Citation Nr: 21021161 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 14-32 486 DATE: April 12, 2021 ORDER Entitlement to service connection for a obstructive sleep apnea, claimed as sleep impairment, to include as secondary to a service-connected disability, is denied. Entitlement to a rating higher than 30 percent prior to April 9, 2015, and higher than 50 percent as of April 9, 2015, for posttraumatic stress disorder (PTSD) is denied. Entitlement to a rating higher than 0 percent prior to July 10, 2019, and higher than 10 percent as of July 10, 2019, for bilateral hearing loss is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. Sleep apnea has not been shown to have been present during active service and has not been related to active service; the most probative evidence is against a finding that sleep apnea was caused or aggravated by any of the service-connected disabilities. 2. Prior to April 9, 2015, PTSD symptoms were productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 3. As of April 9, 2015, PTSD symptoms were productive of occupational and social impairment with reduced reliability and productivity. 4. Prior to July 10, 2019, the Veteran had, at worst, Level I hearing loss in the right ear and Level II hearing loss in the left ear. 5. As of July 10, 2019, the Veteran had, at worst, Level II hearing loss in the right ear and Level V hearing loss in the left ear. 6. The preponderance of the competent and credible evidence of record indicates that the service-connected disabilities alone do not preclude the Veteran from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 2. The criteria for a rating higher than 30 percent prior to April 9, 2015, and greater than 50 percent as of April 9, 2015, for PTSD have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9411. 3. The criteria for a rating higher than 0 percent prior to July 10, 2019, and higher than 10 percent as of July 10, 2019, for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.385, 4.1-4.14, 4.85, 4.86, Diagnostic Code 6100. 4. The criteria for entitlement to TDIU have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341(a), 4.16(b). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1967 to April 1969. These matters are before the Board of Veterans’ Appeals (Board) on appeal from rating decisions from February 2012, March 2015, and May 2015 of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In June 2017 and December 2020, the Veteran testified in hearings before the undersigned Veterans Law Judge. Copies of the transcripts are of record. During the course of the appeal, a May 2015 rating decision assigned a higher 50 percent rating for PTSD, effective April 9, 2015. An August 2019 rating decision assigned a higher 10 percent rating for bilateral hearing loss, effective July 10, 2019. However, as higher ratings are available for PTSD and bilateral hearing loss, and the Veteran is presumed to seek the maximum available benefit for a disability, the claims for higher ratings remain on appeal. AB v. Brown, 6 Vet. App. 35 (1993). This case was previously remanded for further development. In light of the treatment records that have been obtained and associated with the record, the obtaining of the requested medical opinions, and the further adjudicatory actions taken by the Agency of Original Jurisdiction (AOJ), the Board finds that there has been substantial compliance with the prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998); D’Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141 (1999). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b)). Service connection may be established for a disability diagnosed after separation from service, 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 prove service connection, there must be competent, credible evidence of (1) a current disability, (2) 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. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Service connection may be established for disability that is proximately due to or the result of a service-connected disability, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran asserts that he has a sleep disorder that is causally or etiologically related to the service-connected disabilities, to include posttraumatic stress disorder (PTSD), bilateral lower extremity neuropathy, bilateral upper extremity neuropathy, diabetes mellitus, hearing loss, and tinnitus. 1. Entitlement to service connection for obstructive sleep apnea, claimed as sleep impairment, to include as secondary to a service-connected disability The Veteran asserts that he has a sleep disorder that is causally or etiologically related to service-connected PTSD. The service medical records do not show any signs, symptoms, or treatment for obstructive sleep apnea or any sleep disorder. A sleep study conducted in May 1991 resulted in a diagnosis of mild sleep-related obstructive breathing. A sleep study conducted in April 2000 resulted in a diagnosis of severe obstructive sleep apnea. At a January 2012 VA examination, the examiner diagnosed obstructive sleep apnea. The examiner attributed persistent daytime hypersomnolence to sleep apnea. The examiner observed significant oral airway narrowing with a large uvula. The examiner also observed significant and morbid obesity. The examiner noted that the Veteran had been off of work for several days at a time, and that the Veteran’s work had been reduced significantly due to sleep issues. The examiner opined that the Veteran’s obstructive sleep apnea was less likely than not proximately due to or the result of the Veteran’s service-connected PTSD. The examiner explained that the Veteran’s sleep apnea was obstructive in nature and related to obesity. The examiner noted that the Veteran had significant airway obstruction from a very large uvula. That issue was anatomical and not related to PTSD. The examiner commented that the sleep study did not confirm PTSD as a major component of the Veteran’s numerous awakenings. On VA examination in July 2019, the examiner noted a current diagnosis of obstructive sleep apnea. The examiner opined that the Veteran’s sleep apnea was not at least as likely as not incurred in or caused by service. The examiner stated that the Veteran did not have sleep issues consistent with obstructive sleep apnea during service, and he was diagnosed with sleep apnea thirty years after service. The examiner explained that obstructive sleep apnea is characterized by recurrent, functional collapse during sleep of the velopharyngeal and/or oropharyngeal airway, causing substantially reduced or complete cessation of airflow despite ongoing breathing efforts. The examiner stated that led to intermittent disturbances in gas exchange and fragmented sleep. The examiner also opined that the Veteran’s sleep apnea was not at least as likely as not proximately due to or the result of PTSD. The examiner explained that there was no evidence in the current medical literature which stated that PTSD caused sleep apnea. The examiner felt that for this Veteran, it was more likely that the current weight of 321 pounds, which was the same weight as in 2000 when the original sleep study was performed, with a body mass index of 48.91 was the underlying cause of obstructive sleep apnea. The examiner explained that sleep disturbances associated with PTSD would not impact obstructive sleep apnea, which was a physiological, not a psychological, issue. In reviewing the evidence of record, the Board assigns the most probative weight to the VA examination opinions. The Board finds the examiners’ opinions to be probative as the examiners have expertise, reviewed the claims file, and provided reasoning for the expressed opinions that were specific to the Veteran’s case. The Board acknowledges the Veteran’s assertion that sleep apnea was caused or aggravated by service-connected PTSD. However, the Veteran is not considered competent to provide an opinion regarding etiology or aggravation as that is a complex medical question. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran has not been shown to have the requisite expertise or medical knowledge to provide an opinion as to whether his sleep apnea was caused or aggravated by service-connected PTSD. Significantly, there is no competent evidence of record that PTSD was the cause of the Veteran’s sleep apnea or aggravates sleep apnea beyond the natural progression in this particular case. As the VA examiners had the medical training and education and explained the rationale behind the opinions, the Board finds that the statements from the VA examiners outweigh the statements from the Veteran and other lay statements of record. In addition, the Board finds that direct service connection is not warranted. The claims file does not contain any competent medical evidence relating the Veteran’s sleep apnea to active service. The service medical records do not show treatment or diagnosis of sleep apnea. A diagnosis of sleep apnea was made nearly 20 years after separation from service, and the Veteran has not contended that the sleep apnea is related to service or that the symptoms have continued since service. Additionally, the July 2019 VA examiner opined that the Veteran’s obstructive sleep apnea was not at least as likely as not incurred in or caused by service. Therefore, the Board finds that the preponderance of the evidence is against the claim for service connection on a direct basis. Accordingly, the Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for sleep apnea, and the claim is denied. 38 U.S.C. § 5107(b). Increased Rating Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, that does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). 2. Entitlement to a rating higher than 30 percent prior to April 9, 2015, and higher than 50 percent as of April 9, 2015, for posttraumatic stress disorder (PTSD) Psychiatric disabilities other than eating disorders are rated pursuant to a General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under the General Rating Formula, a 0 percent rating is warranted when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent rating is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for 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 (e.g., retention of only highly learned material, 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. A 70 percent rating is assigned for 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 affected 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 inability to establish and maintain effective relationships. A 100 percent rating is assigned for 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; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. The symptoms listed in the rating formula are only examples, and evidence of those specific symptoms is not required to show that the Veteran is totally disabled. In rating a mental disability, VA is required to consider all symptoms that affect social and occupational functioning, and not limit consideration to those symptoms listed in the rating formula. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary consideration is whether the manifestations of the service-connected psychiatric disability result in a level of social and occupational impairment, regardless of whether the Veteran demonstrates the specific symptoms listed in the rating formula. When rating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. In a June 2011 statement, R.R., a friend of the Veteran, stated that the Veteran no longer socialized. R.R. remarked that the Veteran was always depressed and withdrawn. In a June 2011 statement, A.B., the Veteran’s daughter, stated that the Veteran had become withdrawn. The Veteran was often irritable at family functions and seemed depressed. A.B. remarked that the Veteran had uncontrollable anger. In a July 2011 statement, B.D., the Veteran’s spouse, commented that the Veteran’s interest in personal hygiene had dropped. The Veteran no longer did chores around the house. B.D. had also noticed that the Veteran’s memory had slipped. She stated that the Veteran almost never remembered the date, and he forgot the names of family members. In a June 2011 statement, T.D., the Veteran’s son, stated that the Veteran had lost interest in hunting and fishing. The Veteran had become quiet and withdrawn. T.D. stated that the Veteran became irritable easily. In an August 2011 statement, the Veteran stated that he experienced panic attacks when he was stressed. He reported experiencing frequent nightmares. He stated that he was irritable and had outbursts of anger. He had flashbacks to Vietnam. He had become distant to family members, friends, and coworkers. At a January 2012 VA examination, the examiner diagnosed PTSD. The examiner opined that the Veteran’s level of impairment was best summarized as occupational and social impairment due to mild or transient symptoms which decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress; or symptoms controlled by medication. It was noted that the veteran had been married to his present spouse for nearly 20 years. He had three grandchildren. The Veteran stated that he did not have close relationships with family members other than his wife and grandchildren. The Veteran also stated that he was irritable with other people. The examiner indicated that the Veteran had a chronic sleep impairment. At an August 2014 VA examination, the examiner opined that the Veteran’s level of impairment was best summarized as 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. The Veteran reported that he did not participate in any activities. The examiner noted that the veteran denied any suicidal or homicidal ideation. The Veteran had a depressed mood and chronic sleep impairment. The examiner found that the Veteran had no obvious difficulties with speech, concentration, gait, or orientation. At a May 2015 VA examination, the examiner opined that the Veteran’s level of impairment with regard to mental diagnoses was best summarized as occupational and social impairment due to mild or transient symptoms which decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress; or symptoms controlled by medication. The Veteran described having a good relationship with his spouse. He reported a universal lack of enthusiasm. The Veteran showered twice a week. The examiner found that the Veteran was appropriately dressed and had no anomalies with speech, concentration, gait, and orientation. It was noted that the Veteran experienced depressed mood, chronic sleep impairment, flattened affect, impaired abstract thinking, disturbances of motivation and mood, infrequent suicidal ideation, and neglect of personal appearance and hygiene. At a July 2019 VA examination, the examiner opined that the Veteran’s level of impairment with regard to his mental diagnoses was best summarized as occupational and social impairment with reduced reliability and productivity. The Veteran reported that he was currently married to his second wife, and the quality of their relationship was very good. He was very close with his adult son, but he had not seen his adult daughter for about seven years. He reported that he currently had no interaction with other people and was not a social person. He stated that his spouse took care of his medications and finances. His spouse also took care of most of the household chores. The Veteran reported that he felt depressed and had zero motivation. The Veteran denied having any suicidal intent or plan, although he admitted to frequent suicidal ideation which occurred approximately once per day. The Veteran stated that he had firearms for his safety but flatly denied any intent or plan to commit suicide. The examiner noted that the Veteran’s most recent psychiatry notes indicated that the Veteran denied suicidal ideation. The examiner remarked that the Veteran experienced depressed mood, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and suicidal ideation. The Veteran’s dress and hygiene were appropriate. The Veteran’s attention as adequate, and his eye contact was appropriate. There was no evidence to suggest that the Veteran was incompetent to manage his own finances. For the period prior to April 9, 2015, the Board finds that no more than a 30 percent rating was warranted. During that period, the Veteran’s symptoms are characterized as comprising 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. The Board finds that the evidence for that period does not show occupational and social impairment with reduced reliability and productivity due to psychiatric symptoms. While the Veteran faced sleep impairment, irritability, tiredness, intrusive thoughts, flashbacks, and anger, the evidence does not show the level of reduced reliability that would warrant a rating higher than 30 percent. While some memory and concentration impairment was shown, the evidence does not show that he retained only highly learned material or forgot complete tasks as the criteria for a 50 percent rating use as an example of the type of impairment that would warrant a higher rating. The evidence for that period does not show impaired abstract thinking or difficulty in establishing and maintaining effective social relationships. Although the Veteran did not have social relationships outside of his family, he maintained a good relationship with his spouse and his grandchildren. Because the evidence does not show occupational and social impairment with reduced reliability and productivity due to psychiatric symptoms, the Board finds that the preponderance of the evidence is against the assignment of a higher rating. As of April 9, 2015, the Board finds that a rating higher than 50 percent is not warranted. The Board notes that a 70 percent rating is provided for 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 worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. The Board finds that the competent medical evidence of record, to include the VA psychiatric examination reports, does not show the Veteran had any speech issues, continuous panic attacks, spatial disorientation, actual neglect of personal hygiene, or an inability to maintain effective relationships, as demonstrated by his good relationship with his spouse and grandchildren. The Board recognizes that the May 2015 VA examiner noted on a checklist that the Veteran experienced neglect of personal appearance and hygiene, but the same examiner noted that the Veteran showered more than once a week. The Veteran has been verbally aggressive with others, but those altercations have not escalated to periods of violence. Medical records consistently show that the Veteran was appropriately dressed and adequately groomed, cooperative and oriented, and with normal speech, thought process, and judgment. No contemporaneous hallucinations have been reported. The Board places great weight on the outpatient treatment records and the examination reports, as they were created by objective medical personnel in the process of providing professional care to the Veteran. While acknowledging that the VA examiners found that the Veteran had suicidal ideation a couple of times per week, taken as a whole, the Board finds that a review of the medical records shows an overall condition that more nearly approximates the criteria for a 50 percent rating. Considering the totality of the Veteran’s symptomatology, the Veteran’s disability has not shown to manifest to the severity required for the next higher rating of 70 percent. The Board finds that the Veteran’s psychiatric symptoms more nearly approximate a condition that is productive of occupational and social impairment with reduced reliability and productivity, as noted by the July 2019 VA examiner. The Board finds that the Veteran’s suicidal ideation and irritability did not rise to the level of being a persistent danger of hurting himself or others, so as to support any higher rating. The Board has additionally considered the Veteran’s statements regarding the severity of the psychiatric symptoms throughout the period of appeal. The Veteran is competent to report the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). However, the opinions and observations of the Veteran do not meet the burden for even higher ratings imposed by the rating criteria under 38 C.F.R. § 4.130 with respect to determining the severity of his service-connected psychiatric disability throughout the appeal. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of any higher ratings or earlier dates for the assignment of the increase in rating. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to a rating higher than 0 percent prior to July 10, 2019, and higher than 10 percent as of July 10, 2019, for bilateral hearing loss Ratings for hearing loss range from 0 to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests combined with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 Hertz. To rate the degree of disability for hearing loss, the Rating Schedule has established eleven auditory acuity levels, designated from Level I, for essentially normal acuity, through Level XI, for profound deafness. 38 C.F.R. § 4.85(h), Table VI. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. The results are charted on Table VI, or Table VIA in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII. 38 C.F.R. § 4.85. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. In the cases with exceptional patterns of hearing loss, the Roman numeral value is determined using both Table VI and VIA and whichever table results in a higher Roman numeral value is used to calculate a rating using Table VII. 38 C.F.R. § 4.86. On VA examination in May 2015, the Veteran’s pure tone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 AVG RIGHT 30 30 40 65 41 LEFT 40 40 80 80 60 Maryland CNC word recognition was 94 percent in the right ear and 92 percent in the left ear. The Veteran reported that he did not hear conversations well. He had difficulty with clarity, and his television was louder than normal. On VA examination in July 2019, the Veteran’s pure tone thresholds, in decibels, were: HERTZ 1000 2000 3000 4000 AVG RIGHT 40 40 65 80 56 LEFT 50 45 80 85 65 Maryland CNC word recognition was 84 percent in the right ear and 74 percent in the left ear. The Veteran reported that he had difficulty hearing. He had to constantly have his spouse repeat herself. Prior to July 10, 2019, the Board notes that neither ear displays an exceptional pattern of hearing loss. Thus, Table VI will be used to determine the appropriate disability rating. 38 C.F.R. § 4.86(a). Applying the results for the Veteran’s right ear to Table VI shows that he had, at worst, Level I hearing loss, as shown by the May 2015 VA examination results. Under Table VI, the left ear had, at worst, Level II hearing loss, as shown by the May 2015 VA examination results. Applying Level I for the right ear and Level II for the left ear results in a 0 percent rating. 38 C.F.R. § 4.85. Therefore, the Board finds that the preponderance of the evidence is against the assignment of a compensable rating prior to July 10, 2019. As of July 10, 2019, the Board notes that neither ear displays an exceptional pattern of hearing loss. Thus, Table VI will be used to determine the appropriate disability rating. 38 C.F.R. § 4.86(a). Applying the results for the Veteran’s right ear to Table VI shows that he had, at worst, Level II hearing loss, as shown by the July 2019 VA examination results. Under Table VI, the left ear had, at worst, Level V hearing loss, as shown by the July 2019 VA examination results. Applying Level II for the right ear and Level V for the left ear results in a 10 percent rating. 38 C.F.R. § 4.85. Therefore, the Board finds that the preponderance of the evidence is against the assignment of any higher rating from July 10, 2019. The Board in no way discounts the difficulties that the Veteran experiences as a result of bilateral hearing loss. However, it must be emphasized that the assignment of disability ratings for hearing impairment is derived by a mechanical application of the rating schedule to the numeric designation assigned after audiometry results are obtained. The Board has no discretion in this matter and must predicate its determination on the basis of the results of the audiology studies of record. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The Board is bound by law to apply VA’s rating schedule based on the Veteran’s audiometry results. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Lay persons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, in this case, a lay opinion falls outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). To the extent that the Veteran contends that his hearing loss is more severe than currently rated, while he is competent to report symptoms such as difficulty understanding speech, he is not competent to report that his hearing acuity is of sufficient severity to warrant a certain percentage rating because such an opinion requires medical expertise and training in evaluating hearing impairment, which he does not possess, and the use of audiometric equipment. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Based upon the results from the VA examinations, the Board finds that the criteria for higher ratings for bilateral hearing loss have not been met. 38 C.F.R. §§ 4.85, 4.86. The Board finds that the preponderance of the evidence is against the claim for increased ratings and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total if it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of (1) a single service-connected disability ratable at 60 percent or more, or (2) as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a); Mittleider v. West, 11 Vet. App. 181 (1998). Entitlement to TDIU requires the presence of impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching a determination, the central inquiry is whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). Consideration may be given to the Veteran’s level of education, special training, and previous work experience in arriving at a conclusion, but not to age or the impairment caused by nonservice- connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran’s current service-connected disabilities are PTSD, rated 50 percent; bilateral hearing loss, rated 10 percent; and tinnitus, rated 10 percent. The combined service-connected disability rating is 60 percent. Thus, the Veteran does not meet the schedular criteria for consideration of the assignment of TDIU under 38 C.F.R. § 4.16(a). Nevertheless, the Veteran may be entitled to TDIU if it is established that the Veteran is unable to secure or follow substantially gainful employment as a result of the effects of the service-connected disabilities. 38 C.F.R. § 4.16(b). Therefore, the Board must determine whether the service-connected disabilities preclude the Veteran from engaging in substantially gainful employment, or work that is more than marginal, which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). The fact that a Veteran may be unemployed or has difficulty obtaining employment is not determinative. The ultimate question is whether the Veteran, because of service-connected disabilities, is incapable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). An inability to work due to advancing age may not be considered. 38 C.F.R. §§ 3.341(a), 4.19. In making the determination, VA considers such factors as the extent of the service-connected disability, and employment and educational background. 38 C.F.R. §§ 3.340, 3.341, 4.16(b), 4.19. The Board is required to obtain the Director’s decision before the Board may award TDIU under 38 C.F.R. § 4.16(b). Wages v. McDonald, 27 Vet. App. 233. In cases of Veterans who evidence suggests are unemployable by reason of service-connected disabilities and who do not meet the threshold percentage requirements of 38 C.F.R. § 4.16(a), the case is to be submitted to VA’s Director of Compensation Service for consideration of whether entitlement to a TDIU is warranted. 38 C.F.R. § 4.16(b). In order to refer the case, there must be a determination that a particular Veteran is made unable to secure or follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). That means that the Board should take into account the veteran’s specific circumstances including his disabilities, education, and employment history when determining if he is unable to work. A July 2012 letter from the Veteran’s former employer shows that the Veteran was no longer allowed to operate work equipment. The Veteran was laid off and counseled to seek medical assistance to control a sleep disorder. On a VA form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, submitted in November 2014, the Veteran stated that the disabilities that prevented him from securing or following any substantial occupation were a sleep disorder, insomnia, and tinnitus. He last worked full-time in July 2012. His prior job was laborer. He had completed four years of high school. On VA hearing loss and tinnitus examination in May 2015, the Veteran reported that he did not hear conversations well. He had difficulty with clarity, and his television was louder than normal. On VA psychiatric examination in May 2015, the examiner stated that any opinion regarding the Veteran’s occupational and social impairment would be speculative and impressionistic to an almost unacceptable degree. On a VA form 21-4192, Request for Employment Information in Connection With Claim for Disability Benefits, submitted in February 2016, the Veteran’s former employer stated that the Veteran last worked in approximately 2011. The employer stated that the Veteran’s employment was terminated because the Veteran became more unsafe due to stress, tiredness, and numbness. On VA hearing loss and tinnitus examination in July 2019, the Veteran reported that he had difficulty hearing. He had to constantly have his spouse repeat herself. In an August 2019 letter, the Veteran remarked that he was in constant pain from back surgery. He stated that since 2014, he had undergone a dissection of the lower left aorta, left knee replacement, right knee surgery, ongoing treatment with a psychiatrist, abdominal surgery, cataract surgery, and back surgery. The Veteran reiterated that he had sleep apnea and insomnia. He stated that his sleep disorder did not allow him to work. He stated that due to his aorta and back surgeries, he was not allowed to pick up more than 20 pounds. He stated that in his profession, running heavy equipment often required lifting of equipment weighing more than 20 pounds. The Veteran felt that he was unemployable due to PTSD. On VA psychological examination in July 2019, the examiner stated that it was impossible to provide any information about the impact of the Veteran’s current mental health symptoms on current occupational functioning without resorting to mere speculation. The examiner explained that the Veteran’s current age was above traditional retirement age, and by the Veteran’s self-report, his physical health problems appeared to have a significant impact on the Veteran’s ability to work. After reviewing the entire record, the Board concludes that entitlement to TDIU is not warranted. The most probative evidence of record shows that, solely considering the service-connected disabilities, the Veteran more likely than not would be able to obtain gainful employment. The record establishes that the Veteran has multiple disabilities. By the Veteran’s own statement, in addition to service-connected PTSD, bilateral hearing loss, and tinnitus, the Veteran also has sleep, heart, abdomen, eye, bilateral knee, and back disabilities. Significantly, the sleep, heart, abdomen, eye, bilateral knee, and back disabilities are not service-connected, although some sleep disturbance symptoms due to PTSD are considered service-connected. Therefore, the effects of the sleep apnea, heart, abdomen, eye, bilateral knee, and back disabilities are not to be considered in determining entitlement to a TDIU, as they are not service-connected disabilities. The Board finds that the evidence does not show anything out of the ordinary, or not average, in the Veteran’s situation as a result of the service-connected PTSD, hearing loss, and tinnitus disabilities. While the Veteran would have trouble with concentration, significant interactions with others, and ringing in his ears, the weight of the probative evidence of record does not indicate that he is unable to perform some type of substantially gainful employment specifically as a result of service-connected disabilities, with consideration of training and experience, and without consideration of age or nonservice-connected disabilities. Significantly, none of the VA examiners throughout the course of the appeal opined that the service-connected disabilities alone severely impacted the Veteran’s ability to work so as to result in precluding employment. While acknowledging that the Veteran has service-connected symptoms such as verbal aggression, depression, and ringing in his ears, the weight of the persuasive evidence of record does not demonstrate that the service-connected disabilities alone are of such severity as to preclude participation in all forms of substantially gainful employment for which the Veteran is qualified. Accordingly, the Board finds that the preponderance of the evidence is against the claim of entitlement to TDIU and referral to VA’s Director of the Compensation Service is not warranted. The claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Layton, 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.