Citation Nr: 21012359 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 09-11 592 DATE: March 4, 2021 ORDER Entitlement to a compensable rating for bilateral hearing loss prior to October 24, 2018, is denied. Entitlement to a 10 percent rating, but no higher, for bilateral hearing loss from October 24, 2018, is granted. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. Prior to October 24, 2018, evidence of record shows that the Veteran’s bilateral hearing loss has been manifested by no more than Level II hearing acuity in the right ear and no more than Level IV hearing acuity in the left ear. 2. From October 24, 2018, evidence of record shows that the Veteran’s bilateral hearing loss has been manifested by no more than Level II hearing acuity in the right ear and no more than Level VII hearing acuity in the left ear. 3. The Veteran’s service-connected disabilities do not meet the schedular criteria for TDIU and do not render him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. Prior to October 24, 2018, the criteria for entitlement to a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.321, 4.85, Diagnostic Code 6100 (2020). 2. From October 24, 2018, the criteria for entitlement to a 10 percent rating, but no higher, for bilateral hearing loss have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.321, 4.85, Diagnostic Code 6100 (2020). 3. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1966 to April 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2008 rating decision. The Veteran testified at a Board videoconference hearing before the undersigned Acting Veterans Law Judge in July 2009. A transcript of the hearing is of record. The Board remanded this matter in August 2010, April 2014, May 2015, June 2017, and September 2018 for additional development. In a June 2020 rating decision, the agency of original jurisdiction (AOJ) increased the Veteran’s bilateral hearing loss rating to 10 percent, effective August 7, 2019. The Veteran is presumed to be seeking the maximum benefit allowed by law and regulation, and therefore the additional assignment of benefits is not considered to have resolved his claim. AB v. Brown, 6 Vet. App. 35 (1993). The issue of entitlement to a TDIU has also been raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). 1. Entitlement to a compensable rating for bilateral hearing loss prior to October 24, 2018, is denied. 2. Entitlement to a 10 percent rating, but no higher, for bilateral hearing loss from October 24, 2018, is granted. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In evaluating service-connected hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on an organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with the average hearing threshold, as measured by puretone audiometric tests in the frequencies of 1000, 2000, 3000 and 4000 cycles per second. The rating schedule establishes 11 auditory acuity Levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. VA audiological evaluations are conducted using a controlled speech discrimination test together with the results of pure tone audiometry tests. The vertical line in Table VI (printed in 38 C.F.R. § 4.85) represents nine categories of the percentage of discrimination based on a 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. The percentage evaluation is found 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 for the numeric designation for the level for the ear having the poorer hearing acuity. For example, if the better ear had a numeric designation of Level “V” and the poorer ear had a numeric designation of Level “VII” the percentage evaluation is 30 percent. See 38 C.F.R. § 4.85. Regulations also provide that, in cases of exceptional hearing loss, i.e., 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. 38 C.F.R. § 4.86(a). The provisions of 38 C.F.R. § 4.86(b) further provide that when the pure tone threshold is 30 decibels or less at 1,000 hertz and 70 decibels or more at 2000, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or VIa, whichever results in the higher numeral. That numeral will then be evaluated to the next higher Roman numeral. The Veteran asserts that his bilateral hearing loss warrants a compensable rating prior to August 7, 2019, and a rating in excess of 10 percent thereafter. In a June 2008 VA treatment record, it was noted that the Veteran’s history was significant for bilateral high frequency sensorineural hearing loss and constant bilateral tinnitus. There was no report of any recent ear pain, drainage, or dizziness. Upon examination, an audiogram revealed pure tone thresholds, in decibels, as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 25 20 40 65 LEFT 20 25 60 80 The average puretone threshold was 38 decibels for the right ear and 46 decibels for the left ear. Speech audiometry revealed speech recognition ability of 96 percent for the right ear and 92 percent for the left ear. The audiometric findings for the examination equate to Level I hearing loss in the right ear and Level I hearing loss in the left ear. See 38 C.F.R. § 4.85, Table VI. When those values are applied to Table VII, a noncompensable rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. At the March 2009 DRO hearing, the Veteran said that his hearing was worse and he was missing words again even with the hearing aids. When he removed his hearing aids, he had to strain to hear anything. The Veteran had been told to turn the radio and television down because it was too loud for other people. He could hear “huge kettle drums” going off in his right ear. In a March 2009 VA examination, an audiogram revealed pure tone thresholds, in decibels, as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 20 30 40 60 LEFT 25 35 60 75 The Veteran said that his hearing loss interfered with his ability to drive. He had difficulty hearing fire engines and ambulances as well as had difficulty localizing where sound was coming from. He also said that other people complained that the television and radio were too loud. He needed to expend considerable effort in order to position himself favorably for visual cues. The average puretone threshold was 38 decibels for the right ear and 49 decibels for the left ear. Speech audiometry revealed speech recognition ability of 94 percent for the right ear and 88 percent for the left ear. The audiometric findings for the examination equate to Level I hearing loss in the right ear and Level II hearing loss in the left ear. When those values are applied to Table VII, a noncompensable rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. A May 2009 private audiogram revealed puretone thresholds, in decibels, as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 30 30 45 60 LEFT 35 30 65 80 The average puretone threshold was 41 decibels for the right ear and 53 for the left ear. Speech audiometry revealed speech recognition ability of 92 percent for the right ear and 72 percent for the left ear. The audiometric findings for the examination equate to Level I hearing loss in the right ear and Level V hearing loss in the left ear. When those values are applied to Table VII, a noncompensable rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. At the July 2009 Board hearing, the Veteran testified that in daily life his hearing loss affected conversations and that his hearing had worsened. For example, in Bible study, he had to ask numerous times if people understood because it was hard for him to hear replies. Also, when he got a phone call, he would have to turn off the television in order to hear the phone; in the bathroom, he could not hear when the telephone rang. The Veteran was concerned that when he drove, he might not be able to hear ambulances, fire trucks, or police officers, because this had happened in the past. In an October 2010 VA examination, an audiogram revealed puretone thresholds, in decibels, as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 25 35 45 65 LEFT 20 40 65 65 The average puretone threshold was 43 decibels for the right ear and 53 decibels for the left ear. Speech audiometry revealed speech recognition ability of 80 percent for the right ear and 76 percent for the left ear. The audiometric findings for the examination equate to Level III hearing loss in the right ear and Level IV hearing loss in the left ear. When those values are applied to Table VII, a 10 percent rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. In a February 2011 VA examination, an audiogram revealed puretone thresholds, in decibels, as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 20 20 40 60 LEFT 20 25 65 85 The Veteran said that he was not sure why the examination was scheduled and did not think that his hearing had changed since October. The average puretone threshold was 35 decibels for the right ear and 49 decibels for the left ear. Speech audiometry revealed speech recognition ability of 98 percent for the right ear and 78 percent for the left ear. The audiometric findings for the examination equate to Level I hearing loss in the right ear and Level III hearing loss in the left ear. When those values are applied to Table VII, a noncompensable rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. In a February 2012 treatment record, the Veteran reported that he struggled with hearing what people were saying, particularly women’s voices. The right ear revealed normal thresholds from 250 to 1000 Hz with a mild to moderate sensorineural hearing loss from 2000 to 8000 Hz. Findings for the left ear revealed normal thresholds from 250 to 1000 Hz with a mild sloping to profound sensorineural hearing loss. Asymmetry was noted between 3000 and 8000 Hz, with the left ear worse than the right. Speech recognition thresholds were in agreement with these findings and word recognition scores were excellent bilaterally. The audiologist stated that overall results showed asymmetric hearing loss above 3000 Hz, worse in the left ear than the right. It was recommended that the Veteran obtain new hearing aids. In a February 2012 VA audiogram, puretone thresholds, in decibels, were as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 25 30 40 60 LEFT 25 35 60 80 The average puretone threshold was 39 decibels for the right ear and 50 decibels for the left ear. Speech audiometry revealed speech recognition ability of 84 percent for the right ear and 76 percent for the left ear. The audiometric findings for the examination equate to Level II hearing loss in the right ear and Level IV hearing loss in the left ear. When those values are applied to Table VII, a noncompensable rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. In a February 2012 private audiogram, puretone thresholds, in decibels, were as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 20 30 40 60 LEFT 20 30 60 75 The average puretone threshold was 38 decibels for the right ear and 46 decibels for the left ear. Speech audiometry revealed speech recognition ability of 92 percent in both ears. The audiometric findings for the examination equate to Level I hearing loss in the right ear and Level I hearing loss in the left ear. When those values are applied to Table VII, a noncompensable rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. In a February 2012 statement, the Veteran said that his hearing had deteriorated to a point where he watched lips to verify that he was hearing what the lips were saying. When someone was speaking to him, he needed them to look directly at him or he could not understand what was being said. The Veteran said that even with hearing aids there were times when his hearing was as if he was not wearing hearing aids back in 2006. He said he missed words and phrases from the television and radio. He avoided driving, whenever possible, in a heavy traffic area as he did not always hear car horns and/or police or ambulance sirens with the hearing aids. In a June 2014 VA examination, puretone thresholds, in decibels, were as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 20 20 40 60 LEFT 20 25 60 75 The average puretone threshold was 35 decibels for the right ear and 45 decibels for the left ear. Speech audiometry revealed speech recognition ability of 86 percent for the right ear and 80 percent for the left ear. The audiometric findings for the examination equate to Level II hearing loss in the right ear and Level III hearing loss in the left ear. When those values are applied to Table VII, a noncompensable rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. In an addendum August 2014 private audiogram to the February 2012 private audiogram, puretone thresholds, in decibels, were as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 25 30 40 60 LEFT 20 30 60 75 The average puretone threshold was 39 decibels for the right ear and 46 decibels for the left ear. Speech audiometry revealed speech recognition ability of 92 percent for both ears. The audiometric findings for the examination equate to Level I hearing loss in the right ear and Level I hearing loss in the left ear. When those values are applied to Table VII, a noncompensable rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. In a February 2015 VA audiogram, puretone thresholds, in decibels, were as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 25 25 40 60 LEFT 20 30 55 80 The Veteran said that he would hear a loud thumping sound in his left ear and his hearing would “shut down.” The average puretone threshold was 38 decibels for the right ear and 46 decibels for the left ear. Speech audiometry revealed speech recognition ability of 96 percent for the right ear and 80 percent for the left ear. The audiometric findings for the examination equate to Level I hearing loss in the right ear and Level III hearing loss in the left ear. When those values are applied to Table VII, a noncompensable rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. In a March 2015 statement, the Veteran said that within the last two years a loud banging in his left ear had developed. In a December 2015 VA examination, puretone thresholds, in decibels, were as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 15 25 40 60 LEFT 15 30 60 80 The average puretone threshold was 35 decibels for the right ear and 46 decibels for the left ear. Speech audiometry revealed speech recognition ability of 94 percent in the right ear and 90 percent in the left ear. The audiometric findings for the examination equate to Level I hearing loss in the right ear and Level II hearing loss in the left ear. When those values are applied to Table VII, a noncompensable rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. In a VA audiogram performed on October 24, 2018, puretone thresholds, in decibels, were as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 15 40 55 70 LEFT 40 65 70 90 The average puretone threshold was 45 decibels for the right ear and 66 decibels for the left ear. In an October 2018 VA ENT follow-up treatment note, the ENT indicated that speech recognition ability was judged to be 88 percent in the right ear and 52 percent in the left ear. The audiometric findings for the examination equate to Level II hearing loss in the right ear and Level VII hearing loss in the left ear. When those values are applied to Table VII, a 10 percent rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. In an August 2019 VA examination, puretone thresholds, in decibels, were as follows: 1000 Hz 2000 Hz 3000 Hz 4000 Hz RIGHT 35 45 65 65 LEFT 55 70 75 85 The average puretone threshold was 53 decibels for the right ear and 71 decibels for the left ear. Speech audiometry revealed speech recognition ability of 88 percent in the right ear and 74 percent in the left ear. The audiometric findings for the examination equate to Level II hearing loss in the right ear. As there is indication of exceptional hearing loss in the left ear, the Board will look to Table VI and Table VIA to see which one results in the higher numeral. Looking to Table VI, the Veteran shows Level VI hearing loss in the left ear; looking to Table VIA, there is also Level VI hearing loss in the left ear. Therefore, the Board will use Level VI hearing loss. When those values are applied to Table VII, a 10 percent rating for the Veteran’s bilateral hearing loss is reflected under 38 C.F.R. § 4.85. Initially, the Board acknowledges that the Veteran has complained of vertigo issues, including equilibrium and dizziness problems. The Board had referred this matter to the AOJ to obtain an opinion regarding whether those complaints were a symptom of the Veteran’s service-connected bilateral hearing loss. However, the Board finds that based on the most recent September 2019 VA examiner’s opinion, there was no nexus between the Veteran’s vertigo issues and hearing loss. Specifically, the examiner stated that there had been some suggestion recently in the medical literature that long-term, chronic noise exposure could lead to vestibular disturbances, such as Meniere’s like symptoms and even possibly BPPV. However, this was not generally accepted. These diagnoses, Meniere’s Disease and BPPV were less likely than not related to noise induced hearing loss or tinnitus. On the Veteran’s induction examination, he noted tinnitus in his left ear, and on his separation examination, he denied dizziness and hearing loss. In addition, in November 2019 rating decision, the AOJ specifically denied entitlement to service connection for vertigo. Thus, this issue will not be considered as a symptom of the Veteran’s service-connected bilateral hearing loss. The Board has considered the Veteran’s lay assertions regarding his diminished hearing. However, the assignment of disability ratings for hearing impairment are derived by a mechanical application of the Rating Schedule to the numeric designations based on the audiology examination results. See Lendenmann, supra; Doucette v. Shulkin, 28 Vet. App. 366, 368 (2017). It is clear from the Rating Schedule that a higher rating can be awarded only when loss of hearing has reached a specified measurable level. The Board is cognizant that an isolated October 2010 VA examination report detailed audiometric findings that would warrant a 10 percent disability rating. However, only a few months later, in the February 2011 VA examination, findings showed a noncompensable rating. Additionally, VA examinations and private treatment records before and after the October 2010 findings consistently showed evidence which would warrant only a noncompensable rating prior to October 24, 2018. Therefore, the Board finds most probative that a noncompensable rating was consistently shown during the time period prior to October 24, 2018. From October 24, 2018, the VA audiograms and examination report findings showed bilateral hearing loss that warranted the assignment of a 10 percent rating, but no higher. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. Accordingly, the 10 percent rating assigned during this time period for the Veteran’s bilateral hearing loss disability accurately reflects the degree of his service-connected hearing impairment. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.85, Diagnostic Code 6100. Based on the foregoing discussion, evidence of record showed no distinct periods of time during the appeal period when the Veteran’s service-connected bilateral hearing loss varied to such an extent that a rating greater or less than the noncompensable and 10 percent ratings currently assigned would be warranted. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In reaching this decision, the Board considered the doctrine of reasonable doubt. The Board is cognizant that the criteria for an evaluation of 10 percent, but no higher, for bilateral hearing loss have been met for the time period from October 24, 2018. However, as the preponderance of the evidence is against the Veteran’s claims of entitlement to a compensable evaluation prior to October 24, 2018, and entitlement to an evaluation in excess of 10 percent thereafter for his service-connected bilateral hearing loss, that doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran also contends that his bilateral hearing loss warrants an increased evaluation on an extraschedular basis. Generally, disability ratings are determined by evaluating the extent to which a service-connected disability adversely affects the ability to function under the ordinary conditions of daily life, including employment, by comparing symptomatology with the criteria set forth in VA’s Rating Schedule. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. However, where schedular evaluations under the VA Rating Schedule are found to be inadequate, extraschedular evaluations may be awarded pursuant to referral of such claim to the Under Secretary for Benefits or the Director of Compensation Service for consideration of an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability. See 38 C.F.R. § 3.321(b)(1); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). As the Veteran and his representative have requested extraschedular consideration, the Board must consider whether an extraschedular evaluation is warranted in this case. See Doucette, 28 Vet. App. at 369-70. In contrast to the schedular criteria for evaluating hearing loss, extraschedular provisions for hearing loss do not rely exclusively on objective test results to determine whether referral for an extraschedular rating is warranted. See Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). The Board cannot assign an extraschedular rating in the first instance; rather, the Board may consider whether a remand for referral to the Under Secretary for Benefits or Director of Compensation Service is necessary. See 38 C.F.R. § 3.321(b)(1). In determining whether an extraschedular evaluation is warranted, the Board must first consider whether the evidence of record presents such an exceptional or unusual disability picture that the available schedular evaluations for that service-connected disability are inadequate, as the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the service-connected disability on appeal. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If the schedular rating criteria are found to be inadequate, the Board must next determine whether the exceptional disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. See id. at 115-16. Where both of these two elements have been met, the claim at issue must be referred for consideration of an extraschedular rating; otherwise, the schedular evaluation shall be deemed adequate, and no referral is required. See 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that the schedular criteria applicable to the Veteran’s service-connected hearing loss adequately contemplates its severity and symptomatology, as it references objective measurements of puretone thresholds and speech discrimination. The Board notes that the Veteran has made additional complaints describing dizziness, vertigo, and equilibrium issues. However, those complaints were not found to be associated with the Veteran’s bilateral hearing loss. The evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. A comparison between the level of severity and symptomatology of the Veteran’s assigned evaluations with the established criteria found in the Rating Schedule shows that the rating criteria reasonably describe his disability level and symptomatology. In this regard, the Board finds that the Veteran’s reports of his difficulty hearing and understanding speech as well as other sounds like sirens constitute symptomatology and impairment contemplated in the rating criteria for hearing loss. Indeed, the United States Court of Appeals for Veterans Claims (Court) has held that the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech, as these are the effects that VA’s audiometric tests are designed to measure. The Court further indicated that “when a claimant’s hearing loss results in an inability to hear or understand speech or to hear other sounds in various contexts, those effects are contemplated by the schedular rating criteria.” See Doucette v. Shulkin, 28 Vet. App. 366, 369 (2017). The Board also acknowledges the Veteran’s report that his hearing issues cause him to feel frustrated but finds that these feelings are the result of his difficulty hearing and understanding speech, the functional effects of which are contemplated by the rating criteria. It logically follows that difficulty hearing and understanding speech would impact a veteran in a variety of ways, including feeling frustrated, but the Rating Schedule is not written to account for every possible consequence associated with each symptom. The Court in Doucette reviewed a similar factual situation, inasmuch as the Board had considered that claimant’s report of being embarrassed from having to ask others to repeat themselves, among other reported difficulties, in finding that the resultant effect of the reported symptoms, in combination, was difficulty hearing. The Court determined that the claimant had not alleged any symptoms in that case that could be considered exceptional or unusual for a claimant suffering from hearing loss. See Doucette, 28 Vet. App. at 372-73. In addition, the Veteran is separately service-connected for tinnitus. Accordingly, in light of the foregoing, the Veteran’s claim for an increased evaluation for his service-connected bilateral hearing loss is not referred to the Director for extraschedular consideration. 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun, supra; Doucette, supra. 2. Entitlement to a TDIU is denied. A TDIU may be granted where a veteran is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or higher, or as a result of two or more service-connected disabilities, provided at least one disability is ratable at 40 percent or higher, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Consideration may be given to a veteran’s level of education, special training, and previous work experience, but not to his or her age or to impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Substantially gainful employment is defined as work that is more than marginal and that permits the individual to earn a living wage. See Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment is not considered substantially gainful employment. The determination of whether a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability is a factual determination rather than a medical question. Therefore, responsibility for the ultimate determination of whether a veteran is capable of securing or following substantially gainful employment is placed on VA, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); see also 38 C.F.R. § 4.16; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). The Veteran is service connected for tinnitus, rated as 10 percent disabling; and bilateral hearing loss, rated as noncompensable prior to October 24, 2018, and 10 percent disabling thereafter. His combined disability rating was 10 percent prior to October 24, 2018, and 20 percent thereafter. Thus, the schedular percentage requirements for entitlement to a TDIU are not met. Nevertheless, the Board will consider whether the Veteran’s service-connected disabilities have prevented him from securing or following a substantially gainful occupation such that referral for consideration of entitlement to a TDIU on an extraschedular basis is warranted under 38 C.F.R. § 4.16(b). Initially, the Board notes that the Veteran has not submitted a VA Form 21-8940; therefore, information on education level and employment was not provided. Audio VA examinations for the Veteran’s bilateral hearing loss and tinnitus do not show any evidence that the Veteran was unable to obtain and maintain substantially gainful employment. Specifically, the March 2009, October 2010, and February 2011 VA examination reports did not provide any information on whether the Veteran’s hearing loss or tinnitus would impact his ability to work, and the Veteran did not assert this. In a November 2011 VA opinion, the examiner stated that nowhere in the claims folder was there any documentation that the Veteran had either lost, or been denied, employment because of his service-connected hearing loss or tinnitus. The examiner stated that someone with a bilateral high frequency hearing impairment will at times experience difficulty understanding normal conversational speech, especially in the presence of background noise. However, it was the examiner’s opinion that it was less likely than not that the Veteran’s hearing impairment would significantly have an effect on daily or occupational activities. In a June 2014 VA examination report, the examiner noted that the Veteran’s hearing loss impacted his ordinary conditions of daily life, including ability to work. The Veteran reported having difficulties hearing or understanding in all situations, avoiding going to restaurants, and that his hearing difficulties were extremely frustrating. He also said that he could not hear important environmental sounds like an ambulance. The Veteran said he last worked in 2004 as a Nurse’s Aide where he had hearing difficulties on the job, which caused him to lose his job. The examiner said that the Veteran could be expected to have difficulty functioning adequately in all situations where hearing needed to be acute. In situations where hearing was needed, but did not need to be acute, the Veteran should be able to function provided he was wearing hearing aids, was giving access to lip reading cues, and background noise was reduced. Regarding the Veteran’s tinnitus, the examiner stated that his tinnitus impacted his conditions of daily life. However, the examiner said that it should not impact his ability to work. The Veteran said that it interfered with his ability to hear and sleep. In a December 2015 VA examination, it was noted that the Veteran’s hearing loss and tinnitus impacted ordinary conditions of daily life, including ability to work. The Veteran said that he missed words and phrases, even with hearing aids. He indicated that tinnitus occurred day and night and was not relieved or reduced with hearing aid use. In a June 2017 VA opinion, the examiner said that many of the Veteran’s claimed difficulties were clearly valid while others seemed less valid because he had a bilateral high frequency sensorineural hearing loss with reasonably good preservation in the low and mid-frequency range, so that he should not be encountering too much difficulty hearing human voices during conversations. However, the examiner also highlighted that the Veteran’s hearing loss combined with his severe tinnitus probably made it at least as likely as not difficult for the Veteran to work and could interfere significantly with his activities of daily living. In an August 2019 VA examination, it was noted that the Veteran’s hearing loss and tinnitus impacted ordinary conditions of daily life, including ability to work. The examiner said that without the use of hearing aids, the Veteran would have significant difficulty hearing and understanding people using conversational tones even during one-on-one conversations. Regarding tinnitus, the ringing seemed to make it more difficult for him to hear and understand what other people were saying. It was noted that the Veteran had had bilateral hearing aids since 2006 and these seemed to help somewhat. Additional post-service treatment records do not reflect findings that the Veteran was unable to obtain and maintain substantially gainful employment. In fact, VA treatment records dated from 2007 repeatedly detailed that the Veteran was a nurse assistant at St. Luke’s and had stopped working due to back pain. The Board finds the VA examiners’ opinions to be probative because they were rendered by skilled medical professionals in view of an accurate understanding of the Veteran’s medical history and current medical condition. See Nieves-Rodriguez, 22 Vet. App. 295; Prejean v. West, 13 Vet. App. 444. When only his service-connected disabilities are considered, the Veteran has difficulty with hearing. The Board does not doubt the Veteran’s reports that his service-connected disabilities limit his functional abilities, but they have not been shown to alone prevent him from obtaining and maintaining substantially gainful employment. Other VA treatment notes detailed that he stopped working as a nurse’s assistant due to impairment caused by back pain, a nonservice-connected disability. The probative evidence of record does not show that the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities alone. Accordingly, referral for consideration of entitlement to a TDIU on an extraschedular basis is not warranted. The preponderance of the evidence is against a finding of entitlement to a TDIU, the benefit-of-the-doubt rule is not for application, and the claim must be denied. J. D. DEANE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Saudiee Brown 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.