Citation Nr: 21011716 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 05-20 986 DATE: March 2, 2021 ORDER Entitlement to service connection for degenerative joint disease of the (left knee disability) is granted. Entitlement to service connection for a lumbar spine disability is denied. Entitlement to service connection for a cervical spine disability is denied. Entitlement to service connection for a bilateral hand disability is denied. Entitlement to an initial rating in excess of 40 percent, prior to November 17, 2008 and in excess of 50 percent from November 17, 2008 through October 4, 2013 is denied; and an increased rating of 60 percent from October 4, 2013 through October 5, 2015, and a 90 percent rating, thereafter, for bilateral hearing loss disability is granted. Entitlement to an initial rating in excess of 30 percent for right carpal tunnel syndrome is denied. Entitlement to an initial rating in excess 20 percent left carpal tunnel syndrome is denied. REMANDED Entitlement to service connection for right knee disability, to include as secondary to service-connected left knee disability, is remanded. FINDINGS OF FACT 1. The evidence is in relative equipoise as to whether the Veteran’s current left knee disability was incurred in service. 2. The Veteran does not have a current diagnosis for a left-hand disability. 3. The preponderance of the evidence is against finding that the Veteran’s lumbar spine, cervical spine, and right-hand disabilities are etiologically related to his service. 4. Prior to November 17, 2008, the Veteran’s bilateral hearing loss disability resulted with hearing loss, at worse, in findings no greater than Roman Numeral VI (right) and VIII (left). 5. Between November 17, 2008 through October 4, 2013, the Veteran’s bilateral hearing loss disability resulted with hearing loss, at worse, in findings no greater than Roman Numeral VII (right) and IX (left). 6. Between October 4, 2013 through October 5, 2015, the Veteran’s bilateral hearing loss disability resulted with hearing loss, at worse, in findings no greater than Roman Numeral VIII (right) and X (left). 7. Beginning October 5, 2015, the Veteran’s bilateral hearing loss disability resulted with hearing loss, at worse, in findings no greater than Roman Numeral X (right) and XI (left). 8. The Veteran’s bilateral carpal tunnel syndrome manifested with no more than moderate incomplete paralysis throughout the period on appeal, given his wholly sensory symptoms. CONCLUSIONS OF LAW 1. The criteria for service connection for left knee disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a lumbar spine disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for a cervical spine disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for a bilateral hand disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. Prior to November 17, 2008, the criteria for an initial rating in excess of 40 percent for bilateral hearing loss have not been met. 38 U.S.C. § 1110, 1155; 38 C.F.R. §§ 4.1, 4.85, 4.86, Diagnostic Code 6100. 6. Between November 17, 2008 through October 4, 2013, the criteria for an increased rating in excess of 50 percent for bilateral hearing loss have been not met. 38 U.S.C. § 1110, 1155; 38 C.F.R. §§ 4.1, 4.85, 4.86, Diagnostic Code 6100. 7. Between October 4, 2013 through October 5, 2015, the criteria for an increased rating of 60 percent for bilateral hearing loss have been met. 38 U.S.C. § 1110, 1155; 38 C.F.R. §§ 4.1, 4.85, 4.86, Diagnostic Code 6100. 8. Beginning October 5, 2015, the criteria for an increased rating of 90 percent for bilateral hearing loss have been met. 38 U.S.C. § 1110, 1155; 38 C.F.R. §§ 4.1, 4.85, 4.86, Diagnostic Code 6100 9. The criteria for a disability rating in excess of 30 for right carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8515. 10. The criteria for a disability rating in excess of 20 for left carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8515. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1957 through July 1960. This matter comes before the Board of Veterans’ Appeals (BVA or Board) on appeal from April 2003, March 2014, May 2014, March 2015, and October 2020 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran was provided a hearing before Veterans Law Judges in June 2006 and March 2016. Service Connection Generally, service connection requires evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 C.F.R. § 3.303(a). Certain chronic diseases, such as arthritis, will be presumed related to service if they were shown as chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. Entitlement to service connection for left knee disability The Veteran seeks service connection for a left knee disability. There is no question the Veteran has a current diagnosis of a left knee arthritis. See October 2019 VA examination. Thus, the first element of service connection is met. The remaining questions before the Board are whether there was an in-service incurrence of a disease or injury; and whether his current disability is related to an in-service incurrence(nexus), if any. The Veteran has asserted that he jumped into the water from the bow of his ship during service, causing pain and injury to his joints, that was exacerbated by a one-month special assignment. In a July 2014 decision, the Board found that the Veteran’s accounts of trauma as a result of jumping from a ship in-service to be confirmed by the record. Indeed, confirmation of this in-service trauma, in addition to a medical opinion, were the basis for the Board’s grant of service connection for a separate disability in the that case. Under the doctrine of law of the case, questions settled on a former appeal of the same case are no longer open for review. See Browder v. Brown, 5 Vet. App. 268, 270 (1993). The “law of the case” doctrine operates to preclude reconsideration of identical issues.” Johnson v. Brown, 7 Vet. App. 25, 26 (1994). As such, judicial bodies will not generally review or reconsider issues that already have been decided in a previous appeal. See McCall v. Brown,6 Vet. App. 215 (1994) (citing Kori Corp. v. Wilco Marsh Buggies & Draglines, 761 F.2d 649, 657 (Fed. Cir. 1985); Browder. In light of the foregoing, under the law of the case doctrine, the Board accepts the Veteran’s account of jumping off a ship in-service, which caused potential trauma to his body. Resultantly, as the record contains evidence of in-service injury, the second element is satisfied. The remaining question before the Board is whether the Veteran’s current left knee disability is related to his in-service injury (nexus). In December 2001, the Veteran complained about his left knee giving out intermittently during his first VA hospital visit. The Veteran later explained that he had been experiencing problems with his left knee since an injury in-service. In November 2009, the Veteran submitted a buddy statement from an associate who reported that he had known the Veteran since May 1958 and observed the Veteran suffering with injuries to his shoulders and left knee. The Veteran had informed the associate that these injuries were the result of events in-service. In March 2014, the Veteran was afforded a VA examination for his upper and lower extremity disabilities, including his left knee disability. After an examination and review of the record, the VA examiner opined that it was less likely than not that his upper and lower extremity disabilities were related to his service, including his report of in-service injuries. The examiner explained that his upper and lower extremity disabilities were bilateral and relatively symmetrical, which is more indicative of age related or post-service work related changes to the joints and extremities. The examiner further explained that the history of in-service injuries were consistent with minor injuries that would heal on their own. This theory was affirmed by the Veteran indicating that he worked productively without significant impairment related to the extremities until the late 1990s, 40 years subsequent to departing active military service. In November 2014, the Veteran submitted a report from a private examining doctor, who opined that based on the Veteran’s history, physical exam, and review of the records, his multiple orthopedic complaints, including bilateral posttraumatic knee arthritis are consistent with his in-service injury. The examining doctor explained that his injuries could have been exacerbated by his post-service jobs and accidents, such as his post-service bicycle accident. Given that the Veteran has severe degenerative changes in both knees, with the left being worse than the right, the examining doctor believed that they are with a reasonable degree of medical certainty, related to his in-service injury. At the March 2016 hearing, the Veteran testified that after his in-service injury, everything hurt. His knees continued to hurt during service and thereafter. Post-service, he had damage in his knees and was treated with braces. In October 2019, the Veteran was afforded another VA examination for his upper and lower extremities. The examiner opined that it was less likely than not that the Veteran’s bilateral knee disabilities were related to his service. The examiner explained that his disabilities demonstrate post-service trauma several years after separation of service. Post-service trauma events were identified as a bicycle accident in 1991 and employment in a stocking position requiring heavy and repetitive lifting. His current disabilities were most consistent with normal aging process, post-service trauma, and post-service occupational stress on the joints and musculoskeletal system. The Veteran has submitted statements and lay evidence from others suggesting that he has never performed work requiring heavy lifting. He has also alleged that his multiple musculoskeletal disabilities, including his left knee disability, stem from his in-service injury. In assessing the credibility of the Veteran’s statements throughout the record, the Board takes notice that the Veteran has offered vastly different versions of his in-service injury throughout the period on appeal. Compare June 2006 Hearing Transcript with March 2016 Hearing Transcript. At the March 2016 hearing, the Veteran admitted that he did not receive treatment for his alleged injuries after the jump, but instead walked down the stairs to his bunk and slept. This information conflicted with the Veteran’s earlier reports that he fractured his right elbow and was treated with a sling and cast immobilization after his in-service treatment. Further, the Board notes that the Veteran’s versions of events are not reflected by his service treatment records, which are silent for complaints of or treatment for his musculoskeletal systems after an in-service jump, and that the AOJ has identified no military files as outstanding. The inconsistency of the Veteran’s statements lowers the overall probative value of his recollections. See, e.g., Seng v. Holder, 584 F.3d 13, 19 (1st Cir.2009). Likewise, the Board accords little probative value to the November 2014 private opinion, in that, this opinion was based on the assumption that the Veteran’s in-service bilateral knee injuries were aggravated by a job requiring heavy lifting. However, the Veteran has submitted a December 2014 lay statement stating he never lifted heavy boxes during his employment, as well two separate January 2015 lay statements from former coworkers supporting his assertion. As this opinion was based largely on the Veteran’s inconsistent assertions, the Board awards it little probative value. See Reonal v. Brown,5 Vet. App. 458, 461(1993). The Board finds, however, despite the Veteran’s deficiencies in credible statements, there is corroborating evidence to support a continuity of symptomology since service for his left knee disability. As addressed above, the Veteran reported a history of a left knee disability during his first treatment at a VA hospital in 2001. There is also lay evidence confirming the presence of a left knee disability as early as 1968, or before. Thus, presumptive service connection may be established by a showing of a continuity of symptoms since service. Here, the totality of the record, including the Veteran’s statements, lay evidence, and VA treatment notes, all established a continuity of symptoms beginning in-service and continuing ever since. Resultantly, in this limited scope, the Board has no reason to doubt the Veteran’s credibility. There also exists negative competent medical evidence, as shown in the VA examinations, against service connection for the Veteran’s left knee disability. Resultantly, the Board finds that the positive and negative evidence in this matter is in relative equipoise. The Board will resolve all reasonable doubt in the Veteran’s favor and grant service connection for a left knee disability. Entitlement to service connection for a lumbar spine, a cervical spine disability, bilateral hand disabilities The Veteran seeks service connection for lumbar spine, cervical spine, and bilateral hand disabilities. Initially, with regard to the left hand, the Board notes that the Veteran does not have a current, diagnosed disability, separate from his already service-connected left carpal tunnel syndrome. See October 2019 VA examination. Absent the required diagnosis of a current disability, a claim for service connection fails. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, service connection for a left-hand disability is not warranted. Regarding the Veteran’s other musculoskeletal disabilities, there is no question the Veteran has current diagnoses of lumbar spine, cervical spine, and right-hand disabilities. See October 2019 VA examination. Thus, the first element of service connection is met. The remaining questions before the Board are whether there was an in-service incurrence of a disease or injury; and whether his current disabilities are related to an in-service incurrence(nexus), if any. As noted above, the Veteran has asserted that he jumped into the water from the bow of his ship during service, causing pain and injury to his joints, that was later exacerbated by a one-month special assignment. Thus, as the record contains evidence of in-service injury, the second element is satisfied. The remaining question before the Board is whether the Veteran’s current lumbar spine, cervical spine, and right-hand disabilities are related to his in-service injury (nexus). In March 2014, VA treatment notes record the Veteran’s treating rheumatologist’s assessment that his diffuse degenerative osteoarthritis is consistent with age but more likely than not may have been exacerbated by his service and trauma he sustained in-service. The November 2014 private examination documented multiple orthopedic disabilities, including lumbar spine and cervical spine disabilities. The private examining doctor opined that it is likely his cervical and lumbar spine disabilities are related to the Veteran’s service injuries. In January 2015, the Veteran was afforded another VA examination for his musculoskeletal disabilities. The VA examiner ultimately concluded that his cervical and lumbar spine disabilities are less likely than not related to service. The VA examiner explained that there was no history in service treatment records of pain or an injury to the spine. It was further rationalized that if the Veteran had injured his back sufficiently to result in the pathology seen in radiological examination, he would have been in significant, prostrating pain, and there would be record of this in his service treatment records. His profuse degenerative changes of the spine are most consistent with normal aging process, post-service trauma, and post-service occupational stress on the musculoskeletal system. The Veteran was afforded another VA examination in October 2019. The VA examiner similarly opined that the Veteran’s lumbar spine, cervical spine, and right-hand disabilities were less likely than not related to his service. The examiner rationalized that the medical record did not show lumbar or cervical spine arthritis until greater than 55 years after his separation from service and service treatment records are silent for treatment for back injuries. There is no objective evidence of a lumbar or cervical spine diagnosis that can be said that degenerative arthritis was incurred in or related to service. These disabilities are most consistent with the normal aging process or civilian occupation related changes. Regarding his right-hand disability, the examiner stated there was no history of a bilateral hand injury during service. Medical evidence did not show right hand arthritis until greater than 50 years after separation from service. There was no objective evidence of a bilateral hand diagnosis that can be said that right hand degenerative arthritis was incurred or is related to service. Rather, his right-hand disability was also more consistent with the normal aging process or civilian related changes to the right hand. Based on the aforementioned, the Board finds that service connection is not warranted for the Veteran’s lumbar spine, cervical spine, and bilateral hand disabilities. Regarding his bilateral hand disabilities, as addressed above, the Veteran does not have a current left-hand disability. As such, his claim for service connection for a left-hand disability fails. Regarding his lumbar spine, cervical spine and right-hand disabilities, the Board finds the June 2015 and October 2019 VA opinions against a positive nexus are highly probative, as they were based on thorough review of the pertinent evidence of record, they adequately considered lay evidence of record, and they were based on the examiners’ medical training and expertise. While the May 2014 VA rheumatologist’s opinion is in favor of service connection, this opinion is accorded less probative value, as it was conclusionary and there is no indication that the rheumatologist reviewed the pertinent records in the Veteran’s file. Likewise, the November 2014 positive private opinion is accorded less probative value, as it relied heavily on the Veteran’s reporting, did not consider the Veteran’s service treatment records, and did not adequately address the delayed presence of these disabilities of 50 years or more after separation. The Board is aware that service connection may be warranted for the Veteran’s lumbar spine, cervical spine, and right-hand disabilities based on chronicity and continuity of symptoms. However, chronicity has not been established as the record confirms that these disabilities first presented decades after the Veteran’s discharge from service. Additionally, the Veteran has not credibly established a continuity of symptomology since service. Rather, service treatment records are silent for symptoms related to cervical, lumbar, or right-hand disabilities. Moreover, the Veteran’s credibility in recollection of events is faulty as discussed above and there is no other evidence confirming the presence of symptomology since service. Thus, presumptive service connection is not warranted for his cervical spine, lumbar spine, and right-hand disabilities. The preponderance of the evidence is against finding service connection for the Veteran’s cervical spine, lumbar spine, and bilateral hand disabilities. The claims are denied. Increased Rating Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability shall be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. Entitlement to a higher initial rating for a bilateral hearing loss disability The Veteran contends that he is entitled to an increased rating for a bilateral hearing loss disability. By way of procedural history, a June 2008 Board decision granted service connection for a bilateral hearing disability. In a June 2008 rating decision implementing the Board’s grant, the RO assigned a disability evaluation of 40 percent effective January 11, 2002, and 20 percent beginning August 28, 2007, under Diagnostic Code 6100. The Veteran submitted a timely appeal. In a November 2009 rating decision, the RO implemented the 40 percent disability rating, without reduction, and increased the disability rating to 50 percent, effective November 17, 2008. While that appeal remained pending (because less than a total rating was granted), the Veteran filed an informal increased rating claim in December 2013. In a May 2014 rating decision, his 50 percent disability rating was continued. As noted in the Board’s July 2014 decision, however, the matter of entitlement to an higher initial rating for the service-connected hearing loss remained on appeal because of the Veteran’s timely notice of disagreement with his initial rating, and it was remanded for issuance of a statement of the case. Such was accomplished in November 2014; the Veteran perfected his appeal with a December 2014 VA Form 9. In an October 2020 rating decision, his bilateral hearing disability evaluation was increased to 70 percent, effective March 31, 2016. Thus, his current rating is 40 percent from January 2002, 50 percent from November 2008, and 70 percent from March 2016. The entire period is on appeal. Hearing loss is rated based on 38 C.F.R. § 4.85, Diagnostic Code 6100, which provides criteria for evaluating hearing impairment using puretone threshold averages and speech discrimination scores. Numeric designations are assigned based upon a mechanical use of tables found in 38 C.F.R. § 4.85. Scores are then matched against Table VI to find the numeric designation, then the designations are matched with Table VII to find the percentage evaluation to be assigned for the hearing impairment. To evaluate the degree of disability from defective hearing, the Rating Schedule establishes eleven auditory acuity levels from Level I for essentially normal acuity through Level XI for profound deafness. 38 C.F.R. §§ 4.85, 4.87, Tables VI, VIa, VII. Organic impairment of hearing acuity is measured by the results of controlled speech discrimination tests together with the average hearing threshold level as measured by a pure tone audiometry test in the frequencies of 1,000, 2,000, 3,000, and 4,000 cycles per second. See 38 C.F.R. § 4.85 (a), (d). Ratings of hearing loss disability involve mechanical application of the rating criteria to the findings on official audiometry. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The schedular evaluations are intended to make proper allowance for improvement by hearing aids. 38 C.F.R. § 4.86. Exceptional patterns of hearing impairment are rated under 38 C.F.R. § 4.86. Specifically, an exceptional pattern of hearing loss is hearing loss of 55 decibels or more in each of the four specified frequencies (i.e. 1000, 2000, 3000, and 4000 Hertz), and hearing loss with a pure tone threshold of 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86 (a), (b). In December 2001, VA treatment notes document the Veteran’s request for hearing aids. Thereafter, he submitted to a private audiogram in May 2002 that revealed puretone thresholds in the right ear at 1000, 2000, 3000, and 4000 Hertz were 55, 70, 75, and 70, respectively, for an average of 68. Puretone thresholds measured in the left ear at 1000, 2000, 3000, and 4000 Hertz were 50, 70, 80, and 85 decibels, respectively, with an average of 71 decibels. Speech discrimination scores were reported as 68 percent in the right ear and 56 percent in the left ear. The Veteran was diagnosed with moderate to severe bilateral hearing loss. A June 2002 audiogram documented puretone thresholds in the right ear at 1000, 2000, 3000, and 4000 Hertz were 45, 55, 65, and 85, respectively, for an average of 63. Puretone thresholds measured in the left ear at 1000, 2000, 3000, and 4000 Hertz were 35, 60, 80, and 90 decibels, respectively, with an average of 66 decibels. Speech discrimination scores were reported as 74 percent in the right ear and 76 percent in the left ear. The Veteran was diagnosed with moderate to severe bilateral hearing loss. A February 2006 yielded mostly similar results, except that puretone thresholds were not provided. In August 2007, the Veteran submitted to an audiological VA examination. He reported hearing difficulty while teaching in a large classroom. An audiogram revealed puretone thresholds in the right ear at 1000, 2000, 3000, and 4000 Hertz were 50, 70, 70, and 85 decibels, respectively, for an average of 69 decibels. Puretone thresholds measured in the left ear at 1000, 2000, 3000, and 4000 Hertz were 55, 65, 70, and 80 decibels, respectively, with an average of 68 decibels. Speech discrimination scores were reported as 82 percent in the right ear and 82 percent in the left ear. The Board takes notice that the Veteran has contested the results of this audiogram on the basis that his hearing never improved. In November 2008, a private audiogram revealed puretone thresholds in the right ear at 1000, 2000, 3000, and 4000 Hertz were 55, 70, 80, and 80, respectively, for an average of 71. Puretone thresholds measured in the left ear at 1000, 2000, 3000, and 4000 Hertz were 65, 75, 85, and 80 decibels, respectively, with an average of 76 decibels. Speech discrimination scores were reported as 62 percent in the right ear and 44 percent in the left ear. In response to the August 2007 VA examination indicating possible improvement in the Veteran’s hearing loss, the November 2008 private audiologist opined that the Veteran showed a very serious high frequency sensory loss on both sides and likelihood of positive fluctuation in hearing ability in cases such as the Veteran were unlikely. See November 2009 Medical Treatment Record- Non-Government Agency document. In October 2013, private treatment notes show an audiogram with puretone thresholds in the right ear at 1000, 2000, 3000, and 4000 Hertz were 65, 80, 90, and 105 decibels, respectively, for an average of 85 decibels. Puretone thresholds measured in the left ear at 1000, 2000, 3000, and 4000 Hertz were 70, 90, 110, and 125 decibels, respectively, with an average of 98 decibels. Speech discrimination scores were reported as 64 percent in the right ear and 42 percent in the left ear. In May 2014, the Veteran was afforded another VA hearing loss examination. Puretone thresholds in the right ear at 1000, 2000, 3000, and 4000 Hertz were of 55, 80, 90, and 105 decibels, respectively, for an average of 83 decibels. Puretone thresholds measured in the left ear at 1000, 2000, 3000, and 4000 Hertz were 70, 80, 100, and 105 decibels, respectively, with an average of 89 decibels. Speech discrimination scores were reported as 86 percent in the right ear and 74 percent in the left ear. In October 2015, the Veteran had a private audiogram that showed puretone thresholds in the right ear at 1000, 2000, 3000, and 4000 Hertz were of 85, 100, 110, and 120 decibels, respectively, for an average of 104 decibels. Puretone thresholds measured in the left ear at 1000, 2000, 3000, and 4000 Hertz were 95, 105, 120, and 120 decibels, respectively, with an average of 110 decibels. Speech discrimination scores were reported as 46 percent in the right ear and 42 percent in the left ear. The audiologist opined that the Veteran’s hearing thresholds and word recognition has worsened in the right ear. At the March 2016 hearing, the Veteran testified that he has trouble understanding what others say, has problems hearing the TV or sirens, and requires stronger hearing aids. In August 2020, the Veteran was afforded another VA hearing loss examination. However, his hearing loss could not be tested. Later in August 2020, the Veteran underwent another private audiogram which showed puretone thresholds in the right ear at 1000, 2000, 3000, and 4000 Hertz were of 90, 100, 105, and 120 decibels, respectively, for an average of 104 decibels. Puretone thresholds measured in the left ear at 1000, 2000, 3000, and 4000 Hertz were 70, 95, 120, and 120 decibels, respectively, with an average of 101 decibels. Speech discrimination scores were reported as 52 percent in the right ear and 50 percent in the left ear. Applying 38 C.F.R. § 4.85, Table VI to the audiograms of record results in the following: the May 2002 audiogram results warrant a Roman Numeral VI in the right ear and VIII in the left ear, which yields a 40 percent rating; the June 2002 audiogram warrants a Roman Numeral IV for the right ear and a Roman Numeral V for the left ear, which yields a 10 percent rating; the August 2007 VA audiogram results warrant a Roman Numeral IV in the right ear and IV in the left ear, which yields a 10 percent rating; the November 2008 audiogram results warrant a Roman Numeral VII in the right ear and IX in the left ear, which yields a 50 percent rating; the October 2013 audiogram warrants a Roman Numeral VIII for the right ear and Roman Numeral X for the left ear, which yields a 60 percent rating; the May 2014 audiogram warrants a Roman Numeral IV for the right ear and Roman Numeral VII for the left ear, which yields a 20 percent rating; the October 2015 audiogram warrants a Roman Numeral X for the right ear and Roman Numeral X for the left ear in, which yields an 80 rating; and the August 2020 audiogram warrants a Roman Numeral IX for the right ear and Roman Numeral X for the left ear, which yields a 70 percent rating. Most of the Veteran’s audiological testing results, excluding the June 2002 audiogram, meets the criteria for an exceptional pattern of hearing under 38 C.F.R. § 4.86a. 38 C.F.R. § 4.86a notes that 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 and without regard to speech discrimination. Under Table VIA, in the May 2002 audiogram, only the Veteran’s right ear qualified as exceptional hearing loss, which results in the assignment of Roman Numeral V. His left ear would retain a Roman Numeral VIII under Table VI. Thus, his combined hearing impairment under Table VII would result in a 30 percent rating. In August 2007, only his left ear met the criteria of exceptional hearing loss and warranted a Roman Numeral assignment of Roman Numeral V. His right ear is assigned a Roman Numeral IV under Table VI, which results in a combined evaluation of 10 percent. The November 2008 audiogram results warrant a Roman Numeral VI in the right ear and VI in the left ear, which yields a 30 percent rating; the October 2013 audiogram results warrant a Roman Numeral VIII in the right ear and X in the left ear, which yields a 60 percent rating; the May 2014 audiogram results warrant a Roman Numeral VII in the right ear and VIII in the left ear, which yields a 40 percent rating; the October 2015 audiogram results warrant a Roman Numeral X in the right ear and XI in the left ear, which yields a 90 percent rating; and the August 2020 audiogram results warrant a Roman Numeral X in the right ear and left ear X, which yields a 80 percent rating. In summary, an increased rating in excess of 40 percent prior to November 17, 2008, and in excess of 50 percent between November 17, 2008 through October 4, 2013, is denied. Beginning October 4, 2013 through October 5, 2015, an increased rating of 60 percent, and a 90 percent rating, thereafter, is warranted when applying the highest numeral under either Table VI or Table VIA. 38 C.F.R. § 4.86 (a) and reviewing the record in the light most favorable to the Veteran. The Veteran has not raised any other issues with respect to the higher initial rating claim, nor have any other assertions been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Entitlement to increased ratings for bilateral carpal tunnel syndrome By way of procedural history, a July 2014 Board decision granted service connection for bilateral carpal tunnel syndrome. A March 2015 rating decision, implementing the Board’s grant assigned separate 10 percent ratings for the Veteran’s right and left carpal tunnel syndrome, effective April 10, 2013. In an October 2020 rating decision, the RO increased the Veteran’s disability ratings to 30 percent disabling for his right carpal tunnel and 20 percent for left carpal tunnel, and changed the effective date of service connection (and the higher ratings) to January 24, 2013. The Veteran’s bilateral carpal tunnel syndrome is rated under Diagnostic Code 8515. Diagnostic Code 8515 provides ratings for both the “minor” and the “major” wrist. In this context “minor” and “major” refer to the dominant or nondominant side. Here, the Veteran’s major hand (dominant) is the right upper extremity, and the minor hand is the left upper extremity. Diagnostic Code 8515 addresses complete and incomplete paralysis of the median nerve. As relevant, under Diagnostic Code 8515, moderate incomplete paralysis warrants a 30 percent rating for the major wrist, and a 20 percent rating for the minor wrist. Severe incomplete paralysis warrants a 50 percent rating for the major wrist, and a 40 percent rating for the minor wrist. Complete paralysis with the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of thenar eminence, the thumb in the plane of the hand; pronation incomplete and effective, absence of flexion of the index finger and feeble flexion of the middle finger, that cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of the thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances warrants a 70 percent disability rating for the major wrist and a 60 percent rating for the minor wrist. 38 C.F.R. § 4.124a, DC 8515. The term “incomplete paralysis” used in reference to evaluation of peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. The words “mild,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “moderate” by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Neurological disorders are ordinarily to be rated in proportion to the impairment of motor, sensory, or mental function. In rating peripheral nerve injuries and their residuals, attention is given to the site and character of the injury, and the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. When the involvement is wholly sensory, the rating should be evaluated as mild, or at most, the moderate degree. See note under “Diseases of the Peripheral Nerves.” 38 C.F.R. § 4.124a. Turning to the evidence of record, the Veteran underwent a private examination for his bilateral carpal tunnel syndrome in November 2012. The Veteran reported symptoms of numbness, tingling, pain, and loss of fine motor skills. He expounded that he was clumsy when using buttons or tying a tie. The private examiner noted a recent April 2012 EMG study that showed severe bilateral carpal tunnel syndrome. Upon examination, light touch was diminished in the median nerve distribution. He received injections for his symptoms with good relief. The examiner found that the Veteran’s history and examination was consistent with advanced bilateral carpal tunnel. He was afforded a VA examination in January 2015. The examiner noted that the Veteran had bilateral carpal tunnel syndrome with diminished grip and manual dexterity. He also reported that his hands would “go cold”. The examiner documented severe numbness in his upper extremities but no constant pain, intermittent pain, or paresthesias and/or dysesthesias. On examination, his grip strength was full in both hands. There was no muscle atrophy. Light touch sensation was absent in his hands and fingers. There was no trophic changes. The examiner found that that he had mild incomplete, paralysis of the median and ulnar nerves bilaterally. The Veteran underwent a second VA examination in October 2019. The examiner noted that the Veteran had three surgeries for carpal tunnel syndrome in the past. He complained of constant bilateral hand pain and numbness that worsened with driving, gripping, and repetitive motions. He had also had hand locking. The report documented a recent EMG performed in October 2019, which showed severe bilateral carpal tunnel syndrome with interval improvement from his prior study. Clinical examination revealed moderate, constant pain, paresthesias and/or dysesthesias, and numbness bilaterally. Strength testing, however, revealed normal (5/5) muscle strength. There was no atrophy. The examiner found moderate incomplete paralysis of the median nerves bilaterally. At the March 2016 hearing, the Veteran testified that his hands lock on the steering wheel, has pain described as electric shocks or fire, and had numbness bilaterally. He also had problems with zippers, dropping things, holding items, and typing. Based on the aforementioned, the Board finds a rating in excess of 30 percent for right carpal tunnel syndrome, and in excess of 20 percent for left carpal tunnel syndrome is not warranted. The weight of the evidence supports that the Veteran’s bilateral carpal tunnel syndrome has manifested with symptoms consistent with moderate incomplete paralysis. As such, no more than a rating of 30 percent for right hand carpal tunnel syndrome, and a rating of 20 percent for left hand carpal tunnel syndrome, is warranted throughout the appeal period. EMG testing has confirmed severe bilateral carpal tunnel throughout the period on appeal. VA examinations also document decreased sensory findings and moderate symptoms of constant pain, numbness, and paresthesias and/or dysesthesias. However, the Veteran maintained normal grip strength findings and had no evidence of muscle atrophy throughout the period on appeal. The examiners also found mild and moderate incomplete paralysis of the ulnar and median nerves bilaterally. The Veteran’s post-service VA and private treatment records corroborate the VA examiners’ findings of moderate incomplete paralysis, as they have noted the Veteran’s complaints and treatment for bilateral loss of sensation, decreased grip strength, pain and cramping, but do not demonstrate severe or chronic bilateral paralysis. There is no competent evidence of record that establishes that the Veteran has experienced symptoms of severe incomplete paralysis of his bilateral upper extremities during the appeal period. Rather his symptoms have been wholly sensory in nature. As such, the Veteran’s symptomology is consistent with the criteria contemplated by the current ratings assigned for his bilateral carpal tunnel syndrome. There is also no evidence of record that the service connected disabilities are productive of a hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of thenar eminence, the thumb in the plane of the hand; pronation incomplete and effective, absence of flexion of the index finger and feeble flexion of the middle finger, that cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of the thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances. The Board has also considered whether the Veteran could receive a higher rating under other applicable diagnostic codes, including under 38 C.F.R. § 4.123 or 4.124, for neuritis or neuralgia, respectively. Nevertheless, the evidence of record does not demonstrate that the Veteran has experienced symptoms of loss of reflexes, muscle atrophy, or sensory disturbances of such severity that his bilateral carpal tunnel syndrome warrants a higher rating under any of these or any other diagnostic codes. Although the Veteran contends that his bilateral carpal tunnel syndrome warrants higher ratings, he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which his disability is evaluated. As such, the Board finds these records to be more probative than the Veteran’s subjective complaints of increased symptomatology. Since a preponderance of the evidence weights against the Veteran, the Veteran is not entitled to the benefit of the doubt. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed Cir. 2001). Accordingly, the Board finds that a rating in excess of 30 percent rating for the right carpal tunnel syndrome and a rating in excess of 20 percent for the left carpal tunnel syndrome is unwarranted, as the Veteran has exhibited symptoms consistent with moderate incomplete paralysis in both upper extremities during the entirety of the appeal period. REASONS FOR REMAND 1. Entitlement to service connection for right knee disability, to include as secondary to service-connected left knee disability is remanded. The Veteran contends that his bilateral knee disability is related to service. The Board decision, herein, found that the evidence of record was sufficient to grant service connection for a left knee disability on a direct basis. This favorable action affords the Veteran the opportunity for service connection for his right knee disability on either a direct or secondary basis. However, no examiner has considered whether the Veteran’s right knee disability was caused or aggravated by his service-connected left knee disability. As such, further development is necessary. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s right knee disability is at least as likely as not caused or aggravated beyond its natural progression by his service-connected left knee disability. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as against it. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N.B. Mmeje, 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.