Citation Nr: 21026933 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 16-27 543A DATE: May 4, 2021 ORDER Entitlement to service connection for left knee osteoarthritis of the patellofemoral compartment is granted. Entitlement to a disability rating greater than 20 percent prior to October 29, 2019 and greater than 30 percent thereafter, for right shoulder supraspinatus tear and acromioclavicular (AC) osteoarthritis is denied. Entitlement to a disability rating greater than 20 percent for left shoulder supraspinatus tear and AC osteoarthritis and deltoid strain is denied. Entitlement to a compensable disability rating for bilateral hearing loss is denied. FINDINGS OF FACT 1. The evidence is in relative equipoise as to whether the Veteran's left knee osteoarthritis of the patellofemoral compartment is related to active service. 2. For the period prior to October 29, 2019, the Veteran's right shoulder disability did not manifest as limitation of motion of his right arm to midway between his side and shoulder level 3. For the period from October 29, 2019, the Veteran's right shoulder disability did not manifest as limitation of his right arm to 25 degrees from his side. 4. The Veteran's left shoulder disability did not manifest as limitation of his left arm to 25 degrees from his side. 5. The preponderance of the evidence shows the Veteran has had no better than level I hearing in the right ear and level II hearing in the left ear. CONCLUSIONS OF LAW 1. The criteria for service connection for left knee osteoarthritis of the patellofemoral compartment have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for a disability rating greater than 20 percent prior to October 29, 2019 and greater than 30 percent thereafter, for right shoulder supraspinatus tear and AC osteoarthritis have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5201. 3. The criteria for a disability rating greater than 20 percent for left shoulder supraspinatus tear and AC osteoarthritis and deltoid strain have not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5201. 4. The criteria for a compensable disability rating for bilateral hearing loss have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.85, Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1974 to April 1994. These matters come before the Board of Veterans' Appeals (Board) from an August 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. The Board remanded these issues in April 2019 to obtain a VA examination to determine the etiology of the Veteran's left knee disability and the current nature and severity of his service-connected bilateral shoulder disability and bilateral hearing loss. There has been substantial compliance with the April 2019 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). These matters are properly before the Board for adjudication. Entitlement to service connection for left knee osteoarthritis of the patellofemoral compartment. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection for a disability requires evidence of: (1) a current disability; (2) a disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Certain chronic diseases, including arthritis, may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service (one year for arthritis). 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. A close review of the medical evidence of record shows an April 2010 radiology report noting mild left knee osteoarthritis of the patellofemoral compartment. The April 2019 VA examiner's opinion included a detailed medical history of the Veteran's left knee disability. Specifically, she noted the onset of the Veteran's left knee disability was 1974. The Board has weighed the probative evidence of record, including the VA medical opinions, the Veteran's service treatment records, as well as his competent and credible assertions concerning continuing left knee osteoarthritis of the patellofemoral compartment and finds that the evidence is in equipoise. 38 C.F.R. §§ 3.307, 3.309. The benefit of the doubt rule is therefore for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Accordingly, and resolving all doubt in the Veteran's favor, the Board finds that service connection for left knee osteoarthritis of the patellofemoral compartment is warranted. INCREASED RATING GENERALLY Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical and industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. 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. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as staged ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Painful motion is an important factor of joint disability and painful joints are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Where functional loss is alleged due to pain upon motion, the function of the musculoskeletal system and movements of joints must still be analyzed. DeLuca v. Brown, 8 Vet. App. 202 (1995). A finding of functional loss due to pain must be supported by adequate pathology, and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80 (1997). Similarly, painful motion alone does not constitute limited motion for the purposes of rating under diagnostic codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. 38 C.F.R. § 4.40. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Factors of joint disability include increased or limited motion, weakness, and fatigability, or painful movement, swelling, deformity or disuse atrophy. 38 C.F.R. § 4.45. Right and Left Shoulder Claims The Veteran's right shoulder disability is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5201 and his left shoulder disability is rated under Diagnostic Code 5010-5201. Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. 38 C.F.R. § 4.27. Use of the second diagnostic code helps provide further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. Id. Additionally, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated. Id. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). These amendments revised Diagnostic Codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021, and the criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change, Diagnostic Code 5010 instructed the rater to rate traumatic arthritis as degenerative arthritis under Diagnostic Code 5003. Under the revised criteria, Diagnostic Code 5010 applies only to post-traumatic arthritis, which is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Prior to the regulatory change, Diagnostic Code 5003 assigned a disability rating for degenerative arthritis (hypertrophic or osteoarthritis). Under the revised criteria, Diagnostic Code 5003 assigns a disability rating for degenerative arthritis, other than post-traumatic. Under both the earlier and revised rating criteria, arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined and not added, under Diagnostic Code 5003. Diagnostic Code 5201 applies to limitation of motion of the arm. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm. Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). Effective February 7, 2021, the criteria for limitation of motion of the arm under Diagnostic Code 5201 was revised to clarify that limitation of motion of the arm at shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder (flexion and/or abduction limited to 45 degrees) warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Flexion and/or abduction limited to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The amendments further clarify that Diagnostic Codes 5201 and 5202 provide that shoulder level is 90 degrees and midway is 45 degrees. 38 C.F.R. § 4.71a, 85 Fed. Reg. 76453 (Nov. 30, 2020). Id. VA records establish that the Veteran is right hand dominant, which means his right upper extremity/shoulder is his major extremity. 38 C.F.R. § 4.69. The Veteran underwent a VA examination in August 2013. The VA examiner diagnosed bilateral supraspinatus tear and bilateral AC osteoarthritis. The Veteran reported experiencing flare ups which prevented him from raising his arm. Range of motion testing showed right shoulder flexion ended at 160 degrees with evidence of painful motion at 120 degrees; right shoulder abduction ended at 140 degrees with evidence of painful motion at 100 degrees; left shoulder flexion ended at 170 degrees with evidence of painful motion at 130 degrees; left shoulder abduction ended at 150 degrees with evidence of painful motion at 130 degrees. The Veteran performed repetitive use testing with additional loss in range of motion. The examiner indicated that less movement than normal, excess fatigability, incoordination, impaired ability to execute skilled movements smoothly, and pain on movement impacted both shoulders. The right shoulder was also affected by weakened movement and atrophy of disuse. The examiner found no evidence of localized tenderness or pain on palpation of joints/soft tissue/bicep tendon of either shoulder, guarding, ankylosis, instability, of surgical procedures. There was evidence of normal left shoulder strength (5/5), but the examiner noted reduced right shoulder strength (4/5, active movement against some resistance). The Veteran right shoulder tested positive when tested for Hawkins' impingement, empty-can test, lift-off subscapularis test, and external rotation/infraspinatus strength test. The examiner noted bilateral arthropathy without tenderness of the AC joint. Cross-body adduction test showed negative results. The VA examiner noted that pain, weakness, fatigability, or incoordination limited functional ability during flare ups and during repeated use over time. The examiner opined there was an additional loss of 10 degrees in abduction of the left side. The examiner explained that it is not feasible to estimate additional degrees of loss of range of motion of the right shoulder or left shoulder because he would resort to speculation. The Veteran underwent a VA examination in November 2014. The examiner diagnosed bilateral shoulder strain and bilateral rotator cuff tear. The Veteran reported he experienced painful flare ups that made movement difficult. Right and left shoulder testing revealed identical results. Specifically, right and left shoulder range of motion testing showed flexion and abduction measured 150 degrees, and external and internal rotation measured 60 degrees. The examiner noted range of motion contributed to functional loss and impacted the Veteran's ability to meet activities of daily living. Pain was noted on flexion, abduction, external rotation, and internal rotation. The examiner found evidence of localized tenderness upon palpation of the anterior and lateral shoulder areas. There was no evidence of pain with weight bearing of either shoulder. The Veteran was unable to perform repetitive use testing with at least three repetitions because he complained of painful flare ups. He was not examined immediately after repetitive use over time. However, the VA examiner stated that the examination supported the Veteran's statements describing functional loss with repetitive use over time and flare ups. The examiner noted that pain significantly limited functional ability with repeated use over a period of time and during flare-ups. Range of motion testing showed flexion and abduction measured 140 degrees, and external and internal rotation measured 60 degrees with repeated use over a period of time and during flare-ups. The examiner noted the Veteran experienced four painful flare ups per week which measured 8-9/10 in severity and lasted greater than 24 hours. There were no additional factors contributing to the Veteran's shoulder disability. The examiner's report showed a reduction in muscle strength, bilaterally. The examiner noted there was active movement against some resistance during forward flexion and abduction. There was no evidence of muscle atrophy, clavicle, scapula, AC joint, sternoclavicular joint conditions, flail shoulder, false flail shoulder, fibrous union of the humerus, malunion of the humerus, or any other pertinent physical findings, complications, conditions, signs, or symptoms related to the Veteran's diagnosed bilateral shoulder strain and bilateral rotator cuff tear. The examiner noted bilateral shoulder instability with a history of mechanical symptoms. There was no history of recurrent dislocation of the scapulohumeral joint and crank apprehension and relocation tests were negative, however. The Veteran did not use any assistive devices and his shoulder conditions did not suffer functional impairment such that no effective function remained other than that which would be served well by an amputation with prosthesis. Imaging testing revealed bilateral shoulder crepitus. The VA examiner opined that the Veteran's bilateral shoulder pain impeded his range of motion and work ability. The Veteran underwent a VA examination in October 2019. The examiner diagnosed right shoulder supraspinatus tear and AC osteoarthritis, and left shoulder supraspinatus tear, AC osteoarthritis and deltoid sprain. The Veteran denied flare ups of the shoulder or arm. He reported he experienced pain reaching above his head, however. Right shoulder range of motion testing showed flexion and abduction measured 40 degrees, and external and internal rotation measured 90 degrees. The examiner noted range of motion contributed to functional loss and impacted the Veteran's ability to reach above his head. Pain was noted on flexion. The examiner found no evidence of localized tenderness upon palpation right shoulder area. There was no evidence of pain with weight bearing or crepitus. Left shoulder range of motion testing showed flexion and abduction measured 40 degrees, and external and internal rotation measured 90 degrees. The examiner noted range of motion contributed to functional loss and impacted the Veteran's ability to reach above his head. Pain was noted on flexion. The examiner found evidence of mild AC joint pain associated with AC osteoarthritis. There was no evidence of pain with weight bearing or crepitus. The Veteran performed repetitive use testing with three repetitions. There was no additional loss of function or range of motion of the right or left shoulder. The Veteran was not examined immediately after repetitive use over time or during a flare up. The VA examiner opined that the examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time or during flare ups. The examiner stated that pain limited functional ability with repetitive use over time and flare ups, but that no further range of motion loss was anticipated, however. The Veteran exhibited normal muscle strength with forward flexion and abduction of the right and left shoulders. The examiner found no evidence of muscle atrophy, ankylosis, shoulder instability, flail shoulder, false flail shoulder, fibrous union of the humerus, malunion of the humerus, or any other pertinent physical findings, complications, conditions, signs, or symptoms related to the Veteran's left and right shoulder disability. The examiner suspected right and left rotator cuff conditions. He noted the Veteran was unable to perform Hawkins' impingement test, empty-con test, external rotation/infraspinatus strength test, or lift-off subscapularis tests. The examiner noted AC osteoarthritis and cross-body adduction testing were positive for both right and left shoulders. The Veteran did not undergo any surgical procedures, did not use any assistive devices, and his shoulder conditions did not suffer functional impairment such that no effective function remained other than that which would be served well by an amputation with prosthesis. The examiner opined that the Veteran would not do well with significant above-head reaching. The examiner noted no objective evidence of pain on non-weight bearing or passive range of motion testing for the right and left shoulders. Passive range of motion for the right and left shoulders measurements were the same as active range of motion. Evaluation of the Veteran's Right Shoulder Disability The Veteran contends a disability rating greater than 20 percent prior to October 29, 2019 and greater than 30 percent thereafter for his right shoulder disability is warranted. The Board disagrees. In order to obtain a rating greater than 20 percent prior to October 29, 2019, under either the current or previously amended Diagnostic Code 5201, the evidence must show right arm limitation of motion midway between side and shoulder level, or 45 degrees. Additionally, in order to obtain a rating greater than 30 percent from October 29, 2019, under either the current or previously amended Diagnostic Code 5201, the evidence must show right arm range of motion is limited to 25 degrees from the side. Such is simply not shown. The Board has also considered whether higher ratings for the Veteran's right shoulder disability is appropriate under 38 C.F.R. §§ 4.40, 4.45, and 4.59, at any point during the appeal and determined that such is not warranted. Pain during range of motion testing was noted on examination in August 2013, November 2014, and October 2019. However, prior to October 28, 2019 limitation of right arm motion still measured in excess of 45 degrees, and; right arm range of motion measurements exceeded 25 degrees from side since October 28, 2019. The Court has also established that flare-ups must be considered. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Guidance on how to evaluate flare-ups has not been particularly clear. However, the Board finds overall wisdom in Mitchell. Flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because there is a regulation addressing stabilization of ratings, the flare-up must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. With that in mind, consideration has been given the reports of flare-ups during the August 2013 and October 2014 examinations. Importantly, the 2013, 2014 and 2019 VA examiners reviewed the Veteran's medical records, including the frequency and severity of flare-ups, including reports of pain with reaching overhead, difficulty completing activities of daily living, impeding range of motion, impacting his ability to work, and post-test ROM measurements. This evidence, however, does not demonstrate additional functional loss sufficient to warrant an increased rating at any point during the period on appeal. The contemporaneous treatment records contain little, if any, findings pertaining to flare-ups much less information regarding the Veteran's functional ability during a flare-up or after repeated use over time. However, the record is reasonably clear that the Veteran experienced motion loss during flare-ups, described as pain. The medical and lay statements do not indicate that the flare-ups are so severe as to approximate the higher rating criteria more nearly. 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5201; Mitchell, 25 Vet. App. at 44; Correia, 28 Vet. App. at 169-170; Sharp, 29 Vet. App. at 33. For the period prior to October 29, 2019, the 2013 and 2014 VA examination reports indicate that the Veteran has significantly greater movement than the motion loss contemplated for the 30 percent rating criteria for DC 5201 (major). The Veteran does not specifically identify more motion loss suggestive of right arm range of motion limited to midway between side and shoulder level. 38 C.F.R. § 4.71a, DC 5201. For the period from October 29, 2019, the 2019 VA examination report indicates that the Veteran has significantly greater movement than the motion loss contemplated for the 40 percent rating criteria for DC 5201 (major). The Veteran does not specifically identify more motion loss suggestive of right arm range of motion limited to 25 degrees from side. 38 C.F.R. § 4.71a, DC 5201. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating greater than 20 percent prior to October 29, 2019 and greater than 30 percent thereafter for his right shoulder disability under either the current or amended rating criteria. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Evaluation of the Veteran's Left Shoulder Disability The Veteran contends a disability rating greater than 20 percent for his left shoulder disability is warranted. The Board disagrees. In order to obtain a rating greater than 20 percent, under the current or previously amended Diagnostic Code 5201, the evidence must show left arm range of motion limited to 25 degrees from side. Such is simply not shown. August 2013 range of motion measured 130 degrees, November 2014 range of motion measured 140 degrees, and October 2019 range of motion measured 40 degrees, well in excess of the 25 degrees from side required for a 30 percent disability rating. The Board has also considered whether higher ratings for the Veteran's left shoulder disability is appropriate under 38 C.F.R. §§ 4.40, 4.45, and 4.59, at any point during the appeal and determined that such is not warranted. Pain during range of motion testing was noted on examination in August 2013, November 2014, and October 2019. However, left arm range of motion measurements exceeded 25 degrees from side. The Court has also established that flare-ups must be considered. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Guidance on how to evaluate flare-ups has not been particularly clear. However, the Board finds overall wisdom in Mitchell. Flare-ups must be quantifiable and must result in limitation of motion or function beyond that contemplated by the already provided evaluation. In addition, because there is a regulation addressing stabilization of ratings, the flare-up must be of such length as to establish that the overall impairment is more severe than currently evaluated, rather than a brief snapshot in time. With that in mind, consideration has been given the reports of flare-ups during the August 2013 and October 2014 examinations. Importantly, the 2013, 2014, and 2019 VA examiners reviewed the Veteran's medical records, including the frequency and severity of flare-ups, including reports of pain with reaching overhead, difficulty completing activities of daily living, impeding range of motion, impacting his ability to work, and post-test ROM measurements. This evidence, however, does not demonstrate additional functional loss sufficient to warrant an increased rating at any point during the period on appeal. The contemporaneous treatment records contain little, if any, findings pertaining to flare-ups much less information regarding the Veteran's functional ability during a flare-up or after repeated use over time. However, the record is reasonably clear that the Veteran experienced motion loss during flare-ups, described as pain. The medical and lay statements do not indicate that the flare-ups are so severe as to approximate the higher rating criteria more nearly. 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DC 5201; Mitchell, 25 Vet. App. at 44; Correia, 28 Vet. App. at 169-170; Sharp, 29 Vet. App. at 33. The 2014 and 2019 VA examination reports indicate that the Veteran has significantly greater movement than the motion loss contemplated for the 30 percent rating criteria for DC 5201 (minor). The Veteran does not specifically identify more motion loss suggestive of right arm range of motion limited to 25 degrees from side. 38 C.F.R. § 4.71a, DC 5201. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 20 percent for the left shoulder disability under either the current or amended rating criteria. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Evaluations under Other Diagnostic Codes The Board has considered whether higher ratings could be assigned under alternate diagnostic codes. See Butts v. Brown, 5 Vet. App. 532 (1993); see also Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992) (indicating that any change in DC must be specifically explained). The record on appeal does not support evaluating the Veteran's right and left shoulder disabilities under alternate diagnostic codes. The VA examinations did not identify ankylosis in either shoulder; therefore, DC 5200 is not applicable. Diagnostic Code 5202 is not applicable because the record is silent as to any impairment of the Veteran's humerus, to include flail shoulder, false flail shoulder, fibrous union, or recurrent shoulder dislocations. Likewise, DC 5203 is not applicable because the record does not document dislocation, nonunion, or malunion of the clavicle and scapula, and the Veteran's evaluations already meet or exceed the evaluations available under DC 5203. Lastly, DC 5051, which applies to prosthetic shoulder replacements, is not applicable here because the Veteran has not had shoulder replacement surgery. 1. Bilateral Hearing Loss Disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. Lendenman v. Principi, 3 Vet. App. 345 (1992). The rating schedule establishes auditory hearing acuity levels based on average puretone thresholds and speech discrimination. 38 C.F.R. § 4.85. Ratings for hearing loss are determined in accordance with the findings obtained on audiometric examinations. Ratings for hearing impairment range from 0 percent to 100 percent based on organic impairment of hearing acuity, as measured by the results of the controlled speech discrimination tests, together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1000, 2000, 3000, and 4000 Hertz. To rate the degree of disability from hearing impairment, the rating schedule establishes eleven auditory acuity levels designated from Level I for essentially normal acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Diagnostic Code 6100. Hearing tests will be conducted without hearing aids, and the results of testing are charted on Table VI and Table VII. 38 C.F.R. § 4.85, Tables VI, VII. Exceptional patterns of hearing impairment are rated under 38 C.F.R. § 4.86. When the pure tone threshold at each of the four specified frequencies of 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. When the 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 for hearing impairment from Table VI or Table VIa, whichever is higher. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86. An adequate evaluation of impairment of hearing acuity rests upon the results of controlled speech discrimination tests, together with tests of the average hearing threshold levels at certain specified frequencies. 38 C.F.R. § 4.85, Diagnostic Code 6100. The assignment of disability ratings for hearing impairment are to be derived by the mechanical application of the Ratings Schedule to the numeric designations assigned after audiometry evaluations are made. Lendenmann v. Principi, 3 Vet. App. 345 (1992). In addition to dictating objective test results, a VA audiologist should fully describe the functional effects caused by a hearing disability in the final report because of the potential application of 38 C.F.R. § 3.321 (b) in considering whether referral for consideration of the assignment of an extraschedular rating is warranted. Unlike the rating schedule for hearing loss, 38 C.F.R. § 3.321 (b) does not rely exclusively on objective test results to determine whether a referral for an extra-schedular rating is warranted. Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran underwent VA examinations in July 2013, June 2015, and October 2019. The results of the July 2013 VA examination puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 45 25 25 20 29 LEFT 45 25 20 25 29 A speech discrimination score using the Maryland CNC word list revealed speech recognition ability of 98 percent in both ears. Analyzing the results of the July 2013 evaluation, with mechanical application of the rating schedule to the numeric designations assigned based on audiometric test results, the Veteran's average hearing loss of 29 dB in the right ear, 29 dB of hearing loss in the left ear, together with hearing discrimination scores of 98 percent in both ears, results Level I hearing on the right and Level I hearing on the left, utilizing Table VI; which warrants a noncompensable rating according to Table VII. The results of the June 2015 VA examination puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 65 50 45 35 49 LEFT 45 40 30 35 38 A speech discrimination score using the Maryland CNC word list revealed speech recognition ability of 92 percent in his right ear and 84 percent in his left ear. Analyzing the results of the June 2015 evaluation, with mechanical application of the rating schedule to the numeric designations assigned based on audiometric test results, the Veteran's average hearing loss of 49 dB in the right ear, 38 dB of hearing loss in the left ear, together with hearing discrimination scores of 92 percent in his right ear and 84 percent in his left ear, results Level I hearing on the right and Level II hearing on the left, utilizing Table VI; which warrants a noncompensable rating according to Table VII. The results of the October 2019 VA examination puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 40 30 35 35 35 LEFT 45 35 35 35 38 A speech discrimination score using the Maryland CNC word list revealed speech recognition ability of 100 percent in both ears. Analyzing the results of the October 2019 evaluation, with mechanical application of the rating schedule to the numeric designations assigned based on audiometric test results, the Veteran's average hearing loss of 35 dB in the right ear, 38 dB of hearing loss in the left ear, together with hearing discrimination scores of 100 percent in both ears, results Level I hearing on the right and Level I hearing on the left, utilizing Table VI; which warrants a noncompensable rating according to Table VII. At no time during the appeal period were each of the four hearing thresholds 55 decibels or greater, so no provision of 38 C.F.R. § 4.86, used to evaluate exceptional patterns of hearing impairment, is applicable. Consideration is also given to the functional effects of the Veteran's bilateral hearing loss. The Veteran reports asking people to repeat themselves and people raising their voices at him. His statement is competent and credible. However, in light of the Court's holdings in Martinak v. Nicholson, 21 Vet. App. 447, 454 (2007) and Doucette v. Shulkin, 28 Vet. App. 366 (2017), the Veteran's inability to hear or understand speech or to hear other sounds in various contexts have been sufficiently measured during the VA examinations and such functional effects are contemplated by the schedular rating criteria. VA examination reports represent the best evidence for deciding the claim the evidence that contain comprehensive audiometric testing sufficient for rating the disability. In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b). In this case, the Board finds that the preponderance of the evidence is against the claim of entitlement of a compensable rating for bilateral hearing loss. Therefore, the claim is denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mohammad Mahmoudi, 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.