Citation Nr: 21007402 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 15-06 213 DATE: February 9, 2021 ORDER For the appeal period prior to March 17, 2017, entitlement to a disability rating in excess of 10 percent for scoliosis of the lumbar spine with intermittent lumbosacral strain (hereinafter lumbar spine disability) is denied. For the appeal period from March 17, 2017 and prior to April 6, 2018, entitlement to a disability rating in excess of 20 percent for a lumbar spine disability is denied. For the appeal period from April 6, 2018, entitlement to a disability rating of 40 percent, but no higher, for a lumbar spine disability is granted. Entitlement to a compensable rating for hearing loss is denied. Entitlement to a disability rating in excess of 10 percent for residuals of traumatic brain injury (TBI) (previously rated as residual of right temporal skull fracture with recurrent tinnitus), is denied. Entitlement to a disability rating in excess of 10 percent for Bell's Palsy, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to July 1, 2018 is denied. REMANDED Entitlement to a disability rating in excess of 10 percent for residuals of left leg subtrochanteric fracture, is remanded. Entitlement to a TDIU, for the purposes of establishing eligibility to special monthly compensation (SMC) at the housebound rate from July 1, 2018 to the present, is remanded. FINDINGS OF FACT 1. For the appeal period prior to March 17, 2017, the Veteran’s service-connected lumbar spine disability was manifested by functional impairment consisting of pain and limitation of motion, without limitation of forward flexion of the thoracolumbar spine to less than 60 degrees or limitation of the combined range of motion of the thoracolumbar spine less than 120 degrees, even in contemplation of functional impairment resulting from pain, weakness, fatigue, or incoordination, or following repetitive testing or during flare ups; muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour; ankylosis; intervertebral disc syndrome resulting in incapacitating episodes; or associated objective neurological abnormalities. 2. For the appeal period from March 17, 2017 and prior to April 6, 2018, the Veteran's service-connected lumbar spine disability was manifested by functional impairment consisting of subjective complaints of pain, limitation of motion, and muscle spasm and guarding resulting in an abnormal gait or spinal contour, without limitation of forward flexion of the thoracolumbar spine to 30 degrees or less, even in contemplation of functional impairment resulting from pain, weakness, fatigue, or incoordination, or following repetitive testing or during flare ups; ankylosis; intervertebral disc syndrome resulting in incapacitating episodes; or associated objective neurological abnormalities. 3. For the appeal period from April 6, 2018, to the present, the evidence of record shows limitation of flexion to less than 30 degrees, but does not show that the Veteran's lumbar spine is unfavorably ankylosed. 4. During the entire appeal period, the Veteran's hearing loss disability was productive of no worse than a Level II acuity on the right side and a Level I on the left side. 5. During the entire appeal period, the Veteran’s residuals of TBI was manifested by no more than Level 1 impairment. 6. The Veteran's Bell’s Palsy is characterized as moderate incomplete paralysis of the seventh cranial nerve; during the pendency of the appeal, the Veteran's Bell’s Palsy has not been characterized by severe incomplete paralysis or complete paralysis of the cranial nerve. 7. The Veteran was gainfully employed as a mail carrier for the U.S. Postal Service for all times prior to July 1, 2018. CONCLUSIONS OF LAW 1. For the appeal period prior to March 17, 2017, the criteria for entitlement to an increased evaluation greater than 10 percent for the service-connected lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.49, 4.7.1a, Diagnostic Code 5237. 2. For the appeal period from March 17, 2017 and prior to April 6, 2018, the criteria for entitlement to an increased evaluation greater than 10 percent for the service-connected lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.49, 4.7.1a, Diagnostic Code 5237. 3. For the appeal period from April 6, 2018, the criteria for entitlement to an increased evaluation to 40 percent, but no higher, for the service-connected lumbar spine disability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.49, 4.7.1a, Diagnostic Code 5237. 4. The criteria for entitlement to a compensable rating for bilateral ear hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.85, 4.86, Diagnostic Code 6100 (2020). 5. The criteria for entitlement to a disability rating in excess of 10 percent for residuals of a TBI have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.124a, Diagnostic Code 8045. 6. The criteria for a disability rating in excess of 10 percent for Bell’s Palsy, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8207. 7. The criteria for an award of TDIU for the time period prior to July 1, 2018 have not been met. 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1975 to August 1978. He testified at a videoconference hearing before the undersigned in April 2018. A transcript of the hearing is of record. In July 2018, the Board remanded the claims for further development. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability; resolving any reasonable doubt regarding the degree of disability in favor of the claimant; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity. See 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.10 (2019); see also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ( [I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria. ). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). 1. Evaluation of Lumbar Spine Disability The Veteran's lumbar spine disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237, for lumbosacral strain. Diagnostic Code 5237 is rated under the General Rating Formula for Diseases and Injuries of the Spine (Rating Formula). Under the Rating Formula, in pertinent part, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or 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 abdominal kyphosis. The provisions of a 30 percent rating are specific to conditions of the cervical spine. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine measuring to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. To warrant a rating of 50 percent, there must be unfavorable ankylosis of the entire thoracolumbar spine. To warrant a rating of 100 percent, there must be unfavorable ankylosis of the entire spine. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. A. For the appeal period prior to March 17, 2017, entitlement to a disability rating in excess of 10 percent for a lumbar spine disability is denied. The Veteran asserts that his lumbar spine disability warrants a higher rating. At a January 2011 VA examination, the Veteran denied the use of crutches, canes, walkers, or braces. He had pain that was off and on and throbbing/aching that was moderate to severe for years in the left lower back, into the buttocks and into the back of the left leg. There was stiffness, but no deformity, swelling, cruising/redness, fatigue, decreased range of motion, dislocations or subluxations, or alterations in bowel, bladder, and penile function. There was no instability, locking or giving away. There was lack of endurance with heavy lifting or bending over. He could walk 3-4 miles. There were no functional limitations with standing more than 30 minutes. There were no incapacitating episodes or effect on routine activities of daily living. He had severe flare ups 1-2 times a month that lasted hours with no further functional impairment. The pain was worse with jogging, jumping, bending over, and climbing stairs. He did not have arthritis. Regarding the effects of the condition on usual occupation and daily activities, the Veteran reported that he worked as a letter carrier for 28.5 years and the back and left leg hindered him from walking, climbing stairs, or carrying heavy objects. He denied taking time off work and learned to work through the pain with ibuprofen. On examination there was a normal lumbar lordotic curve and normal thoracic and kyphotic curve. There was no tenderness with palpation or guarding or grimacing. There was pain with motion with no evidence of weakens decreased strength with range of motion, lack of endurance, fatigue, spasm, instability, incoordination, subluxation, or obvious atrophy or tone. Ranges of motion were flexion from 0 to 90 degrees, extension from 0 to 35 degrees, and bilateral lateral flexion and rotation each from 0 to 30 degrees. All ranges of motion were without limitations following repetitive use testing. He was diagnosed with lumbar strain without evidence of scoliosis on imaging. On October 2014 VA back examination, the Veteran reported that he has worked at the post office as a letter carrier for 30 years and that he had back pain from prolonged walking, climbing, stooping, and carrying heavy objects. He also had complaints of pain one to two times a week from lifting, pushing, and pulling. He denied weakness, decreased range of motion, numbness, tingling, redness, bruising, or any other complaints. He denied taking time off work and learned to work through his pain with Ibuprofen. He was diagnosed with lumbar strain. He denied the use of crutches, canes, braces, acupuncture, TENS, injections, traction, or surgery. He denied having flare-ups. Range of motion studies showed forward flexion to 90 degrees or greater and extension and bilateral lateral rotation and flexion each to 30 degrees or more. There was no objective evidence of pain on motion. The Veteran was able to perform repetitive-use testing with 3 repetitions with no additional limitation in range of motion. He did not have any functional loss and/or functional impairment. There was tenderness in the right lumbar erector spine region. There were no muscle spasms and he did not have guarding. Muscle strength testing in the hip, knee, ankle, and great toe was normal. There was no muscle atrophy. Reflex and sensory examinations were normal. Straight leg raising test was negative. He did not have radicular pain or any other signs or symptoms due to radiculopathy. There were no other neurological symptoms. He did not have intervertebral disc syndrome. There was no ankylosis. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. He did not have arthritis or thoracic vertebral fracture with loss of 50 percent or more of height. The Veteran’s back condition did not impact his ability to work. Although the examiner stated that he could not comment on any of the joint examination limitations or loss of range of motion due to pain, weakness, fatigability, or incoordination during flare-ups without resort to mere speculation, the Board notes that the Veteran had specifically denied the presence of flare-ups at that examination. The results of the VA examinations did not demonstrate that the Veteran's disability manifested in range of motion loss commensurate with that required for an increased rating to 20 percent. The Board acknowledges the Veteran's lay reports of symptoms and flare-ups in 2011; however, it was noted that pain, weakness, fatigability, or incoordination did not significantly limit functional ability, including with repeated use over a period of time or with a flare-up. Even when considering Deluca factors and functional impairment during flares or after repetitive use, the evidence simply did not show that the Veteran's disability manifested in limitation of motion for forward flexion to 30 degrees or less. The Veteran did not experience ankylosis, kyphosis, muscle spasms or guarding. A rating higher than 10 percent prior to March 17, 2017, is not warranted. The Board has considered whether a higher rating can be awarded at any time during the period under review under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record does not show that the Veteran ever had intervertebral disc syndrome or even was prescribed bed rest by a physician for a duration that met the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The Board adds that radiculopathy has not been found on examination and there are no separately ratable abnormal neurological symptoms, such as bowel or urinary symptoms. The evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. Moreover, the General Rating Formula contemplates back pain, whether or not it radiates. In sum, the Board finds that for the time period prior to March 17, 2017, entitlement to a rating in excess of 10 percent for the Veteran's service-connected spine disability is denied. B. For the appeal period from March 17, 2017 and prior to April 6, 2018, entitlement to a disability rating in excess of 20 percent for a lumbar spine disability is denied. The Veteran asserts that his lumbar spine disability warrants a higher rating. On March 2017 VA examination, the examiner commented that regarding VA established diagnosis of scoliosis and lumbar spine with intermittent lumbosacral strain, there was no change in the diagnosis. The Veteran described flare-ups as not being able to walk due to back pain. Regarding functional impairment, the he reported that walking was difficult. Range of motion studies revealed forward flexion from 0 to 50 degrees and extension from 0 to 10 degrees. Bilateral lateral flexion and rotation were each from 0 to 20 degrees. There was pain with all ranges of motion and evidence of pain with weight bearing. The examiner indicated that the range of motions contributed to functional loss due to pain. There was no objective evidence of tenderness or pain on palpation. There was no additional loss of function or range of motion after three repetitions. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over a period of time or with a flare-up. The examination was not conducted during a flare-up. There was no localized tenderness, guarding, or muscle spasm. There was disturbance of locomotion and interference with sitting and standing. Muscle strength testing showed that knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension were 4/5 on the left side. There was no muscle atrophy. Deep tendon reflexes and sensory examinations were normal. Straight leg raising test was negative. He did not have radicular pain or any other signs or symptoms due to radiculopathy. There were no other neurological symptoms. The Veteran did not have intervertebral disc syndrome. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. There was no ankylosis of the spine or intervertebral disc syndrome. Regarding assistive device, it was noted that he used platform shoes on the left side. Regarding the functional impact of the Veteran’s spine on his ability to work, he reported that walking was painful and difficult. There was objective evidence of pain on passive range of motion and on non-weight bearing testing. VA treatment records dated in September 2017 noted the Veteran’s complaints of a chronic worsening of low back pain for the past month. He felt that it was affecting his ability to do his job. He denied any recent fall, trauma/injury, redness, swelling, numbness, tingling of upper/lower extremity/back/neck, or loss of bladder/bowel control. In March 2018, he had complaints of lower back pain in both sides. The Board finds that preponderance of the evidence is against the assignment of a rating in excess of 20 percent for the Veteran's lumbar spine disability for the appeal period from March 17, 2017 and prior to April 6, 2018. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain. The Board has considered the Veteran's own descriptions of the severity of his flare-ups, including reports of not being able to walk due to back pain and having back pain that flared throughout the day as well as his complaints of worsening back pain; however, pain, weakness, fatigability, or incoordination was not shown to significantly limit functional ability with repeated use over a period of time or with a flare-up, and forward flexion was limited to 50 degrees. The evidence was still not sufficient to warrant an increased rating to 40 percent under the Rating Schedule. The Veteran never contended that he suffered from ankylosis, or that his range of motion was so limited that his flexion was 30 degrees or less during a period of flare-up or after repetitive use. Consideration has also been given to assigning a rating under the Formula for IVDS Based on Incapacitating Episodes. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. However, such would not avail the Veteran as the evidence does not demonstrate that his back disability has manifested in IVDS with incapacitating episodes requiring physician-prescribed bed rest, as is required for a rating under the IVDS Formula. The Board has considered the Veteran’s testimony of experiencing pain that radiated from his neck to his lower back with tingling in his upper and lower extremities, however, on a subsequent VA treatment record he specifically denied having radicular symptoms into the lower extremities. Given that radiculopathy has not been found on examination and there are no separately ratable abnormal neurological symptoms, such as bowel or urinary symptoms. The evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. In sum, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 20 percent for a lumbar spine disability. C. For the appeal period from April 6, 2018, entitlement to a disability rating of 40 percent, but no higher, for a lumbar spine disability is granted. The Veteran asserts that his lumbar spine disability warrants a higher rating. At his April 6, 2018 hearing, the Veteran noted that due to his physical disabilities, to include his back, he was retiring from his long career as a mail carrier on June 30, 2018. The Veteran described worsening symptoms that triggered the Board’s determination that a new examination should be scheduled so that an accurate assessment of the severity of the Veteran’s condition could be obtained. This examination did not take place until October 2019. At the October 2019 VA examination, the Veteran described flare-ups as having a lot of muscle spasms and pulling muscles easily, which felt like pins and needles. He stated that stretching and taking Aleve/Advil helped his back. Regarding functional loss/impairment, he reported that he could not sit or stand for more than 30-60 minutes. He had trouble with stooping and lifting anything heavier than 10 pounds. Range of motion showed forward flexion to 20 degrees, extension to 30 degrees, right lateral flexion to 15 degrees, left lateral flexion to 0 degrees, and bilateral lateral rotation each to 20 degrees. The examiner noted that the Veteran’s range of motion itself contributed to functional loss due to the Veteran’s inability to bend. Pain was noted on examination on all ranges of motion and caused functional loss. There was no evidence of pain with weight bearing. There was mild tenderness and muscle guarding to palpation with moderate myofascial restrictions due to scoliosis. There was no additional loss of function or range of motion after three repetitions. Pain limited functional ability with repeated use over a period of time and with a flare-up. The examination was not conducted during a flare-up. Range of motion during repeated use over time or during a flare-up was estimated as follows: forward flexion from 0 to 10 degrees, extension from 0 to 20 degrees, right lateral flexion and bilateral lateral rotation each to 10 degrees and left lateral flexion to 5 degrees. There was no guarding or muscle spasm. Muscle strength, reflex and sensory examinations were all normal. Straight leg raising test was negative. There were no signs or symptoms of radiculopathy. There was no ankylosis. There were no other neurologic abnormalities. The Veteran did not have intervertebral disc syndrome with incapacitating episodes. He constantly used a cane due to scoliosis and leg length discrepancy. There were no other pertinent physical findings, complications, conditions, signs, or symptoms. There was no ankylosis of the spine or intervertebral disc syndrome. Regarding the functional impact of the Veteran’s spine on his ability to work, he was unable to stoop, squat, lift anything over 10 pounds, sit or stand for more than 30-60 minutes, and had frequent muscle spasm. There was evidence of pain on passive range of motion and no evidence of pain when the joint was used in non-weight bearing. Although the AOJ awarded the Veteran an increased rating for his spine to 40 percent as of the date of his October 2019 examination, the Board will resolve all doubt in the Veteran’s favor and make this increase effective the date of his Board hearing, as this is the date he expressed worsening symptoms that triggered the need for a new assessment. Once that assessment took place, it was clear that the Veteran met the criteria for an increased to 40 percent based on limitation of flexion during flare ups. As such, an increased rating to 40 percent is granted, effective April 6, 2018. That stated, the Board finds that the preponderance of the evidence is against a rating in excess of 40 percent for the Veteran's lumbar spine disability, as the evidence simply does not demonstrate that the Veteran's lumbar spine is ankylosed. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain during flare-ups, and pain during repetitive use over time. See October 2019 VA Examination. Pertinently however, even during flares or after repetitive use, the Veteran was able to move his spine, albeit to a limited degree. Neither he nor his representative asserts to the contrary. As such, a higher rating than the currently assigned 40 percent under the General Rating Formula for spine disabilities is not warranted. Consideration has also been given to assigning a rating under the Formula for IVDS Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran had intervertebral disc syndrome and/or was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating during the period on appeal. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes; see also October 2019 VA Examination. Regarding neurological impairment, the lay and medical evidence of record did not establish that the Veteran had radiculopathy, or any other neurological abnormality associated with his spine disability. For the foregoing reasons, an increased rating to 40 percent is granted effective April 6, 2018. However, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 40 percent for the Veteran's lumbar spine disability. 2. Entitlement to a compensable rating for bilateral hearing loss is denied. In evaluating hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Hearing loss disability evaluations range from noncompensable (zero percent) to a maximum 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests (Maryland CNC) in conjunction with the average hearing threshold, as measured by puretone audiometric tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second (Hertz). The rating schedule establishes eleven auditory acuity levels, designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. VA audiometric examinations are conducted using a controlled speech discrimination test together with the results of a puretone audiometry test. Under 38 C.F.R. § 4.85, the vertical lines in Table VI represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. The horizontal columns in Table VI represent nine categories of decibel loss based on the puretone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the puretone decibel loss. If impaired hearing is service-connected in only one ear, in order 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. See 38 C.F.R. § 4.85(f). The percentage evaluation is determined from Table VII (in 38 C.F.R. § 4.85) by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate to the numeric designation for the ear having the poorer hearing acuity. To establish entitlement to a compensable rating for hearing loss, it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average puretone decibel loss are met. The provisions of 38 C.F.R. § 4.86(a) pertaining to exceptional patterns of hearing impairment provide that, 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. Also, the provisions of 38 C.F.R. § 4.86(b) pertaining to exceptional patterns of hearing impairment provide that, 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. In Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007), the United States Court of Appeals for Veterans Claims (Court) held that relevant to VA audiological examinations, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. The Veteran alleges that a compensable disability rating is warranted for his bilateral ear hearing loss disability. The Board notes that at the time of the Veteran’s claim for increase, only his right ear hearing loss was service-connected. During the course of the appeal, the AOJ awarded service connection for the left ear, and continued the noncompensable rating for all times during the period under review. For the purposes of this decision, the Board will rate the Veteran’s disability as a bilateral hearing disability throughout the entire appeal period. The Veteran underwent a VA examination in October 2010, which showed puretone thresholds as: HERTZ 1000 2000 3000 4000 Average RIGHT 10 20 25 25 20 LEFT 10 15 15 20 15 The average puretone threshold was 20 in the in the right ear and 15 in the left ear. Speech audiometry revealed speech recognition ability of 94 percent in both ears. As no exceptional pattern of hearing loss is reflected by this examination, Table VI is applicable, and reflects that the Veteran had Level I hearing loss in both ears. Applying Level I for the left ear and Level I for the right ear results in a noncompensable disability rating. 38 C.F.R. § 4.85. The Veteran underwent a VA examination in October 2014, which showed puretone thresholds as: HERTZ 1000 2000 3000 4000 Average RIGHT 15 20 30 60 31 LEFT 15 20 20 15 18 The average puretone threshold was 31 in the in the right ear and 18 in the left ear. Speech audiometry revealed speech recognition ability of 100 percent in both ears. As no exceptional pattern of hearing loss is reflected by this examination, Table VI is applicable, and reflects that the Veteran had Level I hearing loss in both ears. Applying Level I for the left ear and Level I for the right ear results in a noncompensable disability rating. 38 C.F.R. § 4.85. During the examination, the examiner described the functional effects of the Veteran's hearing loss on his daily activities. 38 C.F.R. § 4.10; see also Martinak, 21 Vet. App. at 455-56. Specifically, on the October 2014 VA examination, the Veteran reported that he had difficulty understanding what people were saying, especially if they sat in the right side of him. The Veteran underwent a VA examination in September 2016, which showed puretone thresholds as: HERTZ 1000 2000 3000 4000 Average RIGHT 45 50 50 55 50 LEFT 30 30 30 40 33 The average puretone threshold was 50 in the in the right ear and 33 in the left ear. Speech audiometry revealed speech recognition ability of 96 percent in the right ear and 100 percent in the left ear. As no exceptional pattern of hearing loss is reflected by this examination, Table VI is applicable, and reflects that the Veteran had Level I hearing loss in both ears. Applying Level I for the left ear and Level I for the right ear results in a noncompensable disability rating. 38 C.F.R. § 4.85. Regarding the functional effects of the Veteran's hearing loss on his daily activities, including work, he reported that he had frequent ringing in his ear and was not able to understand words at a certain pitch if someone spoke softly. After the Board’s prior remand, the Veteran underwent a VA examination in October 2019, which showed puretone thresholds as: HERTZ 1000 2000 3000 4000 Average RIGHT 30 60 65 75 58 LEFT 20 30 35 45 33 The average puretone threshold was 58 in the in the right ear and 33 in the left ear. Speech audiometry revealed speech recognition ability of 94 percent, bilaterally. As no exceptional pattern of hearing loss is reflected by the examination, Table VI is applicable, and reflects that the Veteran had Level II hearing loss in his right ear and a Level I hearing loss in the left ear. Applying Level II for the right ear and Level I for the left ear results in a noncompensable disability rating. 38 C.F.R. § 4.85. Regarding the functional effects of the Veteran’s hearing loss on his daily activities, including the ability to work, he reported that he needed words repeated, had trouble on the phone, and turned up the television. While the Board in no way calls into question the effects of the Veteran’s hearing loss disability on his ability to hear during conversations or watching television, the Court of Appeals for Veterans Claims has specifically held that the schedular criteria for rating hearing loss contemplates the functional effects of difficulty hearing and understanding speech, such as those reported by the Veteran at his VA examinations and his Board hearing. Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017). Based on the VA audiological test results of record, the Board finds that the Veteran is not entitled to a compensable rating for his bilateral hearing loss at any time. To the extent that the Veteran contends that his hearing loss is more severe than reflected by these evaluations, the Board observes that, while he is competent to report symptoms such as difficulty hearing or indicate that it takes effort to hear things, he is not competent to report that his hearing acuity is of sufficient severity to warrant a higher evaluation under VA's tables for rating hearing loss disabilities because such an opinion requires medical expertise (training in evaluating hearing impairment), which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). For the reasons discussed above, the Veteran's claim for a higher rating for bilateral ear hearing loss must be denied. 3. Entitlement to a disability rating in excess of 10 percent for residuals of TBI is denied. The Veteran’s residuals of TBI, previously rated as residual of right temporal skull fracture with recurrent tinnitus has been assigned a 10 percent evaluation under Diagnosis Code 8045. Diagnostic Code 8045 provides evaluation for three main areas of dysfunction that may result from traumatic brain injury and have profound effects on functioning: (1) cognitive, which is common in varying degrees after a traumatic brain injury; (2) emotional/behavioral; and (3) physical. Each of those areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, DC 8045. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In an individual, symptoms may fluctuate in severity from day to day. Cognitive impairment is evaluated under the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. 38 C.F.R. § 4.124a, DC 8045. Subjective symptoms may be the only residual of a traumatic brain injury or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of a traumatic brain injury, whether or not they are part of cognitive impairment, are evaluated under the subjective symptoms facet in the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. However, any residual with a distinct diagnosis that may be evaluated under another DC, such as migraine headache or Meniere's disease, should be evaluated separately even if that diagnosis is based on subjective symptoms, rather than under the Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified table. 38 C.F.R. § 4.124a, DC 8045. Emotional/behavioral dysfunction is evaluated under 38 C.F.R. § 4.130, based on the schedule of ratings for mental disorders, when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, emotional/behavioral symptoms are evaluated under the criteria in the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified. 38 C.F.R. § 4.124a, DC 8045. Physical (including neurological) dysfunction is evaluated based on the following list, under an appropriate DC: motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. 38 C.F.R. § 4.124a, DC 8045. The preceding list of types of physical dysfunction does not encompass all possible residuals of a traumatic brain injury. For residuals not listed here that are reported on an examination, evaluate under the most appropriate DC. Each condition is evaluated separately, as long as the same signs and symptoms are not used to support more than one evaluation; and combined under 38 C.F.R. § 4.25 for each separately rated condition. The rating assigned based on the Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified table will be considered the rating for a single condition for purposes of combining with other disability ratings. 38 C.F.R. § 4.124a, DC 8045. Cognitive impairment and subjective symptoms are evaluated using the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified which contains ten important facets of a traumatic brain injury related to cognitive impairment and subjective symptoms. That table provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a fifth level, the highest level of impairment, and labeled total. However, not every facet has every level of severity. The consciousness facet, for example, does not provide for an impairment level other than total, because any level of impaired consciousness would be totally disabling. A 100 percent rating is assigned if total is the level of evaluation for one or more facets. If no facet is evaluated as total, the overall percentage rating is based on the level of the highest facet. If the highest is 0, then a 0 percent rating is assigned. If the highest is 1, then a 10 percent rating is assigned. If the highest is 2, then a 40 percent rating is assigned. If the highest is 3, then a 70 percent rating is assigned. 38 C.F.R. § 4.124a, DC 8045. There may be an overlap of manifestations of conditions evaluated under the table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another DC. In such cases, more than one evaluation based on the same manifestations is not to be assigned. If the manifestations of two or more conditions cannot be clearly separated, a single evaluation is assigned under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, a separate evaluation is assigned for each condition. 38 C.F.R. § 4.124a, DC 8045, Note (1). Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. 38 C.F.R. § 4.124a, DC 8045, Note (2). Instrumental activities of daily living refer to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. Those activities are distinguished from activities of daily living, which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. 38 C.F.R. § 4.124a, DC 8045, Note (3). The terms mild, moderate, and severe traumatic brain injury, which may appear in medical records, refer to a classification of traumatic brain injury made at, or close to, the time of injury rather than to the current level of functioning. That classification does not affect the rating assigned under DC 8045. 38 C.F.R. § 4.124a, DC 8045, Note (4). The table titled Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified provides the following evaluations: Impairment of memory, attention, concentration, executive functions are assigned numerical designations of 0 for no complaints of impairment of memory, attention, concentration, or executive functions; 1 for a complaint of mild loss of memory (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing; 2 for objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment; 3 for objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment; and total for objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment. Impairment of judgment is assigned numerical designations of 0 for normal; 1 for mildly impaired judgment for complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision; 2 for moderately impaired judgment, for complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions; 3 for moderately severely impaired judgment, for even routine and familiar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision; and total for severely impaired judgment, for even routine and familiar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, for example, unable to determine appropriate clothing for current weather conditions or judge when to avoid dangerous situations or activities. Impairment of social interaction is assigned numerical designations of 0 for social interaction is routinely appropriate; 1 for social interaction is occasionally inappropriate; 2 for social interaction is frequently inappropriate; and 3 for social interaction is inappropriate most or all of the time. Impairment of orientation is assigned numerical designations of 0 for always oriented to person, time, place, and situation; 1 for occasionally disoriented to one of the four aspects (person, time, place, situation) of orientation; 2 for occasionally disoriented to two of the four aspects (person, time, place, situation) of orientation or often disoriented to one aspect of orientation; 3 for often disoriented to two or more of the four aspects (person, time, place, situation) of orientation; and total for consistently disoriented to two or more of the four aspects (person, time, place, situation) of orientation. Impairment of motor activity (with intact motor and sensory system) is assigned numerical designations of 0 for motor activity normal; 1 for motor activity normal most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function); 2 for motor activity mildly decreased or with moderate slowing due to apraxia; 3 for motor activity moderately decreased due to apraxia; and total for motor activity severely decreased due to apraxia. Impairment of visual spatial orientation is assigned numerical designations of 1 for mildly impaired, occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions, is able to use assistive devices such as GPS (global positioning system); 2 for moderately impaired, usually gets lost in unfamiliar surroundings, has difficulty reading maps, following directions, and judging distance, has difficulty using assistive devices such as GPS; 3 for moderately severely impaired, gets lost even in familiar surroundings, unable to use assistive devices such as GPS; and total for severely impaired, such as unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment. Subjective symptoms are assigned numerical designations of 0 for subjective symptoms that do not interfere with work, instrumental activities of daily living, or work, family, or other close relationships, examples are mild or occasional headaches, mild anxiety; 1 for three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family, or other close relationships, examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light; and 2 for three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living; or work, family, or other close relationships, examples of findings that might be seen at this level of impairment are: marked fatigability, blurred or double vision, headaches requiring rest periods during most days. Neurobehavioral effects are assigned numerical designations of 0 for one or more neurobehavioral effects that do not interfere with workplace interaction or social interaction, examples of neurobehavioral effects are: Irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability, any of these effects may range from slight to severe, although verbal and physical aggression are likely to have a more serious impact on workplace interaction and social interaction than some of the other effects; 1 for one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them; 2 for one or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them; and 3 for one or more neurobehavioral effects that interfere with or preclude workplace interaction, social interaction, or both on most days or that occasionally require supervision for safety of self or others. Impairment of communication is assigned numerical designations of 0 for able to communicate by spoken and written language (expressive communication), and to comprehend spoken and written language; 1 for comprehension or expression, or both, of either spoken language or written language is only occasionally impaired, can communicate complex ideas; 2 for inability to communicate either by spoken language, written language, or both, more than occasionally but less than half of the time, or to comprehend spoken language, written language, or both, more than occasionally but less than half of the time, can generally communicate complex ideas; 3 for inability to communicate either by spoken language, written language, or both, at least half of the time but not all of the time, or to comprehend spoken language, written language, or both, at least half of the time but not all of the time, may rely on gestures or other alternative modes of communication, able to communicate basic needs; and total for complete inability to communicate either by spoken language, written language, or both, or to comprehend spoken language, written language, or both, unable to communicate basic needs. Initially, the Veteran's service-connected residual of right temporal skull fracture is the result of an in-service TBI. The Veteran is also in receipt of separate disability ratings for service-connected depressive disorder, rated as 70 percent disabling, effective April 6, 2018); and, for tinnitus, rated as 10 percent from August 31, 2010, that was previously rated together with residual right temporal skull fracture. The discussion turns to the evidence in the record relevant to the severity of the service-connected residuals of a TBI during the appeal period. During his April 2018 videoconference hearing, the Veteran asserted that the residuals of his right temporal skull fracture disability and symptoms of his Bell’s Palsy disability have increased in severity and he had headaches that currently occurred two to three times per week rather than two times per month as previously reported. He also reported increased episodes of dizziness. On July 2020 VA TBI examination, a medical history reported that the Veteran had current symptoms of dizziness and disorientation. As a result, he had to avoid extreme laughter, turning around in circles, and avoid any apparatus that spins. Regarding a TBI related cognitive impairment, the examiner indicated that the Veteran a complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing. On Montreal Cognitive Assessment, he had difficulty with recent memories and completing the object name recollection. His judgment, social interaction, orientation, motor activity, communication, and consciousness were normal or appropriate. Regarding visual spatial orientation, there was mild impairment. The examiner indicated that the Veteran occasionally got lost in unfamiliar surroundings, had difficulty reading maps or following directions, but was able to use assistive devices such as GPS (global positioning system). The Veteran had difficulty with visual spatial orientation that caused anxiety with emotional stimulus precipitating headaches, dizziness, and disorientation. He used GPS for most navigation out of the local area to avoid this emotional trigger. Regarding neurobehavioral effects, there were one or more neurobehavioral effects that did not interfere with the workplace interaction or social interaction. The effects were described as increased emotional stress productive of headaches and occasional dizziness. The examiner determined that the Veteran did not have any subjective symptoms or any mental, physical, or neurological conditions or residuals attributable to TBI (such as migraine headaches or Meniere’s disease). The Veteran did not have any other pertinent physical findings, complications, conditions, signs and/or symptoms. Regarding the impact on the Veteran’s ability to work, the Veteran reported that he was retired, but would have difficulty returning to the post office if working the front counter with continuous interpersonal exposure. The examiner noted that the Veteran had an additional. documented mental health disorder of depressive disorder and that it was not possible to differentiate the symptoms of TBI and each confirmed/documented mental health disorder because the two were very closely related with symptoms of depression and TBI being similar. Applying the rating criteria set out under DC 8045, the medical evidence in the record, specifically the July 2020 DBQ, shows that the Veteran's residuals of TBI are not of such severity as to warrant assignment of a rating in excess of the currently assigned 10 percent. Specifically, none of the ten facets of cognitive impairment and other residuals of TBI not otherwise classified are shown by the evidence in the record to cause a level of impairment greater than 1, as would warrant assignment of a rating greater than 10 percent. See 38 C.F.R. § 4.124a (DC 8045). The Board notes that the Veteran is service-connected for depressive disorder rated as 70 percent disabling. He is also service-connected for tinnitus rated as 10 percent disabling. Although the Veteran was reported to have mild memory loss, it has been associated with his depressive disorder and the July 2020 VA examiner added that it was not possible to differentiate the symptoms of TBI and his depressive disorder. The Board also notes that tinnitus has likewise been separately rated. Regarding, visual spatial orientation, it was described as a mild impairment, which would be productive of no more than a level 1 impairment of visual special orientation. Regarding neurobehavioral effects, there were one or more neurobehavioral effects that did not interfere with the workplace interaction or social interaction. The effects were described as increased emotional stress productive of headaches and occasional dizziness, which would be no more than level 1 impairment. The examiner determined that the Veteran did not have any subjective symptoms or any mental, physical, or neurological conditions or residuals attributable to TBI (such as migraine headaches or Meniere’s disease) to warrant any additional separate ratings for migraine headaches or Meniere’s disease. The Veteran's judgment, social interaction, orientation, motor activity, communication, and consciousness have been noted as normal. A higher rating is not appropriate because none of the facets, for which there is impairment shown by competent and credible evidence, warrant an assignment of more than level 1 impairment. In sum, the criteria for a rating in excess of 10 percent for residuals of TBI are not met. The preponderance of evidence is against the claim. There are no additional issues expressly or reasonably raised on the record related to this appeal. 4. Entitlement to a rating in excess of 10 percent for Bell’s Palsy is denied. The Veteran's Bell’s Palsy has been rated as 10 percent disabling since August 31, 2010 under Diagnostic Code 8207, pertaining to paralysis of the seventh (facial) cranial nerve. Under Diagnostic Code 8207, a 10 percent rating is assigned for moderate incomplete paralysis; a 20 percent rating is assigned for severe incomplete paralysis; and a 30 percent rating is assigned for complete paralysis of the seventh (facial) cranial nerve. 38 C.F.R. § 4.124a, Diagnostic Code 8207. VA treatment records dated in September 2010 included the Veteran’s reports of his face twitching and causing him to bite his lower lip while chewing. On October 2010 VA examination, the Veteran reported symptoms of twitching in his eyes, biting the sides of his lips and tongue, and slight twitching of his face. He had not seen a neurologist for these symptoms, and they did not affect his ability to work. He denied right/left facial droop/weakness, inability to blink/close eye/sensitivity to light, dry eye or mouth, difficulties tasting/speaking/eating, drooling, facial swelling, pain to ear, excess or reduced salivation, hypersensitivity to sound, or other problems. On October 2014 VA cranial nerve examination, the Veteran was diagnosed with Bell’s Palsy resolved. He reported that over the past 10 years he noticed a "twitching of his eyes, biting the sides of his lips and tongue, and slight twitching of his face". He had not been seen by a neurologist for these symptoms and they had not affected his ability to work. He denied recent right/left facial droop/weakness, inability to blink/close eye/sensitivity to light, dry eye or mouth, difficulties tasting/speaking/eating, drooling, facial swelling, pain to ear, excess or reduced salivation, hypersensitivity to sound, or other problems. Muscle strength testing and sensory examination was normal. Cranial nerve summary evaluation indicted that none of the cranial nerves were affected. The condition did not impact his ability to work. The examiner noted that the Veteran continued to complain about similar neurological symptoms in 2011 and 2014, yet these symptoms were not from a recurrence or residuals of Bell’s Palsy. At an August 2017 VA cranial nerve diseases examination, the Veteran reported that he would bite the inside of his right cheek or lip and still could not whistle with force. Mild difficulty with chewing was identified as a symptom related to the Veteran’s cranial nerve condition, Bell’s Palsy. Cranial nerve VII (fascial) was the nerve affected by the Veteran’s condition. There was moderate incomplete paralysis of cranial nerve VII. Although the examiner noted muscle strength testing showed a mild impact on the right cranial nerve V, this appears to have been in misplaced, as all other parts of the report indicate impairment of cranial nerve VII only. Sensory examination was normal. The condition did not impact the Veteran’s ability to work. During his April 2018 videoconference hearing, the Veteran asserted that the symptoms of his Bell’s Palsy disability had increased in severity and that he had increased muscle spasms of the face and incidents of biting his tongue and lips. He stated that he bit his lips or tongue approximately 8 times per week when eating and laughing. On October 2019 VA cranial nerves examination, the Veteran reported a history of Bell’s Palsy on the left side of his face. He reported tinnitus, dry mouth and dry eyes, which he used prescription eye drops. He claimed that he bit his lips and mouth while chewing on a daily basis. He denied headaches, ear pain, sensitivity to sound, swallowing problems, drooling, decreased ability to taste/smell and weight loss. He also denied muscle weakness, numbness, and tingling. He was diagnosed with Bell’s Palsy, which affected the cranial nerve VII (facial) and caused mild difficulty with chewing. Muscle strength testing and sensory examination were normal. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms related to the Veteran’s Bell’s Palsy. His cranial nerve condition did not impact his ability to work. The Board has considered the Veteran’s complaints of twitching of his eyes, biting the sides of his lips and tongue, and twitching of his face. While such symptoms clearly are present, and undoubtedly painful and frustrating, no physician has indicated that they are manifestations of incomplete paralysis of the cranial nerve that is severe in disability. Indeed, the Veteran has specifically denied other symptoms indicative of more severe disability to include right/left facial droop/weakness, inability to blink/close eye/sensitivity to light, difficulties tasting and speaking, drooling, facial swelling, pain to ear, excess or reduced salivation, or hypersensitivity to sound. At his most recent examination in October 2019, he reported tinnitus, dry mouth and dry eyes, for which he used prescription eye drops. He claimed that he bit his lips and mouth while chewing on a daily basis. On examination, it was shown that his Bell’s Palsy impacted his cranial nerve VII, which caused mild difficulty with chewing, without indication that the disability was the cause of dry mouth or eyes. The Board finds that even if such symptoms were attributable to the Veteran’s service-connected disability, the evidence does not demonstrate the presence of severe incomplete paralysis of the cranial nerve. No such suggestion was made by any of the medical professionals charged with assessing the nature and severity of the disability. As noted above, the Veteran has already been assigned a maximum separate rating for tinnitus. Additionally, as there is no evidence of more than moderate incomplete paralysis of the seventh cranial nerve, and no allegation or evidence of complete paralysis of the seventh cranial nerve, the Board finds that a rating in excess of 10 percent for Bell's palsy is not warranted. Accordingly, as a higher disability rating is not warranted under Diagnostic Code 8207 or any other code, the Veteran's claim must be denied. 5. Entitlement to a TDIU prior to July 1, 2018 is denied. Veterans who are unable to secure and follow a substantially gainful occupation by reason of service connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training and previous work experience, but not to his age or to any impairment caused by non-service connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The evidence of record demonstrates that the Veteran was gainfully employed by the U.S. Postal Service as a mail carrier for the entirety of the appeal period prior to his retirement on June 30, 2018. See the April 2018 Board hearing transcript. The Veteran does not indicate that his employment was marginal or protected in any way, and the evidence does not so suggest. Entitlement to a TDIU may not be granted for the time period the Veteran was gainfully employed. Thus, for all times prior to July 1, 2018, entitlement to a TDIU is denied. Insofar as entitlement to a TDIU may be relevant to an award for SMC at the housebound rate for all times after the Veteran’s retirement, such will be discussed in the Remand section below. REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent for residuals of left leg subtrochanteric fracture with shortening of the bones is remanded. In July 2019, the Board remanded to Veteran’s claim to seek clarification as to whether the Veteran’s left knee impairment is attributable to the Veteran’s service-connected left leg subtrochanteric fracture. A review of the record shows that on August 2017 VA examination, the Veteran had complaints of pain in his back, knee, and thigh when wearing certain modified shoes to compensate for his left leg shortening. VA treatment records also documented complaints of left knee pain. An October 2017 VA examiner concluded that the Veteran’s knee disability was not caused by shortening of the Veteran’s left leg as a result of the subtrochanteric fracture, but instead was a result of the extensive walking required by the Veteran’s employment. However, the May 2018 VA examiner opined that the service-connected left femur fracture contributed to all of the Veteran’s knee problems. In an attempt to clarify the matter, the Veteran was afforded with a VA examination in October 2019. The examiner noted that the Veteran underwent a left knee arthroscopic meniscectomy in October 2014 and had a scar below the left knee that measured .25 cm. X .25 cm., but otherwise concluded that the Veteran had a normal left knee that did not affect the Veteran’s service-connected left subtrochanteric fracture. The examiner did not discuss whether prior knee impairment during the appeal period, to include the need for the meniscectomy, was attributable to his service-connected fractured femur. As the rating criteria require consideration of impairment of the knee, such clarification is still necessary before a merits determination can be made. 2. Entitlement to TDIU, for the purposes of establishing SMC at the housebound rate, from July 1, 2018 to the present, is remanded. For all times since the Veteran’s retirement, the Veteran has been in receipt of a 100 percent combined schedular disability rating. Nevertheless, the issue of entitlement to a TDIU is not moot as a separate TDIU rating predicated on one disability (although perhaps not ratable at the schedular 100 percent level) when considered together with another disability separately rated at 60 percent or more could warrant special monthly compensation. 38 U.S.C. § 1114(s); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). As such, the issue of entitlement to TDIU for all times after the Veteran’s retirement (i.e., July 1, 2018 to the present) remains before the Board. Because the adjudication of this claim could be impacted by the development being ordered with respect to the Veteran’s femur fracture increased rating claim, the Board finds the issue of entitlement to TDIU is inextricably intertwined with the claim that is being remanded; as such, the adjudication of the claim for TDIU from July 1, 2018 to the present must be deferred. See Harris v Derwinski, 1 Vet. App. 80 (1991). The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination to assess the severity of his service-connected left leg subtrochanter fracture with shortening of the bones. The claims file should be sent to, and reviewed by the examiner. In particular, the examiner should discuss whether the Veteran’s service-connection fracture residuals included impairment to the left knee at any time during the period under review (i.e., since August 2010), to include his need for arthroscopic meniscectomy in October 2014. All opinions should be supported by a medical explanation or rationale. 2. Readjudicate the appeal, to include entitlement to a TDIU from July 1, 2018 to the present, for the purposes of establishing eligibility for SMC at the housebound rate. If the benefits sought remain denied, in whole or in part, send the Veteran and his representative a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Crohe, 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.