Citation Nr: 21012392 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 16-39 206 DATE: March 4, 2021 ORDER A rating in excess of 50 percent for organic brain syndrome and traumatic brain injury (TBI) is denied. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. FINDING OF FACT The Veteran’s organic brain syndrome and TBI, rated as a mental disorder, has not been manifested by symptomatology causing occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSION OF LAW The criteria for a rating in excess of 50 percent for organic brain syndrome and TBI have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.20, 4.21, 4.124a, Diagnostic Code 8045-9304.   REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1980 to November 1996. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). A Board hearing was held before the undersigned in September 2019. A transcript of the hearing is of record. These matters were previously before the Board in March 2020 when they were remanded for further development. Entitlement to a rating in excess of 50 percent for organic brain syndrome and TBI is denied. The Veteran contends he is entitled to a rating in excess of 50 percent for his service-connected organic brain syndrome and TBI. Generally, disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide used in the evaluation of disabilities 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. A Veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran’s organic brain syndrome and TBI is rated as a mental disorder under hyphenated Diagnostic Code 8045-9327. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. In this case, the hyphenated diagnostic code indicates that the Veteran's mental disability is rated as analogous to residuals of a TBI (Diagnostic Code 8045). Diagnostic Code 9327 has been removed from the rating schedule; consequently, the assignment of a new diagnostic code is warranted. As the Veteran has a mental disorder due to TBI, the Board finds that Diagnostic Code 9304 for major or mild neurocognitive disorder due to TBI is the most appropriate diagnostic code for rating the Veteran’s symptoms. As mental disorders are rated under the General Rating Formula for Mental Disorders, the rating criteria does not change despite the assignment of a different diagnostic code. Additionally, the Board acknowledges that the Veteran's 50 percent rating under Diagnostic Code 8045-9327 has been in effect since November 29, 1996, which is more than 20 years. Although the rating is protected, there is no reduction in rating or severance of service connection from a change in the diagnostic code; thus, the change in diagnostic code is appropriate in this case. See Murray v. Shinseki, 24 Vet. App. 420, 428 (2011); see also Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). The General Rating Formula for Mental Disorders provides the following: A 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory, for example, retention of only highly learned material or forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A maximum 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms in the General Rating Formula for Mental Disorders is not intended to constitute an exhaustive list, but rather provides examples of the type and degree of symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, “a [V]eteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Furthermore, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. As the Veteran’s disability is due to a TBI, the Board will also consider whether the Veteran is entitled to a separate rating under Diagnostic Code 8045, residuals of TBI. There are three main areas of dysfunction that may result from TBI and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical. Each of these areas of dysfunction may require evaluation. 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 a given individual, symptoms may fluctuate in severity from day to day. Evaluate cognitive impairment under the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” Subjective symptoms may be the only residual of TBI or may be associated with cognitive impairment or other areas of dysfunction. Evaluate subjective symptoms that are residuals of TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, 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. Evaluate emotional/behavioral dysfunction under § 4.130 (Schedule of ratings—mental disorders) when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified.” Evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: 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. The table titled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” contains 10 important facets of TBI related to cognitive impairment and subjective symptoms. It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, 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,” since any level of impaired consciousness would be totally disabling. Assign a 100-percent evaluation if “total” is the level of evaluation for one or more facets. If no facet is evaluated as “total,” assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. For example, assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet. Note (1): 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 diagnostic code. In such cases, do not assign more than one evaluation based on the same manifestations. If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation 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, assign a separate evaluation for each condition.   The Evaluation of Cognitive Impairment and Other Residuals of TBI not Otherwise Classified provides the following: Facets of cognitive impairment and other residuals of TBI not otherwise classified Level of impairment Criteria Memory, attention, concentration, executive functions 0 No complaints of impairment of memory, attention, concentration, or executive functions. 1 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 Objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment. 3 Objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment. Total Objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment. Judgment 0 Normal. 1 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 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 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. Total 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. Social interaction 0 Social interaction is routinely appropriate. 1 Social interaction is occasionally inappropriate. 2 Social interaction is frequently inappropriate. 3 Social interaction is inappropriate most or all of the time. Orientation 0 Always oriented to person, time, place, and situation. 1 Occasionally disoriented to one of the four aspects (person, time, place, situation) of orientation. 2 Occasionally disoriented to two of the four aspects (person, time, place, situation) of orientation or often disoriented to one aspect of orientation. 3 Often disoriented to two or more of the four aspects (person, time, place, situation) of orientation. Total Consistently disoriented to two or more of the four aspects (person, time, place, situation) of orientation. Motor activity (with intact motor and sensory system) 0 Motor activity normal. 1 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 Motor activity mildly decreased or with moderate slowing due to apraxia. 3 Motor activity moderately decreased due to apraxia. Total Motor activity severely decreased due to apraxia. Visual spatial orientation 0 Normal. 1 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 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 (global positioning system). 3 Moderately severely impaired. Gets lost even in familiar surroundings, unable to use assistive devices such as GPS (global positioning system). Total Severely impaired. May be 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 0 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 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. 2 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 0 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 One or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them. 2 One or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them. 3 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. Communication 0 Able to communicate by spoken and written language (expressive communication), and to comprehend spoken and written language. 1 Comprehension or expression, or both, of either spoken language or written language is only occasionally impaired. Can communicate complex ideas. 2 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 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. Total 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. Consciousness Total Persistently altered state of consciousness, such as vegetative state, minimally responsive state, coma. Turning to the evidence in this case, the record reflects that the Veteran underwent a VA Central Nervous System and Neuromuscular Diseases examination in February 2014. The examiner noted a diagnosis of organic brain syndrome. During the examination, the Veteran reported working as a Heating, Ventilation, and Air Conditioning (HVAC) technician. He indicated that he had recently been demoted at work, noting various incidents where he did not perform his job adequately. The examiner noted that the Veteran’s condition did not require continuous medication and did not result in muscle weakness, swallowing conditions, respiratory conditions, sleep disturbances, bowel functional impairment, voiding dysfunctions, a history of recurrent symptomatic urinary tract infections, or erectile dysfunction. The neurologic examination revealed normal speech, gait, strength, and deep tendon reflexes. There also was no evidence of muscle atrophy attributable to a central nervous system condition. The examiner indicated that the Veteran’s disorder did not have any impact on his ability to work. In March 2014, the Veteran underwent a VA Initial Evaluation of Residuals of TBI. The examiner noted that the Veteran had been diagnosed with a TBI in the 1990s. During the examination, the Veteran stated his short-term memory was affected as per reports by others; however, he indicated that he did not notice any changes in his memory. Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI revealed 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 (his immediate and delayed recall were both 3/3). The examiner noted the Veteran’s judgement was normal; social interaction was routinely appropriate; the Veteran was always oriented to person, time, place, and situation; motor activity was normal; visual spatial orientation was normal; consciousness was normal; and the Veteran was able to communicate by and comprehend spoken and written language. There were no subjective symptoms or neurobehavioral effects. The examiner also indicated that the Veteran’s residual conditions attributable to TBI had no impact on his ability to work. In May 2014, the Veteran underwent a VA Mental Disorders examination. The examiner noted a diagnosis of brain syndrome, in accordance with the DSM-5, and TBI. The examiner noted that a review of the Veteran’s file had been conducted and that service treatment records indicated neuropsychological testing had been completed shortly after the Veteran’s in-service head injury. During the examination, the Veteran reported that he was involved in a motor vehicle accident during service. He described retrograde and anterograde amnesia, noting that he remembered some of his activities the morning of the accident and being released from the hospital into a rehabilitation program but had no access to other memories. He reported that, after extensive rehabilitation, he returned to active duty but did not perform well, so he eventually separated from service. After separation, he worked at a marina before entering the HVAC field. He reported that he had been having difficulties at work, noting that it is sometimes hard for him to complete tasks properly and work efficiently. Regarding his family history, the Veteran reported that he had been married for more than 30 years and that he had five children. He denied any legal issues and significant medical history (other than the in-service motor vehicle accident). The examiner noted that, at the time of the examination, the Veteran was alert and oriented in all three spheres, his mood was somewhat apprehensive and slightly dysthymic, he had unremarkable speech as the content was coherent and goal directed, he had good insight and judgment, he denied having a depressed mood, and he denied changes in his sleep or appetite. The Veteran denied experiencing suicidal or homicidal ideations. The examiner reported that the Veteran’s memory for verbal material was mildly impaired based on his age, noting that it was not unusual for those who have had a mild head injury to have impairments at times of stress or physical illness. The examiner noted that the Veteran’s symptoms included mild memory loss (such as forgetting names, directions, or recent events) and impairment of short- and long-term memory (for example, retention of only highly learned material, while forgetting to complete tasks). Lastly, the examiner estimated that the Veteran’s symptoms resulted in occupational and social impairment with reduced reliability and productivity, attributable to the TBI. During the September 2019 Board hearing, the Veteran reported short- and long-term memory problems and indicated that he uses notes as reminders. He also reported that he had been married since 1982, had five children, and five grandchildren (and good relationships with his grandchildren). The Veteran reported problems with working, noting that he was demoted to a position in general maintenance due to his memory problems. He denied experiencing headaches, sleep problems, depression, anxiety, and anger issues. In September 2020, the Veteran underwent a VA Review Evaluation of Residuals of TBI. The examiner noted that the Veteran’s condition had progressed/worsened since onset, noting that his memory has worsened. Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI revealed 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. It was noted that the Veteran had short-term memory loss. The Veteran’s social interactions were routinely appropriate; he was always oriented to person, time, place, and situation; and he had normal judgment, motor activity, consciousness, and spatial orientation. There were no subjective symptoms or neurobehavioral effects and he was able to communicate by and comprehend written and spoken language. The examiner noted that additional residuals included a mental disorder. The examiner also indicated that the Veteran’s residual conditions attributable to TBI did not impact the Veteran’s ability to work. In October 2020, the Veteran underwent a VA Mental Disorders examination. The examiner diagnosed personality and behavioral disorders due to known physiological conditions, noting that the diagnosis encompasses the diagnosis of organic brain syndrome. The examiner also noted the TBI diagnosis and indicated that all symptoms of mental health diagnosis were attributable to the TBI. During the examination, the Veteran reported that he had been married since 1982 and currently lived with his wife and daughter. He also reported working full-time in general maintenance and denied any significant issues with his job. Regarding behavioral observations, the examiner noted that the Veteran was cooperative and friendly and that his manner of relating and social skills was adequate. The examiner also noted that the Veteran was appropriately dressed and that his grooming was adequate; his posture, motor behavior, and eye contact was normal; his speech was fluent and grammatical; his thought process was coherent and logical with no evidence of hallucinations, paranoia, or delusions; his affect was tense; and his mood was ‘alright’. The examiner indicated that the Veteran was alert and oriented in all spheres; that his recent and remote memory functioning were fairly intact; and his attention, concentration, reasoning, and judgment were good. Lastly, the examiner estimated that the Veteran’s symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation, which is attributable to the TBI. In November 2020, an addendum opinion was obtained to determine what symptoms pertain to the Veteran’s disorder. In response, the examiner indicated that the Veteran’s symptoms include mild memory loss, such as forgetting names, directions, or recent events. After review of the evidence of record, the Board finds a preponderance of the evidence is against a rating in excess of 50 percent for the Veteran’s organic brain syndrome and TBI. The Veteran’s symptoms do not more nearly approximate a rating of 70 percent under the General Rating Formula for Mental Disorders, as they are not of such a severity, frequency, or duration to result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In addition, the 70 percent rating criteria considers symptoms such as, suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships, and the Board finds there is no evidence the Veteran experienced these symptoms during the period on appeal. The evidence of record indicates that the Veteran’s symptoms may cause a deficiency in the area of work. Specifically, during the February 2014 VA examination, the Veteran reported that he was demoted at work as a result of various incidents where he had not performed adequately. In addition, during the May 2014 VA examination, he reported difficulty at work, noting that it was difficult for him to complete tasks properly and work efficiently. However, at the October 2020 VA psychiatric examination, the Veteran reported that he was working full time in maintenance and that he did not have any significant issues doing his job. To the extent this evidence more nearly approximates that the Veteran has a deficiency in the area of work, the evidence does not indicate the Veteran experienced a deficiency in any other area, including family relations, judgment, thinking, or mood. Thus, the Veteran’s symptoms do not rise to the level contemplated by the 70 percent rating criteria as there is no evidence his symptoms result in a deficiency in most areas. The Board further finds the Veteran’s disability picture does not reflect symptoms that more nearly approximate the frequency, duration, and severity of total social and occupational impairment at any time during the appeal period. There is no evidence of gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform the activities of daily living, including maintenance of minimal personal hygiene; disorientation as to time or place; memory loss for names of close relatives, own occupation, or own name; or other symptoms of similar frequency, duration, and severity. The Veteran’s disability picture as shown in the evidence for the period on appeal does not approximate the level of impairment which would warrant a 100 percent rating. The Board has also considered whether the Veteran would be entitled to a higher or separate rating under Diagnostic Code 8045. A separate rating would not be warranted as the only symptom that has been noted is mild memory loss and that is already accounted for in the rating provided under Diagnostic Code 9304; hence, a separate rating under Diagnostic Code 8045 would constitute pyramiding. 38 C.F.R. § 4.14. Regarding whether the Veteran would be entitled to a higher rating under Diagnostic Code 8045, for the facet of memory, attention, concentration, or executive functions, the Board finds that a score of 1 is warranted based on a complaint of mild memory loss without objective evidence on testing, as such was shown on both the March 2014 and September 2020 VA examinations. A score of 0 is warranted for the facets of judgment, social interaction, orientation, motor activity, visual spatial orientation, subjective symptoms, neurobehavioral effects, communication, and consciousness, as these facets had normal findings on examination in March 2014 and September 2020. In summary, the Veteran’s symptoms meet the criteria for a score of 1 due to his mild memory loss, which equates to a 10 percent evaluation under Diagnostic Code 8045. Therefore, it would not be more favorable to evaluate the Veteran under Diagnostic Code 8045. 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (1). In sum, the Board finds the Veteran’s organic brain syndrome and TBI most closely and consistently corresponds to the 50 percent rating criteria under hyphenated Diagnostic Code 8045-9304. Therefore, a rating in excess of 50 percent is not warranted. In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against an evaluation in excess of 50 percent for the Veteran’s PTSD, the doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3.   REASONS FOR REMAND Entitlement to service connection for bilateral hearing loss is remanded. Although the additional delay is regrettable, the Board finds further development is required before a decision can be made regarding the Veteran’s claim. In accordance with the March 2020 remand order, a medical opinion as to whether the Veteran’s left ear hearing loss preexisted service was obtained. In the September 2020 opinion, the VA examiner opined that there was clear and unmistakable evidence that the Veteran’s left ear hearing loss existed prior to service, noting that a September 1980 induction examination noted mild to moderate hearing loss in the left ear. The examiner also opined that the Veteran’s left ear hearing loss clearly and unmistakably was not aggravated by service. In support of this opinion, the examiner indicated that, while there was no exit examination in the record, the Veteran’s hearing was considered stable in 2014. The examiner also noted that the results of the examination demonstrated a typical presbycusis pattern consistent with aging. An addendum opinion was obtained in September 2020. In the opinion, the examiner opined that there was clear and unmistakable evidence the Veteran’s left ear hearing loss preexisted service, again noting that a September 1980 induction evaluation revealed mild to moderate hearing loss in the left ear. The examiner also opined that the Veteran’s left ear hearing loss clearly and unmistakably was not aggravated by service. In support of the opinion, the examiner noted that audiometric testing completed in 2014 was stable when compared to the results obtained at induction. Thus, the examiner noted, a permanent threshold shift did not occur as a result of military noise exposure or head trauma in the 1993 motor vehicle accident. However, the Board finds the opinions inadequate as they relied on an inaccurate fact. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In concluding that the Veteran’s left ear hearing loss clearly and unmistakably preexisted service, the examiner stated that an induction evaluation noted mild to moderate hearing loss in the left ear. However, as noted in the March 2020 Board decision, the September 1980 test was not an induction evaluation as it was completed two days after the Veteran entered service. Consequently, remand for a new medical opinion is required. Regarding the Veteran’s right ear hearing loss, a September 2020 VA examiner opined that the Veteran’s right ear hearing loss was not related to his active service. In support of the opinion, the examiner noted that the Veteran denied a history of ear infections, otologic surgeries, and physical ear trauma. The examiner also noted that a September 1980 induction evaluation revealed normal hearing sensitivity in the right ear. The Board finds the opinion inadequate as the examiner failed to provide an adequate rationale to support the opinion. Specifically, the examiner has not explained how the absence of ear infections, otologic surgeries, and physical ear trauma or the presence of normal hearing on the September 1980 evaluation indicates the Veteran’s current right ear hearing loss disability is not related to his service. In addition, the examiner failed to address lay statements of record regarding noise exposure from the Veteran’s military occupational specialty working on boat engines and working in an engine room during service. Thus, remand for a new medical opinion is necessary. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file updated VA treatment records from July 2020 to the present. 2. Obtain an addendum opinion from a clinician other than the September 2020 VA examiner to determine the nature and etiology of the Veteran’s bilateral hearing loss. An examination should only be scheduled if the examiner deems one is necessary for providing the requested opinions. Following a review of the claims file, the examiner is asked to respond to the following: (a)(1) Is there clear and unmistakable evidence (undebatable) that the Veteran’s left ear hearing loss pre-existed his service? (a)(2) If there is clear and unmistakable evidence that the Veteran’s left ear hearing loss preexisted service, then was the left ear hearing loss clearly and unmistakably not aggravated by service? In providing an opinion on this question the examiner should consider the Veteran’s in-service noise exposure and the in-service motor vehicle accident. (a)(3) If the left ear hearing loss did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, then is it at least as likely as not (a 50 percent or greater probability) related to an in-service injury, event, or disease, including in-service noise exposure and/or the in-service motor vehicle accident? (b) Is the Veteran’s right ear hearing loss at least as likely as not (a 50 percent or greater probability) related to an in-service injury, event, or disease, including in-service noise exposure and/or the in-service motor vehicle accident? A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be   rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Jiggetts 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.