Citation Nr: 21014592 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 17-59 205 DATE: March 15, 2021 ORDER A compensable disability rating for scars of the right great toe is denied. Service connection for right foot condition, to include pain and associated functional loss, that is separate and distinct from service-connected degenerative joint disease of the right great toe, is denied. REMANDED The claim for a compensable disability rating for bilateral hearing loss is remanded. FINDINGS OF FACT 1. The Veteran’s scars of right great toe are not manifested by any disabling effects not already considered under Diagnostic Codes 7800, 7801, 7802, and 7804. 2. The evidence of record weighs against finding that the Veteran has a current disability, to include right foot pain and associated functional loss, that is separate and distinct from his service-connected degenerative joint disease of his right great toe at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for a compensable disability rating for scars of the right great toe have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Codes, 7800, 7801, 7802, 7804, 7805. 2. The criteria for service connection for a right foot condition, to include pain and associated functional loss, that is separate and distinct from service-connected degenerative joint disease of the right great toe, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from August 1965 until his honorable discharge in December 1965, and again from January 1968 until his honorable discharge in June 1969. This appeal has been advanced on the Board of Veterans’ Appeals’ (Board) docket pursuant to 38 U.S.C. § 7107(b) and 38 C.F.R. § 20.902(c). These matters come before the Board on appeal from a November 2015 rating decision by the Phoenix, Arizona, Regional Office (RO) of the United States Department of Veterans Affairs (VA), which denied increased, compensable disability ratings for scarring on the Veteran’s right great toe and for bilateral hearing loss, and denied service connection for right foot pain. In July 2019, the Veteran testified at a videoconference Board hearing before a Veterans Law Judge (VLJ) who is no longer with the Board. Unfortunately, portions of the audio recording were unable to be transcribed. The Veteran was offered the opportunity to have a second hearing, which he accepted. In October 2020, the Veteran testified before the undersigned VLJ at a videoconference hearing. A transcript of the hearing has been associated with the record on appeal. During the hearing, the undersigned held the record open for 30 days to allow for the submission of additional evidence identified by the Veteran; however, no additional evidence was added to the record within that time period. Evidentiary Standards In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. 38 U.S.C. § 7104(a). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits, 38 U.S.C. §§ 1154(a); 5107(b), and when rating disabilities, Golden v Shulkin, 29 Vet. App. 221, 224 (2017) (citation omitted); see 38 C.F.R. §§ 4.1, 4.6. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (service connection); 38 C.F.R. § 4.3 (disability rating). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 128‒29 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claim(s). 1. The claim for a compensable rating for scars of the right great toe The Veteran is service connected for scarring on his right great toe. He currently receives a noncompensable rating. According to his March 2016 notice of disagreement, he seeks a minimum 10 percent disability rating. The Board finds his right toe scarring does not warrant an increased, compensable rating for the reasons that follow. Disability Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The 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. Diagnostic Codes (DCs) are assigned to individual disabilities. Diagnostic Codes provide rating criteria specific to a particular disability. If two DCs are applicable to the same disability, the DC that allows for the higher disability rating applies. 38 C.F.R. § 4.7. When a question arises as to which of two ratings apply under a particular DC, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Id. Rating Criteria – Scars The Veteran’s right great toe scarring is currently rated under 38 C.F.R. § 4.118, DC 7805, which instructs an adjudicator to “[e]valuate any disabling effect(s) not considered in a rating provided under diagnostic codes 7800[, 7801, 7802, or 7804] under an appropriate diagnostic code.” Thus, an analysis under each of these DCs is required to appropriately rate the Veteran’s right toe scarring. Diagnostic Code 7800 is entitled, “Burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck.” Because the Veteran’s scar is located on his right toe, DC 7800 is inapplicable because it only applies to scars of the “head, face, or neck.” Diagnostic Code 7801 is entitled, “Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage.” “Soft tissue damage” is not defined within DC 7801. Absent an express definition, it is presumed that VA regulations employ words using their ordinary dictionary meanings at the time the regulations were promulgated. See Nielson v. Shinseki, 607 F.3d 802, 805–06 (Fed. Cir. 2010). “Soft tissue damage” generally includes damage to muscles, tendons, and ligaments. Sprains, Strain and Other Soft-Tissue Injuries, American Academy of Orthopaedic Surgeons, available at https://orthoinfo.aaos.org/en/diseases--conditions/sprains-strains-and-other-soft-tissue-injuries/ (last visited Feb. 17, 2021). The Veteran’s scarring stems from an in-service injury that resulted in removal of the nailbed of his right great toe. The medical evidence of record does not indicate or reasonably suggest that his scarring is “associated with underlying soft tissue damage.” Therefore, DC 7801 is inapplicable. Diagnostic Code 7802 is entitled, “Burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage.” As the Veteran’s right toe scarring is “not of the head, face, or neck” and is “not associated with underlying soft tissue damage,” DC 7802 is applicable. Diagnostic Code 7802 provides only a 10 percent rating for scarring that covers an area or areas of 144 square inches (929 sq. cm.) or greater. 38 C.F.R. § 4.118, DC 7802. Diagnostic Code 7804 is entitled, “Scar(s), unstable or painful,” and provides: Rating (%) Scar(s), unstable or painful: Five or more scars that are unstable or painful 30 Three or four scars that are unstable or painful 20 One or two scars that are unstable or painful 10 “An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar.” 38 C.F.R. § 4.118, DC 7804, Note (1). The regulation does not provide a definition for “painful.” As such, the Board applies the commonly understood meaning of the term. Nielson, 607 F.3d at 805–06. “Painful” means “feeling or giving pain.” Painful, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/painful, Definition 1 (last visited Feb. 17, 2021). “Pain,” in turn, means “a localized or generalized unpleasant bodily sensation or complex of sensations that causes mild to severe physical discomfort and emotional distress and typically results from bodily disorder (such as injury or disease).” Pain, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/pain, Definitions 1.a.(1) (last visited Feb. 17, 2021). Note (3) to 38 C.F.R. § 4.118, DC 7804 provides, “Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable.” Analysis The Board must analyze the evidence within the year preceding the Veteran’s filing of his claim for an increased, compensable rating, to determine if is factually ascertainable that an increased rating was warranted during that time. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). Thus, the appropriate appeal period is from approximate to August 4, 2014, through the present. First, the Board observes that a June 2013 VA examiner opined that the Veteran’s right great toe scarring was not painful and/or unstable, nor was the total area of the scarring greater than 39 square centimeters (6 square inches) at that time. The examiner documented the Veteran’s right great toe scars measured: 1.5 x 0.2 cm; 2.5 x 0.2 cm. The examiner documented no erythema or swelling. The scars were well-healed, non-tender, and stable. There were no signs of functional limitation. There was also no pain over the big toe. In September 2015, the Veteran was afforded a VA examination in connection with his claim for an increased, compensable rating. The examiner described the Veteran’s right great toe scarring as “linear.” He had two scars. The first scar measured 1.5 x 0.2 cm. The second scar measured 2.5 x 0.2 cm. Neither scar was classified a “superficial non-linear” or “deep non-linear.” The examiner documented that neither scar was painful or unstable. The area of each scar, individually and combined, was less than 39 square centimeters (6 square inches). The Veteran has not provided any relevant medical evidence that contradicts the findings of the June 2013 or September 2015 VA examiners. Nor has the Board located any medical evidence within the record that contradicts the examiners’ respective findings. The Veteran has offered his own testimony on the matter. While a transcript of the Veteran’s first Board hearing in July 2019 has been associated with his claims file, the Board finds it would be against the interest of justice to consider any information within the transcript that is not in support of the Veteran’s position due to the incompleteness of the transcript. With respect to his October 2020 Board hearing, the Veteran testified his right great toe was sensitive to touch “a little bit.” October 2020 Board Hearing Transcript, at 7. The Veteran’s testimony, however, never associated his pain with his right great toe scars. At one point, he seemed to agree that his scars were not themselves painful, rather it was his right great toe degenerative joint disease that was causing pain. Id. at 9–10. This was the extent of his testimony about his right great toe scars. The Board observes that the Veteran did not submit correspondence to VA or otherwise make statements within his procedural documents relating to the severity or other symptoms of his right great toe scars. Absent evidence to the contrary, the Board finds the above-mentioned medical professionals were competent to exam and diagnose the Veteran and to provide medical judgments related to the Veteran’s right great toe scars. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (the competency of medical professionals is presumed absent evidence to the contrary). The Board finds the medical professionals’ respective examinations, medical findings, and medical opinions are credible and probative unless otherwise indicated. The medical professionals conducted thorough examinations, relied on accurate facts, considered the Veteran’s relevant medical records, medical history, and lay statements, and provided well-reasoned medical judgments. The Board finds the Veteran competent to report his physical sensations of pain and experiences associated with his scarring. Jandreau v. Nicholson, 493 F.3d 1372, 1377 (Fed. Cir. 2007) (noting general competence of laypersons to testify as to symptoms but not medical diagnosis). The Board finds the Veteran’s statements to the various medical professionals and his testimony credible and probative unless otherwise indicated. Diagnostic Code 7802 As the Veteran’s right great toe scars measured 1.5 x 0.2 cm and 2.5 x 0.2 cm, respectively, which is considerably less than 144 square inches (929 sq. cm.), individually or collectively, the Veteran is not entitled to a 10 percent disability rating under 38 C.F.R. § 4.118, DC 7802. The Board notes that the Veteran has not asserted, nor does the record reasonably indicate, that the Veteran’s right great toe scars have increased in size since the 2015 VA examination. See Robinson v. Mansfield, 21 Vet. App. 545, 552 (2008), aff’d sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (Board is required to consider theories of entitlement to benefits that are either raised by the claimant or reasonably raised by the record). Therefore, the Board finds no basis to remand this matter for a new VA examination. See Fagan v. Shinseki, 573 F.3d 1282, 1286 (2009) (stating that the claimant has the burden to “present and support a claim for benefits” and noting that the benefit of the doubt standard in [38 U.S.C. §] 5107(b) is not applicable based on pure speculation or remote possibility). Diagnostic Code 7804 The medical evidence of record indicates the Veteran’s right great toe scars were not unstable or painful during the appeal period. The Veteran has asserted generalized right foot pain, but he has not reasonably or sufficiently associated his pain with his right great toe scars through medical evidence or lay evidence. The Board does not interpret his October 2020 testimony as indicating or reasonably suggesting his right great toe scars were unstable or painful, even when providing the Veteran benefit of the doubt, as there is no logical connection between his scars and his pain within his testimony. Instead, the Board interprets his testimony as indicating that he had pain due to his degenerative arthritis of his right great toe. The Board also finds the VA examiners’ specific documentation of no painful or unstable scarring more probative than the Veteran’s broad and generalized testimony. As neither of the Veteran’s right great toe scars were unstable or painful throughout the appeal period, a compensable rating under DC 7804 is not warranted. 38 C.F.R. § 4.118, DC 7804. Other disabling effects The Veteran has not asserted, nor does the record reasonably raise, any other disabling effects associated with the Veteran’s great right toe scars. To the extent the Veteran, or the record, asserts he suffers functional loss due to his scars, the Board finds a lack of evidence supporting such an assertion. Moreover, the Board finds any functional-loss or associated symptomatology is adequately encompassed by the Veteran’s rating for his right great toe degenerative joint disease. To award the Veteran twice for the same symptomatology would constitute impermissible pyramiding. 38 C.F.R. § 4.14 (“The evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation . . . . the evaluation of the same manifestation under different diagnoses [is] to be avoided.”).Therefore, there are no other disability effects for which the Veteran is entitled to a compensable disability rating under 38 C.F.R. § 4.118, DC 7805. Conclusion The Board finds the Veteran’s scarring on the right great toe did not encompass area(s) of 144 square inches (929 sq. cm.) or greater, individually or collectively, during the appeal period. Nor were his right great toe scars unstable or painful during the appeal period. The Board finds the Veteran has not raised any other symptomatology associated with his right great toe scarring such that another DC is appliable. Nor does the record reasonably raise such arguments. Accordingly, entitlement to an increased, compensable disability rating for scarring of the right great toe is not warranted. 38 C.F.R. § 4.118, DC 7805. 2. The claim for service connection for right foot condition, to include pain and limitation of motion. Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a “service connection.” 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to be entitled to service connection there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When these elements are satisfied, service connection may be granted on a direct basis. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of, or aggravated by, a service-connected disability. 38 C.F.R. §§ 3.310(a), (b). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) a current disability exists, (2) the veteran has a service-connected disability; and (3) the current disability was either (a) proximately due to or the result of; or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Where aggravation is the relied upon theory, compensation may only be provided to that degree over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen, 7 Vet. App. at 448. Analysis The Board finds the Veteran does not have a current disability of the right foot that is separate and distinct from his right great toe degenerative joint disease (right toe DJD) for which he is currently service connected. Rather, his right foot condition is a symptom of his right toe DJD and encompassed in the evaluation assigned for that disability. In his August 2015 application for service connection, the Veteran asserted he had right foot pain that was secondary to his right toe DJD. August 2015 VA Form 21-526EZ, Application for Disability Compensation. Prior to submitting his claim, the Veteran experienced right heel pain in January 2012 according to a VA internal medicine telephone encounter note. The pain was noticeable when he began to walk, then it improved. The Veteran was also afforded a June 2013 VA examination in relation to his right toe DJD. At that time, the examiner recorded that the Veteran experienced right foot pain, which was aggravated by prolonged walking and standing. The examiner found pain on palpitation along the plantar fascia of the right foot. In connection with his present claim, he was afforded a VA examination in September 2015. The examiner recorded that the Veteran experienced pain during flare-ups. The Veteran reported experiencing flare-ups four to five times a year, which caused him to limp, and to have difficulty walking and climbing stairs. “At other times, his foot [was] not in pain.” The examiner did not identify any separate or distinct right foot disability apart from the Veteran’s right toe DJD. The examiner opined that the Veteran’s right foot pain and limitation of function was at least as likely as not due to his right toe DJD. The examiner explained, “The Veteran’s symptoms continue to be due to his [service-connected] [right toe] DJD, as previously noted, and appear to be stable.” In May 2016, the Veteran reported to a VA physician that his right great toe sometimes caused him pain when walking. May 2016 VA Internal Medicine Note. In September 2017, the Veteran was afforded a VA-contracted examination in connection with his claim. The examiner did not diagnose the Veteran with any additional foot disabilities outside of his right toe DJD. The Veteran reported right foot pain. He experienced flare-ups when walking or running, which limited his movement and resulted in fatigue. He developed a right heel spur and calluses over the years. About three to four times a year he reported having right foot pain that lasted several days at a time, “typically after trauma.” The examiner opined that the Veteran’s right foot conditions were consistent with his right toe DJD such that there was no change in the Veteran’s diagnosis. Again, the Board will only utilize testimony from the Veteran’s July 2019 Board hearing that aids his position, of which the Board finds none. During his October 2020 Board hearing, the Veteran testified he was not receiving treatment for his right foot pain. October 2020 Board Hearing Transcript, at 10. The Veteran testified that a foot surgeon, Dr. H., said that because the Veteran favored his right great toe, he had other foot problems. Id. at 11. The Veteran referenced an October 2018 X-ray report he had in his possession while testifying. Id. at 13. Based on the information provided, the Board held the record open for 30 days so the Veteran could submit the evidence in his possession, which the Veteran confirmed he would do. Id. at 15. The Board has not received such documents. Duty to Assist The hearing revealed that there were potential records regarding treatment in the possession of the Veteran that had not been submitted. As discussed above, those records were not overlooked by the Veteran because he had clearly reviewed them and considered submitting them. Indeed, he explicitly stated he would submit them. Moreover, the Board explicitly left the record open so that those records—or any others—could be submitted if the Veteran so desired. VA’s duty to assist, and due process, was therefore satisfied regardless of the Veteran’s decision not to submit the records. Current Disability The Veteran did not have a specifically diagnosed right foot disability in addition to his right toe DJD throughout the appeal period. He did, however, experience right foot pain, to include heel pain and calluses, with associated functional loss and limitation of motion. The U.S. Court of Appeals for the Federal Circuit has held that pain alone may constitute a disability, even without an identifiable underlying pathology. Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). The veteran’s pain, however, must amount to a functional impairment to constitute a disability. Id. at 1367. “Functional impairment,” the Federal Circuit noted, is defined as the inability of the body or a constituent part of it “‘to function under the ordinary conditions of daily life including employment.’” Id. at 1363 (quoting 38 C.F.R. § 4.10). In other words, pain alone can qualify as a disability where it diminishes the body’s ability to function, even where it is not diagnosed as connected to a current underlying condition. Id. The Board finds the Veteran’s pain and associated functional loss does constitute a disability for purposes of service connection. But the Veteran’s right foot pain and functional loss are not a separate and distinct disability apart from his currently service-connected right toe DJD. The Veteran’s right toe DJD symptomatology includes pain and functional loss of his right foot. The Veteran’s initial VA examination in June 2013 documented pain that began in his right great toe and spread along the arch of his heel. The examiner attributed the Veteran’s right foot pain to his degenerative joint disease, which was at least as likely as not due to his in-service injury. That is, the examiner did not separate the Veteran’s right foot pain and functional loss, in general, from his right toe DJD as they were one disability. McCray v. Wilkie, 31 Vet. App. 243, 257 (2019) (Board is capable of interpreting medical opinion evidence) (citing Harvey v. Shulkin, 30 Vet. App. 10, 20 (2018)). The September 2015 VA examiner similarly documented the Veteran’s right foot pain, in general, particularly during flare-ups. The examiner also recorded that the Veteran suffered functional loss due to pain due flare-ups, which caused him to limp and to have difficulty walking and climbing stairs. This examiner, like the June 2013 VA examiner, did not separate the Veteran’s right foot pain and functional loss as a separate and distinct disability apart from his right toe DJD. The September 2015 VA examiner opined that the Veteran’s “symptoms continue to be due to” his right toe DJD. Likewise, the September 2017 VA-contracted examiner did not document a separate and distinct right foot disability or find the Veteran’s right foot pain and associated functional loss were a separate and distinct disability apart from his right toe DJD. The examiner opined there was no change in the Veteran’s diagnosis. Overall, the medical evidence of record demonstrates the Veteran’s right foot pain and associated functional loss is part of the symptomatology of his right toe DJD. There is no medical evidence to the contrary within the record. In addition, the Board points out the Veteran’s 10 percent rating for his service-connected right toe DJD under 38 C.F.R. § 4.71a, DC 5010-5280, encompasses his present right foot pain and associated functional loss. See October 2017 Rating Decision (“38 C.F.R. § 4.59 allows consideration of functional loss due to painful motion. Credible evidence reveals painful motion; therefore, a 10 percent evaluation is assigned, effective August 4, 2015.”). As such, the Board is prohibited from awarding the Veteran service connection for the same symptomatology as to do so would constitute impermissible pyramiding. 38 C.F.R. § 4.14. The Veteran’s right foot pain and associated functional loss are symptoms of his service-connected right toe DJD and are encompassed within his right toe DJD disability rating. Therefore, the Veteran does not have separate and distinct current disability. A current disability is a necessary element under either a direct or secondary theory of service connection. Accordingly, service connection is not warranted on a direct or secondary basis. REASONS FOR REMAND The claim for a compensable disability rating for bilateral hearing loss is remanded. Service connection is in effect for the Veteran’s bilateral hearing loss disability. It is currently assigned a noncompensable (zero percent) disability rating. During his October 2020 Board hearing, the Veteran testified that his hearing has worsened since his last VA audiology examination in 2017. October 2020 Board Hearing Transcript, at 3. He based his testimony on the ineffectiveness of his hearing aids and personal experiences. He has also submitted an audiology examination dated January 8, 2018, which states the Veteran experienced severe sensorineural hearing loss and he had low speech discrimination scores. The examination, however, is not accompanied by information about the testing procedures. The Board cannot determine whether the tests were done in accordance with VA compensation requirements. See 38 C.F.R. § 3.385. “Generally speaking, VA must provide a new examination when the veteran claims a disability is worse than when originally rated, and the available evidence is too old to adequately evaluate the current state of the condition.” Moody v. Wilkie, 30 Vet. App. 329, 341 (2018). Here, the Veteran has raised a reasonable claim of worsened hearing loss and has provided medical evidence to support his assertion. Thus, remand is necessary for a new examination. The matter is REMANDED for the following actions: 1. Obtain any of the Veteran’s outstanding VA medical records and associate them with the claims file. 2. Send appropriate correspondence to the Veteran asking him to identify and authorize release of any relevant audiological records associated with his January 8, 2018, audiological examination, and any other relevant records. If sufficient information is received from the Veteran, the RO should request information from the January 8, 2018, audiological examiner about what testing procedure and standards were used to measure the Veteran’s hearing loss, i.e., Puretone Threshold testing; Maryland CNC Word testing; or some other testing standard. (Continued on the next page)   Reasonable attempts must be made to obtain relevant private medical records. 3. After any additional records are associated with the claims file, obtain a new VA audiological examination from an appropriately qualified clinician to determine the severity of the Veteran’s service-connected bilateral hearing loss. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. F. Sawka, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.