinion from Dr. C.E.M.Q., devoid as it was of any real explanation or analysis is not probative evidence. Most importantly, the record does not contain any lay statement by the Veteran asserting a theory of entitlement regarding how his musculoskeletal conditions and radiculopathy are related to service. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (while VA is obligated to assist a claimant in the development of a claim, there is no duty on VA to prove the claim). The Veteran has also not submitted any private medical records or evidence that would assist the Board in understanding how the Veteran’s current conditions are related to his service. As such, the record does not demonstrate a potential relationship between the Veteran’s military service and his musculoskeletal conditions. Upon careful review and weighing of the evidence, the Board finds the second and third Shedden elements for service connection are not met. 38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (2009); 38 C.F.R. § 3.303(d). Accordingly, the preponderance of the evidence weighs against the Veteran’s claim that his musculoskeletal conditions and radiculopathy are related to his time in service; thus, entitlement to service connection is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, 1 Vet. App. at 53. Stomach condition and hypothyroid Service treatment records (STRs) do not contain any complaints or notations of treatment for any stomach or thyroid condition. The Veteran’s separation examination was also absent of any complaints or history of a stomach or thyroid condition. See January 1983 separation examination report. Additionally, his periodic National Guard examinations contain no notation of a stomach or thyroid condition. See, e.g., May 1991 examination report. The medical treatment records in the Veteran’s file do not indicate any relationship between the Veteran’s military service and his stomach condition or hypothyroidism. Most importantly, the record does not contain any lay statement by the Veteran asserting a theory of entitlement regarding how his stomach condition or hypothyroid is related to service. See Wood, 1 Vet. App. 190 at 193. The Veteran has also not submitted any private medical records or evidence that would assist the Board in understanding the Veteran’s claim. As such, the record does not demonstrate a potential relationship between the Veteran’s military service and his stomach condition or hypothyroid. Upon careful review and weighing of the evidence, the Board finds the second and third Shedden elements for service connection are not met. 38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (2009); 38 C.F.R. § 3.303(d). Accordingly, the preponderance of the evidence weighs against the Veteran’s claim that his current stomach condition and hypothyroid are related to his service; thus, entitlement to service connection for a stomach condition and hypothyroid are denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Acquired psychiatric disorder In August 1978, the Veteran was examined in service for noting on his enlistment examination that he was seen by a psychologist as a child for “withdrawing” during his childhood. See August 1978 service treatment records. After the Veteran’s enlistment consultation, the physician found the Veteran’s psychiatric clinical evaluation “normal” and he was approved for enlistment. Id. Later, in April 1981, the Veteran received an in-service psychiatric interview for nuclear surety as it was noted in his records that he was treated “as a small child” for being “rather shy [and] withdrawn.” See April 1981 STRs. The interviewer found the Veteran did not have a chronic problem and had “no present diagnosis” as his shyness was “not active now and [he was] mentally normal.” Id. Aside from these records, STRs do not contain any complaints or notations of treatment for any psychiatric condition. The Veteran’s separation examination was also absent of any complaints or history of a psychiatric condition. See January 1983 separation examination report. Additionally, his periodic National Guard examinations contain no notation or complaints of a psychiatric condition. See, e.g., May 1991 examination report. The medical treatment records in the Veteran’s file do not indicate any relationship between the Veteran’s military service and a current psychiatric disorder. Most importantly, the record does not contain any lay statement by the Veteran asserting a theory of entitlement regarding how any psychiatric condition is related to service. As noted above, the AOJ requested the Veteran submit further details regarding his claim for service connection for an acquired psychiatric disorder, but the Veteran did not respond. See October 2016 correspondence. The Veteran has also not submitted any private medical records or evidence that would shed light on understanding the Veteran’s claim. See Wood, 1 Vet. App. 190 at 193. As such, the record does not demonstrate a potential relationship between the Veteran’s military service and any acquired psychiatric disorder. Upon careful review and weighing of the evidence, the Board finds the second and third Shedden elements for service connection are not met. 38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (2009); 38 C.F.R. § 3.303(d). Accordingly, the preponderance of the evidence weighs against the Veteran’s claim that an acquired psychiatric disorder is related to his service. Entitlement to service connection is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, 1 Vet. App. at 53. Increased Rating The Veteran claims his service-connected bilateral hearing loss is more severe than his current noncompensable rating under 38 C.F.R. § 4.85, Diagnostic Code 6100. Disability ratings are determined by applying a schedule of ratings based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned based upon organic impairment of hearing acuity as measured in the frequencies of 1000, 2000, 3000, and 4000 Hertz and controlled speech discrimination tests. See 38 C.F.R. § 4.85, Tables VI, VIA, VII; Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). To evaluate the degree of disability for service-connected bilateral hearing loss, the rating schedule establishes eleven auditory acuity levels, designated from Level I for essentially normal acuity, through Level XI for profound deafness. Table VI is used to determine the Roman numeric designation, based on test results consisting of pure tone thresholds and Maryland CNC test speech discrimination scores. The numeric designations are then applied to Table VII to determine the appropriate rating for hearing impairment. Id. When the pure tone threshold at each of the four frequencies 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. 38 C.F.R. § 4.86(a). In the Veteran’s case, a rating under 38 C.F.R. § 4.86 is not applicable as no examination report indicates the pure tone threshold at each of the four frequencies is 55 decibels or more and his puretone threshold is not recorded at 30 decibels or less at 1000 Hertz, with 70 decibels or more at 2000 Hertz. Id. The decibel loss and speech discrimination ranges designated for each level of hearing impairment were chosen in relation to clinical findings of the impairment experienced by veterans with certain degrees and types of hearing disability, as per the regulatory history of 38 C.F.R. § 4.85 and § 4.86. Functional impairment due to hearing loss that is compounded by background or environmental noise is a disability picture that is considered in the current schedular rating criteria. Complaints related to actual functional impairment are therefore factored into the criteria as applied. Doucette v. Shulkin, 28 Vet. App. 366 (2017). Accordingly, the Board finds that the Veteran’s complaints of hearing difficulty have been considered under the numerical criteria set forth in the rating schedule. The Veteran was afforded a VA audiological evaluation in January 2017. The pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 35 70 90 LEFT 10 15 15 55 60 The average of the pure tone thresholds findings at 1000, 2000, 3000, and 4000 Hertz was 54 decibels in the right ear, and 36 decibels in the left ear. The speech recognition scores on the Maryland CNC word list were 96 percent for the right ear and 98 percent for the left ear. Applying the test results of the January 2017 examination to Table VI of the Rating Schedule results in a Roman numeric designation of Level I for the right ear, and I for the left ear. 38 C.F.R. § 4.85, Table VI. Then, applying the Roman numeric designations to Table VII, the result is a noncompensable rating. The Board acknowledges the Veteran has high frequency hearing loss, especially in his right ear. However, the January 2017 VA audiology examination was conducted by a licensed audiologist competent to conduct audiological evaluations for VA purposes and she did not indicate any problems with the reliability of the test results or difficulty in test administration. As such, the Board finds the examination sufficient for VA rating purposes. Accordingly, the Veteran is not entitled to a compensable disability rating for his service-connected bilateral hearing loss. See Lendenmann, 3 Vet. App. at 349. TDIU Total disability will be considered to exist where there presently is any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. See 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that the Veteran meets the schedular requirements. Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). During the appeal period, the Veteran’s service-connected disabilities created a combined rating of 20 percent throughout the appeal period. See February 2017 rating decision codesheet. Specifically, his disabilities were rated at 10 percent for residuals of a left index finger fracture, 10 percent for tinnitus, and noncompensable for bilateral hearing loss pursuant to the Order above. Id. As such, he does not meet the schedular criteria for TDIU under 38 C.F.R. § 4.16(a). When the percentage requirements are not met, entitlement to TDIU may be considered on an extraschedular basis. 38 C.F.R. § 4.16(b). However, the Board does not have the authority to assign extra-schedular TDIU in the first instance, but it may determine the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disabilities and then refer the issue to the Director of the Compensation Service, for a determination in the first instance as to whether the Veteran is entitled to TDIU on an extra-schedular basis under 38 C.F.R. § 4.16(b). See Bowling v. Principi, 15 Vet. App. 1 (2001). Accordingly, the Board will analyze whether the evidence of record demonstrates the need for a referral to the Director of the Compensation Service for extraschedular consideration. After review of the evidence, the Board finds the Veteran’s service-connected disabilities do not render him unable to secure or follow a substantially gainful occupation. The record reflects the Veteran worked at a post office throughout the appeal period. See October 2004 Decision Review Officer (DRO) hearing transcript at 5; August 2015 VA treatment records; July 2020 VA treatment records. In October 2004, he reported his post office job did not require working with clients and his job consisted of “sorting the letters through the machine.” See October 2004 DRO hearing transcript at 5. Nevertheless, a private medical opinion noted the Veteran’s “service-connected disabilities significantly affect his ability to perform in a competitive work environment.” See June 2016 Dr. C.E.M.Q. medical opinion. Additionally, the Veteran reported his bilateral hearing loss impaired his ability to work in that he had “difficulty participating in meetings.” See August 2015 VA treatment records. Despite the aforementioned impairment, the Board finds no evidence the Veteran has not been employed by the post office for the entirety of the appeal period or that he received any accommodations for his service-connected disabilities. See Cantrell v. Shulkin, 28 Vet. App. 382, 390-391 (2017); 38 C.F.R. § 4.16(a). Further, the Veteran, himself, noted minimal effects of his service-connected hearing loss on his ability to work. Based on the foregoing, the percentage criteria set forth in 38 C.F.R. § 4.16(a) have not been met for the appeal period in question, and the evidence does not demonstrate that referral under 38 C.F.R. § 4.16(b) to the Director of the Compensation Service for extraschedular consideration is warranted. As such, the Board concludes that the preponderance of the evidence is against the claim of entitlement to TDIU; the benefit-of-the-doubt doctrine does not apply and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND The Veteran has left hand pain and carpal tunnel syndrome. See August 2015 VA treatment records. Service treatment records reflect the Veteran was treated for left wrist pain in September 1980. The treating physician diagnosed the Veteran with left wrist tendonitis. See September 1980 service treatment records. The Veteran contends his current left hand condition is related to service. See September 2016 VA Form 21-526EZ. Satisfying the third McLendon element requires only that the evidence ‘indicates’ that there ‘may’ be a nexus between the two and is a low threshold. See McLendon, 20 Vet. App. at 83. Thus, as the Veteran has not yet received a VA examination, a remand is required. The matters are REMANDED for the following action: 1. Obtain any outstanding and updated relevant VA and/or private treatment records and associate the same with the claims file. 2. Thereafter, schedule the Veteran for an examination to determine the nature and etiology of the Veteran’s current left hand condition, to include carpal tunnel syndrome. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the reviewing clinician. The opinion should include a notation that this review took place. After a thorough review of the record, the examiner should answer the following: Is it at least as likely as not (a 50 percent probability or more) the Veteran’s left hand condition, to include carpal tunnel syndrome, was incurred in or is otherwise related to his time in service? The examiner is directed to September 1980 service treatment records noting treatment for left wrist pain and left wrist tendonitis. The examiner should note the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, a reason for doing so should also be provided. A full and complete rationale for all opinions must be provided, and a discussion of the facts and medical principles should be considered. 3. After the above has been completed to the extent possible, readjudicate the claim. If any benefit sought remains denied, provide the Veteran with an SSOC and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Bona, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.