Citation Nr: 21013781 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 16-38 062 DATE: March 10, 2021 ORDER Entitlement to service connection for a lumbar spine disability is granted. Entitlement to service connection for a cervical spine disability is granted. Entitlement to a compensable rating for hypertension is granted. Entitlement to a compensable rating for bilateral hearing loss disability is denied. Entitlement to a rating greater than 10 percent for sinusitis is denied. FINDINGS OF FACT 3 The evidence shows that a lumbar spine disability is related to trauma from an in-service motor vehicle accident. 4 The evidence shows that a cervical spine disability is related to trauma from an in-service motor vehicle accident. 5 The Veteran’s hypertension more nearly approximates the criteria for a 10 percent rating with systolic pressure 160 or more; however, it has not been productive of diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. 6 The service-connected bilateral hearing loss disability is not shown to be manifested by worse than level III in the right ear and level II in the left ear. 7 At no point during the duration of the appeal has the Veteran’s sinusitis manifested incapacitating episodes per year, of more than six non-incapacitating episodes per year characterized by headaches, pain and purulent discharge or crusting. CONCLUSIONS OF LAW 3 The preponderance of the evidence is in favor of service connection for a lumbar spine disability. 38 U.S.C. §§ 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 4 The preponderance of the evidence is in favor of service connection for a cervical spine disability. 38 U.S.C. §§ 1110, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 5 With resolution of all reasonable doubt in favor of the Veteran, the criteria for an initial 10 percent rating, but no more, for hypertension are met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.21, 4.104, Diagnostic Code 7101 (2020). 6 The criteria for entitlement to a compensable rating for bilateral hearing loss disability are not met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.85, Diagnostic Code 6100, 4.86 (2020). 7 The criteria for entitlement to a rating greater than 10 percent for sinusitis are not met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.97, Diagnostic Code 6512 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from January 1977 to August 1984. See DD Forms 214. The Board notes that the Veteran had a military occupational specialty as a medical specialist. Id. The Veteran was afforded an August 2018 Board hearing, and a transcript is associated with the record. See August 2018 Hearing Transcript. This appeal was remanded in February 2019 for outstanding records and VA examinations, and there has been substantial compliance with the remand instructions. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with Board’s remand instructions). This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c) (2020). 38 U.S.C. § 7107(a)(2) (2012). REFERRAL The issue of entitlement to a potential psychiatric disability characterized by loneliness, cognitive decline, and difficulty communicating, as secondary to bilateral hearing loss was raised in an October 2020 VA examination report where the examiner discussed cognitive decline, loneliness, and difficulty thinking resulting from the hearing loss. The issue is referred to the Agency of Original Jurisdiction (AOJ) to address in the first instance. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 3 - 2 Entitlement to service connection for a cervical and lumbar spine disability The Veteran contends that he has a back disability, which based on the evidence of record the Board has recharacterized as claims for a lumbar spine disability, and for a cervical spine disability, due to service, to include a 1981 motor vehicle accident (MVA), and carrying a heavy rucksack. Alternatively, he contends that his back (lumbar and cervical spine) disability is secondary to his service-connected right ankle disability. The Board concludes that the Veteran has a current disability that is related to his in-service MVA. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A November 2020 imaging report shows that the Veteran has severe spinal canal stenosis at L2-L3 and L3-L4 levels, L4-L5 anterior spondylolisthesis, and intervertebral disc degeneration with Schmorl nodes. See November 2020 Medical Treatment Record- Non-Government Facility. A June 2019 Disability Benefits Questionnaire by Dr. Otero shows the Veteran has current diagnoses of chronic back pain with degenerative disc disease (DDD), and chronic cervicalgia with DDD and cervical subluxation. See June 2019 Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire. As to the second element of service connection, during service the Veteran was in an MVA. See January 1982 Military Personnel Record. The service treatment records indicate that he suffered multiple injuries from the MVA, to include to the back and the head. See STR-Medical. Given such, the second element of service connection has been established. Thus, the question becomes whether the current disabilities are related to service. On this question there are probative opinions in favor of and against the claim. The evidence in favor of the claim includes a June 2019 opinion by Dr. Otero that the Veteran’s lumbar spine disability, chronic back pain with DDD, is relative to military service, specifically his in-service accident. See June 2019 Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire. The examiner notes that there were post-traumatic changes of the spine. Additionally, a December 2019 opinion by Dr. J. Espina noted that the Veteran’s lumbar DJD was secondary to his MVA during active duty. See December 2019 Medical Treatment Record Non-Government Facility. In this context, although he uses the word “secondary” it appears Dr. Espina meant one thing caused the next thing, the Board interprets the doctor’s findings favorably, as directly relating the Veteran’s back condition to his in-service MVA In October 2018 Dr. Otero noted that the Veteran had a history of trauma to his neck, which explained his neck pain. See October2018 Translation Related. Again, the Board interprets this favorably. In addition, at his hearing the Veteran explained that his in-service accident was so strong he was thrown from the vehicle and left unconscious. See August 2018 Hearing Transcript. He reported that his back hurt from the rucksack even in boot camp, and continued to hurt after that accident. Further he indicated that he has a dislocation in his neck since that accident, although he was only originally treated for muscle spasms. Notably, there are opinions against the claim. However, these examinations are inadequate. As to the May 2016 VA examination report, the examiner did not provide a nexus opinion. As to the January 2020 VA examination report, the Board observes that the reasoning, which was replicated for all conclusions, failed to adequately address the Veteran’s contentions regarding his back and neck pain from his accident, and in effect relies on an absence of records of treatment in service. Given such, the Board finds the preponderance of the evidence supports the Veteran’s current lumbar spine disability, to include DDD and DJD, and cervical spine disability are related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for lumbar spine disability and for cervical spine disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Because the Board is granting these claims of service connection on a direct basis, there is no need to discuss entitlement to service connection on a secondary basis, as the direct aspect of these claims is the greater benefit. Initial and Increased Ratings Disability ratings are determined by application of the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2020). The Veteran’s entire history is to be considered when making a disability evaluation. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, staged ratings will be considered and discussed, as warranted. 4 Entitlement to a compensable rating for hypertension The Veteran’s service-connected hypertension is currently evaluated as noncompensably disabling since April 30, 2012, pursuant to 38 C.F.R. § 4.104, DC 7101. This is an appeal of an initial rating. See October 2012 Rating Decision- Narrative. . Under DC 7101, a 10 percent rating is assigned for hypertension when diastolic pressure is 100 or more; or when systolic pressure is predominantly 160 or more; or when there is a history of diastolic pressure predominantly 100 or more and continuous medication for control is required. A 20 percent rating is assigned when diastolic pressure is predominantly 110 or more, or systolic pressure is predominantly 200 or more. A 40 percent rating is assigned when diastolic pressure is predominantly 120 or more, and a 60 percent rating is assigned when diastolic pressure is predominantly 130 or more. There are three notes to 38 C.F.R. § 4.104, Diagnostic Code 7101. Note (1) provides that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure (i.e., bottom number) is predominantly 90 mm or greater, and isolated systolic hypertension means the systolic blood pressure (i.e., top number) is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm. Note (2) requires the evaluation of hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation. Note (3) states that hypertension should be evaluated separately from hypertensive heart disease and other types of heart disease. The Board emphasizes that more than one blood pressure reading is not required for evaluation purposes for rating hypertension under VA regulations. See Gill v. Shinseki, 26 Vet. App. 386, 391 (2013) (holding that the need for a specific number of blood pressure readings over multiple days is not required for determining disability evaluation, as the need for multiple blood pressure readings pertains only to the confirmation of the existence of hypertension). The evidence warrants a 10 percent evaluation, but no higher, for hypertension under Diagnostic Code 7101. 38 C.F.R. § 4.7. Even with his medication, the Veteran has exhibited elevated systolic pressure (top number) 160 or more, which is supportive of a 10 percent rating under Diagnostic Code 7101. Factual Background Examples of elevated blood pressure readings while on medications for hypertension, include October 2017 reading of 162/90; January 2017 readings of 175/94, September 2020 reading of 170/84, and November 2020 readings of 182/92 and 170/96. See CAPRI. September 2012 VA examination charted blood pressure readings in the 140s/80s, and the Veteran reported using medications to control it. See September 2012 VA Examination Hypertension. At a VA examination of May 2016 it was indicated that the Veteran had a history of taking continuous medication for hypertension, which had been confirmed by blood pressure readings taken two or more times on at least three different days. See May 2016 VA Examination Hypertension Disability Benefits Questionnaire. He did not have a history of a diastolic blood pressure elevation to predominantly 100 or more. During the August 2018 Board hearing the Veteran suggested that his morning blood pressure readings showed his systolic ranged in the 160 to 180 readings, and his diastolic in the 90 to 100 range. See August 2018 Hearing Transcript. A January 2021 VA examination report indicates that the Veteran reported his hypertension persisted even with good compliance with oral medications. See January 2021 VA Examination Hypertension Disability Benefits Questionnaire. The Veteran took Lisinopril, Hyrdochlorothiazide, Metoprolol, Aspirin, and Amlodipine for his hypertension. On that date readings were in the 150s/80s. Hypertension did not impact his ability to work, although he always needed to have medication nearby. Analysis The Board has carefully considered the Veteran’s pleadings regarding his symptoms, which include elevated blood pressure readings at home even while on medications. The Board is considering the Veteran’s reports of his blood pressure readings as competent. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Further, the medical findings (as provided in the examination reports and treatment records) directly address the criteria under which the disability is evaluated. Here, there are medical readings that also support the Veteran’s reports as they pertain to the systolic readings, which fall within a 10 percent rating, and as far as the diastolic numbers reported, they too pertain to the 10 percent rating criteria. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The fact that the Veteran intermittently had systolic blood pressure readings above 160 is sufficient to more nearly approximate the criteria for the 10 percent evaluation. As such, a 10 percent rating, but no more, is warranted under DC 7101. As the Veteran’s diastolic pressure has not been predominantly 110 or more, or his systolic pressure has not been predominantly 200 or more, the next higher, 20 percent rating, is not warranted under DC 7101. Indeed, he does not contend otherwise. Staged ratings have been considered, but are not warranted. The Board acknowledges the Court’s holding that VA may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). However, the Court subsequently determined that for hypertension, the plain language of Diagnostic Code 7101 contemplates the effects of medication and, thus, the Jones case is not applicable to cases involving hypertension. McCarroll v. McDonald, 28 Vet. App. 267, 271-73 (2016). That is, the rating criteria for hypertension already takes into account the ameliorative effects of medication. Id. As such, the Board is not required to discuss the ameliorative effects of medication when evaluating whether the Veteran is entitled to a rating over 10 percent for hypertension. Thus, in light of the foregoing, and resolving all reasonable doubt in the Veteran’s favor, the Board finds that the Veteran’s service-connected hypertension more nearly approximates an initial 10 percent disability rating, but no higher. 38 C.F.R. § 4.3. Extra-schedular Consideration In January 2021, the Veteran’s representative requested the maximum benefit, to include consideration for an extraschedular rating. See January 2021 Appellate Brief. Extra-schedular evaluations under 38 C.F.R. § 3.321(b) are available only where a disability is incapable of evaluation under the rating schedule. See Long (Walter G.) v. Wilkie, No. 16-1537 (Dec. 30, 2020) (extra-schedular consideration involves evaluation of whether the Veteran’s disability picture as a whole presents an impairment that is so exceptional that the rating schedule is not capable of assessing it in the first instance). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extra-schedular rating. First, as a threshold matter, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). Considering the first step of the extra-schedular analysis, the Board finds that all the symptomatology and impairment caused by the hypertension are contemplated by the schedular rating criteria, and no referral for extra-schedular consideration is required. The totality of factors does not show that the Veteran’s hypertension is exceptional. Id. Here, there are no specific contentions that the symptoms of the Veteran’s hypertension are so unusual as to render it exceptional, and the medical evidence shows symptoms such as elevated blood pressure readings even while taking medications, are contemplated by the rating criteria. The Board finds that the Veteran’s disability is fully capable of evaluation under the rating schedule. 5 Entitlement to a compensable rating for bilateral hearing loss disability The Veteran’s bilateral hearing loss disability is service connected and rated as noncompensably disabling effective April 30, 2012. The Veteran seeks entitlement to a higher initial evaluation for his bilateral hearing loss disability, which is evaluated under 38 C.F.R. § 4.86(a) (2020). Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, Diagnostic Code 6100. To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, 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. Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). 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. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). As was explained in the law and regulations section above, the resolution of this issue involves determining the level of hearing acuity in each ear. Factual Background An October 2012 VA examination report reveals that the Veteran reported difficulty following interactions. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran’s Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: October 2012 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 25 40 50 50 42 96 LEFT 15 25 40 55 34 96 Table VI provides a numeric designation of hearing impairment as Level I, each, for the right and the left ears per Table VI, which corresponds to a noncompensable rating according to Table VII. A May 2016 VA examination report reveals that the Veteran reported difficulty understanding conversations and needed to ask for repetition. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007); see May 2016 VA Examination Hearing Loss and Tinnitus Disability Benefits Questionnaire. The Veteran’s Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: May 2016 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 25 50 50 55 45 100 LEFT 20 25 45 55 36 96 Table VI provides a numeric designation of hearing impairment as Level I, each, for the right and the left ears per Table VI, which corresponds to a noncompensable rating according to Table VII. A December 2018 VA examination report reveals that the Veteran reported trouble understanding speech in noisy environments and with distant speakers. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007); see December 2018 VA Examination Hearing Loss and Tinnitus Disability Benefits Questionnaire. The Veteran’s Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: December 2018 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 30 50 55 60 49 100 LEFT 20 30 45 55 38 100 Table VI provides a numeric designation of hearing impairment as Level I, each, for the right and the left ears per Table VI, which corresponds to a noncompensable rating according to Table VII. There is an April 2019 VA audiogram of record which shows puretone values from 1000 to 4000 Hertz the same as those provided in December 2018; however, it failed to either provide speech recognition scores, or indicate that they could not be provided. See April 2019 CAPRI. As such, the audiometric evaluation is not adequate for rating purposes under § 4.85(a). An October 2020 VA examination report reveals that the Veteran reported struggling most when more than one person was speaking at the same time, and having to request people repeat themselves, in addition to difficulty hearing on the phone. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007); see October 2020 VA Examination Hearing Loss and Tinnitus Disability Benefits Questionnaire. The Veteran’s Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: October 2020 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 40 60 70 75 61 84 LEFT 30 50 65 70 54 84 Table VI provides a numeric designation of hearing impairment as Level III for the right ear and Level II for the left ear per Table VI, which corresponds to a noncompensable rating according to Table VII. The examiner indicated that the Veteran’s hearing loss prohibited him from understanding conversations, contributed to cognitive decline, and lead to social isolation. Based on the degree of hearing loss the Veteran had, his ability to function occupationally was restricted to very quiet areas, with the least possible verbal communication demands. It would be very difficult for him to communicate, unless he was in a one-to-one situation. He could have significant problems participating in meetings, when using the telephone, or communicating in open/noisy environments. The Veteran needed to be in an environment that was quiet to prevent further damage to his auditory structures. The Veteran should wear hearing aids occupationally to assist with his ability to converse and communicate with his supervisors and other employees. In sum, he would have difficulty understanding verbal instructions, understanding on telephones, and hearing and understanding in one to one situations and groups could cause the Veteran to make mistakes and errors at work, miss important information to complete assigned tasks and cause him to be unable to effectively participate in meetings. Analysis Based on the evidence above, a compensable rating for the Veteran’s bilateral hearing loss is not warranted. The Board has considered the application of 38 C.F.R. § 4.86 [exceptional patterns of hearing impairment]. However, the Veteran’s hearing loss disability does not meet the criteria under that section. More specifically, the Veteran’s hearing tests do not show a result of 30 dB or less at 1000 Hz and a result of 70 dB or more at 2000 Hz, as would be required for application of Table IVA under 38 C.F.R. § 4.86(b). The Veteran also does not meet the criteria for 38 C.F.R. § 4.86(a). Each of the four specified frequencies are not all 55 dB or more in either ear, or less than 30 decibels at 1000 Hertz while more than 70 decibels at 2000 Hertz in any audiological examination. For each examination, applying the numeric designations to the applicable tables rendered a noncompensable rating. At worst, in October 2020 the Veteran’s numeric designation for hearing impairment as Level III in the right ear and Level II in the left ear. The Board expressly acknowledges its consideration of the lay evidence of record when adjudicating this claim, including the Veteran’s difficulty hearing with background noise or when more than one person is speaking. The Veteran is competent to report difficulty with his hearing; however, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). Moreover, the rating criteria contemplates speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes, is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran’s main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a compensable rating for hearing loss. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extra-schedular Consideration In January 2021 the Veteran’s representative requested the maximum benefit, to include consideration for an extra-schedular rating. See January 2021 Appellate Brief. Extraschedular evaluations under 38 C.F.R. § 3.321(b) are available only where a disability is incapable of evaluation under the rating schedule. See Long (Walter G.) v. Wilkie, No. 16-1537, 2020 WL 7757076 (Dec. 30, 2020) (en banc) (extra-schedular consideration involves evaluation of whether the Veteran’s disability picture as a whole presents an impairment that is so exceptional that the rating schedule is not capable of assessing it in the first instance). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, as a threshold matter, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). Considering the first step of the extra-schedular analysis, the Board finds that all the symptomatology and impairment caused by the bilateral hearing loss are contemplated by the schedular rating criteria, and no referral for extra-schedular consideration is required. The totality of factors does not show that the Veteran’s bilateral hearing loss is exceptional. Id. Here, the medical evidence has shown bilateral hearing loss, which diminished hearing acuity interfered with his ability to understand conversations and made communication difficult (in noisy environments, on the telephone, in more than a one-on-one situation), contributed to cognitive decline, and lead to social isolation. See October 2020 VA Examination Hearing Loss and Tinnitus Disability Benefits Questionnaire. Functionally, the Veteran’s hearing loss restricted his communication, as he needed a quiet environment and would have difficulty participating in meetings. A diagnostic code does not have to list every symptom or impairment of a disability in order to fully contemplate the impairments caused by that disability. See Long at 8-10 (explaining that a diagnostic code is not incapable of evaluating a disability simply because the disability presents with symptoms that are not specifically identified as part of the diagnostic criteria). Diagnostic codes generally contemplate those symptoms commonly associated with the disability they were designed to evaluate. See Long at 9 (explaining that the basis of its ruling in Doucette was a “common-sense observation that a diagnostic code designed to assess hearing loss necessarily contemplates those symptoms and effects commonly associated with such”). The Board may draw reasonable inferences about the ability of rating criteria to evaluate the full extent of a veteran’s disability picture. See Long at 10 (explaining that, in Doucette, “the court considered the veteran’s full disability picture and drew reasonable inferences about the ability of the rating criteria to evaluate it”). Here, there is no competent evidence in the record suggesting any particular symptoms of the Veteran’s bilateral hearing loss disability is not one that is commonly associated with his disability, and as such the evidence does not reasonably raise the need to affirmatively establish that the symptoms are commonly associated with the disability. The Board observes that even considering the October 2020 examiner’s indication that the Veteran had difficulty communicating, cognitive decline and social isolation, there is no indication that these cannot and are not adequately rated under VA’s General Rating Formula for Mental Disorders (which contemplates among other things: “social impairment” and “impairment in thought processes or communication”). Essentially, these symptoms are not exceptional as they can be assessed under VA’s General Rating Formula for Mental Disorders. Importantly, the Veteran is currently rated as 70 percent disabled for unspecified anxiety. See January 2021 Rating Decision- Codesheet. Given such, the Board finds that the Veteran’s disability is fully capable of evaluation under the rating schedule. 6 Entitlement to a rating greater than 10 percent for sinusitis The Veteran’s sinusitis (frontal and maxillary) was service connected according to Diagnostic Code 6512, effective August 24, 1984, rated as 10 percent disabling. The decision on appeal is from October 2012, when the increased rating claim was denied, and the appellate period is from one year prior to the claim, from April 2011. See April 2012 Statement in Support of Claim; see October 2012 Rating Decision. The Veteran is separately service connected for deviated nasal septum, and for allergic rhinitis. The Board notes that when a condition is specifically listed in the Schedule, as is sinusitis, it may not be rated by analogy. Copeland v. McDonald, 27 Vet. App. 333, 337 (2017). The Board will therefore not consider any other diagnostic codes. According to Diagnostic Code 6512, a 10 percent rating is assigned for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating is assigned for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A Note to the General Rating Formula for Sinusitis provides that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97. Factual Background A May 2016 VA examination report indicates that the Veteran experienced maxillary, frontal, and ethmoid sinusitis, with episodes of sinusitis including headaches and tenderness of the affected sinus. See May 2016 VA Examination Sinusitis, Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire. The Veteran experienced five non-incapacitating episodes over the previous year, but no incapacitating episodes requiring prolonged antibiotic treatment. A December 2018 VA examination report shows that the Veteran had four non-incapacitating episodes of sinusitis in the previous year. See December 2018 VA Examination Sinusitis, Rhinitis and Other Conditions of the Nose Throat, Larynx and Pharynx disability Benefits Questionnaire. He did not have any incapacitating episodes requiring four to six weeks of antibiotic treatment. Although the Veteran underwent septum correction in 1985, he did not undergo repeated sinus-related surgical procedures. A July 2019 Disability Benefits Questionnaire provided by Dr. Otero indicates that the Veteran had three non-incapacitating episodes characterized by headaches, pain and purulent discharge or crusting in the previous year. See July 2019 Private Examination Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire. The examiner did not check a box indicating whether the Veteran did or did not have incapacitating episodes requiring prolonged antibiotics. At the December 2019 VA examination, it was reported that the Veteran experienced chronic, nearly daily sinus and nasal congestion worse with dry or very rainy, cold days. See December 2019 VA Examination Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire. He reported experiencing congestion, headaches, runny nose, tenderness and pressure. The examiner indicated current findings of near-constant sinusitis with nearly daily congestion and pressure over the sinuses, headaches, pain and tenderness of affected sinus. The Veteran experienced three non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the previous year. The Veteran did not experience incapacitating episodes during the previous year. A December 2019 record from Dr. Espina indicates that the Veteran reported six non-incapacitating episodes per year of sinusitis characterized by pain and purulent discharge or crusting. See December 2019 Medical Treatment Record Non-Government Facility. At a January 2021 VA examination the Veteran reported nasal congestion, post-nasal drip and discharge, yellowish in color and viscous. See January 2021 VA Examination Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx. He indicated that he used Loratadine twice daily, and experienced frontal and paranasal tenderness of the sinuses. He experienced five non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the previous year. The Veteran had not experienced any incapacitating episodes of sinusitis that required prolonged antibiotic treatment. The Veteran was not precluded from obtaining or maintaining work due to sinusitis, although he always needed to have medications nearby. Analysis The Board finds that a rating in excess of 10 percent is not warranted for the Veteran’s sinusitis at any point during the duration of this appeal. As noted, the next available rating of 30 percent requires three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. This has not been shown by the preponderance of the evidence. In this regard, the May 2016 VA examiner reported five non-incapacitating episodes characterized by headaches, pain and purulent discharge or crusting within the previous 12 months. In December 2018 the VA examiner reported four non-incapacitating episodes; in July 2019 Dr. Otero reported three non-incapacitating episodes; in December 2019 the VA examiner reported three non-incapacitating episodes; in December 2019 Dr. Espina reported six non-incapacitating episodes; and finally, in January 2021 the VA examiner indicated the Veteran experienced five non-incapacitating episodes. Moreover, no examiner, VA or private, reported more than 6 non-incapacitating episodes. In addition, all examiners noted that the Veteran did not have any incapacitating episodes of sinusitis within the last 12 months (with the exception of Dr. Otero in July 2019 who failed to check a box indicating one way or the other). For the foregoing reasons, a rating in excess of 10 percent for chronic sinusitis is not warranted at any point during the duration of this appeal. As the preponderance of the evidence is against the claim for a rating higher than 10 percent, the benefit-of-the-doubt doctrine is inapplicable. 38 U.S.C. § 5197(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extra-schedular Consideration In January 2021 the Veteran’s representative generally requested the maximum benefit, to include consideration for an extra-schedular rating. See January 2021 Appellate Brief. Extra-schedular evaluations under 38 C.F.R. § 3.321(b) are available only where a disability is incapable of evaluation under the rating schedule. See Long (Walter G.) v. Wilkie, No. 16-1537 (Dec. 30, 2020) (extra-schedular consideration involves evaluation of whether the Veteran’s disability picture as a whole presents an impairment that is so exceptional that the rating schedule is not capable of assessing it in the first instance). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extra-schedular rating. First, as a threshold matter, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). Considering the first step of the extra-schedular analysis, the Board finds that all the symptomatology and impairment caused by the sinusitis are contemplated by the schedular rating criteria, and no referral for extra-schedular consideration is required. The totality of factors does not show that the Veteran’s sinusitis is exceptional. Id. Here, there are no specific contentions that the symptoms of the Veteran’s sinusitis are so unusual as to render it exceptional, and the medical evidence shows the Veteran’s symptoms include headaches, sinus pain, pressure and tenderness, congestion, runny nose with post-nasal drip, purulent discharge or crusting, even while taking medications. These symptoms are contemplated by the rating criteria, with Diagnostic Code 6512 specifically addressing headaches, pain and tenderness of the sinuses, and purulent discharge or crusting, to include with prolonged antibiotic use. Although congestion, runny nose, and post-nasal drip are not explicitly listed in the criteria, the inclusion of purulent discharge and crusting in the listed diagnostic criteria is logically inclusive of such symptoms. As such, the Veteran’s symptoms are adequately contemplated by the rating criteria, and included in the language for non-incapacitating episodes of sinusitis. The Board finds that the Veteran’s disability is fully capable of evaluation under the rating schedule. Accordingly, the claim is denied. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Barner, 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.