Citation Nr: 21042523 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 11-08 680A DATE: July 13, 2021 ORDER Entitlement to an initial evaluation in excess of 10 percent prior to Sept 16, 2010 for bilateral hearing loss on an extraschedular basis is denied. Entitlement to an initial evaluation in excess of 20 percent from Sept 16, 2010 to Aug 20, 2011 for bilateral hearing loss on an extraschedular basis is denied. Entitlement to an initial evaluation in excess of 30 percent from August 20, 2011 to October 22, 2017 for bilateral hearing loss on an extraschedular basis is denied. Entitlement to an initial evaluation in excess of 50 percent from October 23, 2017 to February 12, 2020 for bilateral hearing loss on an extraschedular basis is denied. Entitlement to total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. Pursuant to September 2017 and July 2020 Board remands and the provisions of 38 C.F.R. § 3.321(b)(1), the VA Director of Compensation Service issued an advisory opinion that denied an extraschedular rating for the service-connected bilateral hearing loss. 2. The Veteran's bilateral hearing loss does not present an exceptional or unusual disability picture so as to render impractical the application of the regular schedular standards at any time during the initial rating period. 3. The Veteran has had at least a 10 percent rating for his service-connected disabilities for the entire period on appeal. 4. The Veteran did not complete and return a VA Form 21-8940 in connection with an inferred claim for entitlement to a TDIU. 5. There is incomplete information of record regarding the Veteran's educational background and employment history. 6. The evidence of record is insufficient to determine whether the Veteran has been substantially gainfully employed during the TDIU period and whether there has been a material change in employment during the course of the appeal. CONCLUSIONS OF LAW 1. The criteria for a rating for the service-connected bilateral hearing loss on an extraschedular basis pursuant to 38 C.F.R. § 3.321(b)(1) at any time during the initial rating period are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1) (2020). 2. The criteria for entitlement to a TDIU are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from July 1963 to March 1965. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision of a Department of Veterans Affairs (VA) regional office, the agency of original jurisdiction (AOJ). In that decision, the AOJ granted service connection for bilateral hearing loss and assigned a noncompensable evaluation effective November 24, 2008. The Veteran appealed. Procedural History In a May 2014 decision, the Board increased the schedular evaluation for the Veteran's service-connected hearing loss to 10 percent effective November 24, 2008 to September 16, 2010; to 20 percent effective September 16, 2010 to August 20, 2011; and to 30 percent effective August 20, 2011. See Board Decision dated May 13, 2014. The Veteran appealed the May 2014 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a December 2014 Order, the Court granted a joint motion for partial remand in which the parties agreed that the Board erred when it failed to discuss whether the Veteran's claim should be referred for extraschedular consideration. The parties also agreed that the Board erred by not providing adequate reasons or bases as to whether the Veteran was provided adequate VA examinations in June 2009 or August 2009 and concluded that neither examination addressed the functional effects of the Veteran's hearing disability. See Joint Motion for Partial Remand filed December 22, 2014. The Board remanded the case for development in March 2015, and the case was subsequently returned to the Board for appellate review. In August 2015, the Board denied the issues of entitlement to increased evaluations for bilateral hearing loss. The Veteran then appealed that decision to the Court, challenging the denial of an extraschedular rating. In a May 2017 Order, the Court granted another joint motion for partial remand, in which the Veteran specifically noted that he did not challenge the Board's denial of a higher schedular rating for his bilateral hearing loss. The parties agreed that remand was warranted because the Board erred when it failed to discuss certain evidence potentially favorable to whether the Veteran's claim for an increased rating for bilateral hearing loss should have been referred for extraschedular consideration, specifically a June 2009 audiology consultation noting the Veteran reported that he experienced unsteadiness with occasional loss of balance due to his hearing loss, the Veteran's August 2009 report of occasional dizziness as a result of his hearing loss, and the Veteran's September 2010 report that he experienced "the area around me is spinning" as a result of his hearing loss and tinnitus. See Joint Motion for Partial Remand filed May 10, 2017. In September 2017, the Board remanded the case for further development, to include obtaining an addendum medical opinion and for referral of the issue of entitlement to an extraschedular rating to the Under Secretary for Benefits or the Director of the Compensation Service. The Board again remanded the claim in June 2018 to obtain an addendum opinion. Notably, in August 2019, the AOJ granted service connection for vertigo. See Rating Decision dated August 20, 2019. To the extent that the issue of entitlement to service connection was on appeal, the August 2019 rating decision is considered a full grant of the benefits on appeal for that claim. As such, the issue of entitlement to service connection for vertigo is not in appellate status. A.B. v. Brown, 6 Vet. App. 35 (1993). In December 2019, the Board again remanded the claim pursuant to the Veteran's request to allow the AOJ to have initial consideration of additional evidence relevant to his hearing loss claim and for additional development of the TDIU claim. In a May 2020 rating decision, the AOJ granted a 50 percent schedular rating for bilateral hearing loss effective October 23, 2017, and a 100 percent maximum schedular rating effective February 12, 2020. See Rating Decision dated May 4, 2020. In July 2020, the Board again remanded the claims due to deficiencies in a July 2019 VA opinion regarding the Veteran's hearing loss claim to obtain a new examination and opinion. A VA ear conditions examination and medical opinion dated February 2021 have been associated with the Veteran's electronic claims file and reviewed. The Board finds substantial compliance by the AOJ with the Board's July 2020 remand directives. See D'Aries, supra. The Veteran's claims now return to the Board for further appellate review to determine if an extraschedular rating for bilateral hearing loss is warranted. Preliminary Matter The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Ratings - Applicable Laws and Regulations Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. Ratings of hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled 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 cycles per second (Hertz). To rate the degree of disability for service-connected 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. In order to establish entitlement to a compensable rating for hearing loss, it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average pure tone decibel loss are met. 38 C.F.R. § 4.85, Diagnostic Code (DC) 6100 (Table VII). 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 rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. These results are then charted on Table VI, or Table VIA in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII, as set out in the Rating Schedule. 38 C.F.R. § 4.85, DC 6100. 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. Controlling laws provide that ratings shall be based, as far as practicable, upon the average impairments of earning capacity. The decibel loss and speech discrimination ranges designated for each level of hearing impairment in Tables VI and VIa found at 38 C.F.R. § 4.85 were chosen in relation to clinical findings of the impairment experienced by veterans with certain degrees and types of hearing disability. The regulatory history of 38 C.F.R. § 4.85 includes revisions, effective June 10, 1999. See 64 Fed. Reg. 25206 (May 11, 1999). In forming these revisions, VA sought the assistance of the Veteran's Health Administration (VHA) in developing criteria that contemplated situations in which a veteran's hearing loss was of such a type that speech discrimination tests may not reflect the severity of communicative functioning these veterans experienced or that was otherwise an extreme handicap in the presence of any environmental noise, even with the use of hearing aids. VHA found through clinical studies of veterans with hearing loss that, when certain patterns of impairment are present, a speech discrimination test conducted in a quiet room with amplification of the sounds does not always reflect the extent of impairment experienced in the ordinary environment. The decibel threshold requirements for application of Table VIa were based on findings and recommendations of VHA. The intended effect of the revision was to fairly and accurately assess the hearing disabilities of veterans as reflected in a real life industrial setting. 59 Fed. Reg. 17295 (April 12, 1994). To accord justice to the exceptional case where the schedular evaluation is inadequate to rate a single service-connected disability, the Director of Compensation Service (Director) or his or her delegate is authorized to approve on the basis of the criteria set forth in this paragraph (b), an extra-schedular evaluation commensurate with the average impairment of earning capacity due exclusively to the disability. The governing norm in these exceptional cases is a finding by the Director that application of the regular schedular standards is impractical because the disability is so exceptional or unusual due to such related factors as marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321. The Board cannot grant an extraschedular rating in the first instance. Anderson v. Shinseki, 23 Vet. App. 423 (2009). Here, the Director issued an advisory opinion in April 2021 finding that an extraschedular rating is not warranted. As such, the issue of whether an extraschedular rating is warranted may be adjudicated by the Board in the instant appeal. Nevertheless, the Board is not bound by the Director's decision or otherwise limited in its scope of review of that determination. Wages v. McDonald, 27 Vet. App. 233, 236-38 (2015) (citing to 38 U.S.C. §§ 511 (a), 7104(a); 38 C.F.R. § 4.16 (b)); see Anderson v. Shinseki, 22 Vet. App. 423 (2009). Consideration of an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the veteran's disability picture. To this point, the Court has firmly held that the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday work environment. Doucette v. Shulkin, 28 Vet. App. 366 (2017). If the schedular evaluation does not contemplate the level of disability and symptomatology shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element compares a claimant's symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If the veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Director to determine whether an extraschedular rating is warranted. Thun, 22 Vet. App. 111. In sum, both Thun elements must be met for an extraschedular rating to be warranted. Yancy v. McDonald, 27 Vet. App. 484, 494-95 (2016) ("If either [Thun] element is not met, then referral for extraschedular consideration is not appropriate"); Anderson v. Shinseki, 22 Vet. App. 423, 427 (2009) (noting that the Thun "steps are, in fact, elements that must be established before an extraschedular rating can be awarded"). Following receipt of an opinion from the Director, the Board may review all the Thun elements. See Kuppamala v. McDonald, 27 Vet. App. 447, 457 (2015) (holding that once the Director has conducted his review, as Anderson clarified, all three elements of Thun are reviewable by the Board). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). Rating Analysis As indicated above, the Veteran's service-connected bilateral sensorineural hearing loss disability is assigned an initial 10 percent rating from November 24, 2008, an initial 20 percent rating from September 16, 2010, an initial 30 percent rating from August 20, 2011, an initial 50 percent rating from October 23, 2017, and an initial 100 percent (maximum schedular) rating from February 12, 2020 under 38 C.F.R. §§ 4.85, 4.86, DC 6100. See Board Decision dated May 13, 2014; Rating Decision dated June 26, 2014; Rating Decision dated May 4, 2020. The Veteran asserts that he is entitled to increased ratings for bilateral hearing loss on an extraschedular basis. See Appellant's Post-Remand Brief received May 21, 2021. The Board notes, as an initial matter, that the issue on appeal is entitlement to an extraschedular rating for bilateral hearing loss greater than the assigned schedular staged ratings. See, e.g., Joint Motion for Partial Remand filed May 10, 2017 at pg. 1. Nevertheless, a comprehensive review of the record necessitates evaluation of relevant evidence in the context of both schedular and extraschedular rating criteria. Turning to the record, the Veteran underwent a VA outpatient audiological evaluation in June 2009. The diagnosis was moderate to severe sensorineural hearing loss. The Veteran reported hearing difficulty in many situations and unsteadiness with occasional loss of balance. He denied otalgia and otorrhea; however, he endorsed tinnitus and unsteadiness. The audiometric data indicates right ear puretone thresholds of 45 decibels, 50 decibels, 65 decibels, 70 decibels, and 75 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Left ear audiometric data indicates left ear puretone thresholds at 40 decibels, 55 decibels, 70 decibels, 70 decibels, and 75 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Puretone threshold averages (the average of puretone thresholds from 1000 through 4000 Hertz) were 58 decibels for the right ear and 59 decibels for the left ear. The Veteran's right ear speech discrimination was noted as 84 percent; his left ear speech discrimination was noted as 80 percent. See VA Audiological Evaluation dated June 11, 2009. A puretone threshold average of 58 decibels in the right ear and 59 decibels in the left ear with speech discrimination at 84 percent and 80 percent in the right and left ears respectively is assigned numeric designations of III for the right ear and IV for the left ear. The point where designations III and IV meet in Table VII yields a 10 percent disability rating. See 38 C.F.R. § 4.85, DC 6100. The Board notes that while the June 2009 puretone thresholds reflect an exceptional pattern of hearing impairment, in the Veteran's left ear, see 38 C.F.R. § 4.86(a), Table VIa does not provide a higher disability rating. See 38 C.F.R. § 4.85, DC 6100. A July 2009 VA treatment record reflects that the Veteran was fitted with new hearing aids. In August 2009, the Veteran was afforded a VA audiological examination. The diagnosis was mild to moderate sensorineural hearing loss, bilaterally, and bilateral tinnitus. The Veteran denied otalgia and otorrhea; however, he endorsed occasional dizziness. The Veteran had recently been fitted with hearing aids and said he was having a hard time getting used to them but noted he could hear things with hearing aids he was unable to hear for 40 years. The audiometric data indicates right ear puretone thresholds of 20 decibels, 25 decibels, 45 decibels, 50 decibels, and 55 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Left ear audiometric data indicates left ear puretone thresholds at 25 decibels, 25 decibels, 50 decibels, 55 decibels, and 60 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Puretone threshold averages (the average of puretone thresholds from 1000 through 4000 Hertz) were 44 decibels for the right ear and 48 decibels for the left ear. The Veteran's right ear speech discrimination was noted as 96 percent, bilaterally. See VA hearing loss examination dated August 11, 2009. A puretone threshold average of 44 decibels in the right ear and 48 decibels in the left ear with speech discrimination at 96 percent and 96 percent in the right and left ears respectively is assigned numeric designations of I for the right ear and I for the left ear. The point where designations I and I meet in Table VII yields a 0 percent, or noncompensable, disability rating. See 38 C.F.R. § 4.85, DC 6100. The Veteran underwent a VA outpatient audiological evaluation in September 2010. The diagnosis was bilateral sensorineural hearing loss. The examiner noted that the Veteran was negative for otalgia and otorrhea. The Veteran endorsed unsteadiness, which the examiner characterized as vertigo. The audiometric data indicates right ear puretone thresholds of 40 decibels, 55 decibels, 65 decibels, 65 decibels, and 75 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Left ear audiometric data indicates left ear puretone thresholds at 35 decibels, 55 decibels, 65 decibels, 65 decibels, and 70 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Puretone threshold averages (the average of puretone thresholds from 1000 through 4000 Hertz) were 65 decibels for the right ear and 64 decibels for the left ear. The Veteran's right ear speech discrimination was noted as 68 percent; his left ear speech discrimination was noted as 76 percent. Although the evaluation form does not reflect that the examiner used the Maryland CNC speech discrimination test, there is a presumption of regularity under which it is presumed that government officials have properly discharged their official duties. Ashley v. Derwinski, 2 Vet. App. 307, 308-309 (1992). As such, the examination is adequate for rating purposes. See VA Audiological Evaluation dated September 16, 2010; 38 C.F.R. § 4.85(a). A puretone threshold average of 65 decibels in the right ear and 64 decibels in the left ear with speech discrimination at 68 percent and 76 percent in the right and left ears respectively is assigned numeric designations of V for the right ear and IV for the left ear. The point where designations V and V meet in Table VII yields a 10 percent disability rating. See 38 C.F.R. § 4.85, DC 6100. The Board notes that the September 2010 puretone thresholds reflect an exceptional pattern of hearing impairment, bilaterally, see 38 C.F.R. § 4.86(a), and application of Table VIa provides for level V hearing acuity in each ear, which warrants a 20 percent rating. See 38 C.F.R. § 4.85, DC 6100. In his September 2010 notice of disagreement, the Veteran said that on a number of occasions he experienced a sensation of the area around him "spinning," which he attributed, in part, to his hearing loss, and said he had fallen on several occasions. He said his hearing loss had detrimentally affected his relationship with his family. See Correspondence received September 17, 2010. A September 2010 VA audiology note shows that the Veteran reported constant ringing tinnitus, bilaterally. He reported unsteadiness but denied otalgia and otorrhea. In statements received from the Veteran's spouse J.B. in February 2011, she said, in part, that the Veteran attempted to avoid contact with family members and other people due to embarrassment over his impaired hearing and constant ringing in his ears, which resulted in sleep interruptions, exhaustion, and stress on them both. A February 2011 statement from S.G., an acquaintance of the Veteran, described how the Veteran's hearing loss had placed a severe strain on the Veteran and his family, including due to people having to repeat what was said several times, agitation over not understanding what was said, misunderstandings, and arguments. S.G. said he personally witnessed the Veteran falling several times due to loss of balance. The Veteran underwent a VA outpatient audiological evaluation in August 2011. The diagnosis was moderate to severe bilateral sensorineural hearing loss. The Veteran continued to wear hearing aids issued by VA in June 2009. He denied otalgia, otorrhea, and vertigo. The audiometric data indicates right ear puretone thresholds of 50 decibels, 55 decibels, 70 decibels, 75 decibels, and 85 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Left ear audiometric data indicates left ear puretone thresholds at 50 decibels, 60 decibels, 70 decibels, 75 decibels, and 80 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Puretone threshold averages (the average of puretone thresholds from 1000 through 4000 Hertz) were 71 decibels for the right ear and 71 decibels for the left ear. The Veteran's right ear speech discrimination was noted as 72 percent; his left ear speech discrimination was noted as 80 percent. See VA audiological evaluation dated August 20, 2011. A puretone threshold average of 71 decibels in the right ear and 71 decibels in the left ear with speech discrimination at 72 percent and 80 percent in the right and left ears respectively is assigned numeric designations of VI for the right ear and IV for the left ear using table VI. The point where designations V and IV meet in Table VII yield a 20 percent disability rating. See 38 C.F.R. § 4.85, DC 6100. However, as the August 2011 puretone thresholds reflect an exceptional pattern of hearing impairment, bilaterally, see 38 C.F.R. § 4.86(a), Table VIa provides a higher numeral for the Veteran's left ear hearing loss, specifically VI for the right ear and VI for the left ear. The point where designations VI and VI meet in Table VII yields a 30 percent disability rating. See 38 C.F.R. § 4.85, DC 6100. During a January 2014 VA outpatient audiology consultation, the Veteran denied otalgia, otorrhea, vertigo, and head trauma. The Veteran endorsed bilateral tinnitus. The diagnosis was moderate to severe right ear sensorineural hearing loss, and moderately severe to severe left ear sensorineural hearing loss. The VA audiologist noted that audiometric testing was done with a puretone average of 64 decibels, bilaterally, although specific puretone data for each frequency 1000 to 4000 Hertz was not noted. The Maryland CNC word recognition scores were 68 percent for the right ear and 72 percent for the left ear. Absent evidence of exceptional patterns of hearing loss during the January 2014 evaluation, a puretone threshold average of 64 decibels in the right ear and 64 decibels in the left ear with speech discrimination at 68 percent and 72 percent in the right and left ears respectively is assigned numeric designations of V for the right ear and V for the left ear. The point where designations V and V meet in Table VII yield a 20 percent disability rating. See 38 C.F.R. § 4.85, DC 6100. A March 2014 VA audiology note indicates that the Veteran received new hearing aids. It was noted that the hearing aids were a good fit with no feedback. On examination, the Veteran's tympanic membranes were intact. In February 2015, the Veteran was afforded a VA audiological examination. The examiner noted a diagnosis of bilateral sensorineural hearing loss. Regarding functional effects of the Veteran's hearing loss, the VA examiner noted the Veteran's report that "he has difficulty communicating with his family, especially if there is background noise. He annoys people with his incorrect responses and because he has to have them repeat themselves." Although the examiner recorded audiometric data reflecting puretone thresholds, she concluded that the documented puretone tests results were not valid for rating purposes because they were "inconsistent with organic hearing loss." Notably, the examiner stated that she performed puretone testing three times with inconsistent results. The Veteran's right ear speech discrimination was noted as 58 percent; his left ear speech discrimination was noted as 54 percent, with the examiner noting that the speech discrimination scores were appropriate for this Veteran. See VA hearing loss examination dated February 25, 2015. Nevertheless, as the examiner determined that the puretone data is not valid, the February 2015 VA examination report is inadequate for rating purposes. The Veteran's July 2015 appeal brief asserts that the Veteran is entitled to a 40 percent rating for bilateral hearing loss on the basis of a May 2015 VA examination. However, the VA examination reflecting a receipt-date of May 2015 is a duplicate of the February 2015 VA examination, shown above to be inadequate for rating purposes. The Veteran again underwent a VA audiological examination in October 2017. The diagnosis was bilateral sensorineural hearing loss. the VA examiner noted the Veteran's report that he has difficulty hearing in noisy environments or group situations, which necessitated people all the time repeating what they said, and as a result he does not like to go out with others because he is unable to hear them. The October 2017 audiometric data indicates right ear puretone thresholds of 70 decibels, 70 decibels, 80 decibels, 90 decibels, and 55 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Left ear audiometric data indicates left ear puretone thresholds at 70 decibels, 75 decibels, 85 decibels, 85 decibels, and 90 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Puretone threshold averages (the average of puretone thresholds from 1000 through 4000 Hertz) were 84 decibels for the right ear and 84 decibels for the left ear. The VA examiner noted that the use of speech discrimination scores was not appropriate for the Veteran because of problems that made combined use of puretone average and speech discrimination scores inappropriate. See VA hearing loss examination dated October 23, 2017. Notwithstanding that the October 2017 puretone thresholds reflect an exceptional pattern of hearing impairment, bilaterally, see 38 C.F.R. § 4.86(a), where, as here, speech discrimination scores are unavailable, the puretone threshold average of 84 decibels in the right ear and 84 decibels in the left ear are each assigned numeric designations of VIII under Table VIa. 38 C.F.R. § 4.85(c). The point where designations VIII and VIII meet in Table VII yield a 50 percent disability rating. See 38 C.F.R. § 4.85, Tables VIa and VII, DC 6100. During a November 2017 VA ear conditions examination, the examiner noted diagnoses of hearing loss and tinnitus. The Veteran was negative for vestibular conditions, and the examiner noted that she observed no unsteadiness, dizziness, or loss of balance during the examination. The Veteran reported that he was employed in small engine repair and that he was unable to hear customers and did not understand what was being said to him, and his wife had to help him in the business. He said he lost two to four weeks of work time over the past twelve months, although the reason for the loss of work time was not indicated. See VA ear conditions examination dated November 18, 2017. During a March 2018 VA outpatient appointment, a VA social worker noted that the Veteran said his wife has to do his "hearing" for him because he was so hard of hearing. During an April 2018 VA mental health evaluation, the Veteran said his wife is his interpreter due to his hearing loss. He said he had difficulties hearing the television and when he raised the volume loud his family would get upset with him, and that these difficulties have affected his family life and his professional life. He has had difficulties communicating with his children and grandchildren. His said his voice is loud, which bothered his granddaughters because they are sensitive to loud sounds. Correspondence from non-VA audiologist M.N. received May 2018 includes a favorable etiology opinion regarding the Veteran's hearing loss and tinnitus, and notes that the Veteran had no history of balance disorders or vertigo. A VA ear conditions DBQ that appears to have been submitted with the correspondence is undated and unsigned and therefore inadequate for rating purposes. A May 2018 audiological evaluation by M.N., who is a state licensed audiologist, notes that the Veteran reported he had been wearing hearing aids for about 15 years, but he has difficulty hearing in background noise. He also endorsed constant tinnitus that could impair his sleep. M.N.'s evaluation indicates right ear puretone thresholds bilaterally but does not clearly reflect puretone threshold averages that are consistent with the puretone data. See 38 C.F.R. § 4.85(d) (sum of puretone thresholds at 1000, 2000, 3000, and 4000 Hertz divided by four). Additionally, the May 2018 audiological evaluation form does not reflect that Maryland CNC testing was used to obtain the speech recognition scores. As such, the examination is inadequate for VA purposes. See Audiologic Report dated May 1, 2018 from audiologist M.N. Therefore, the May 2018 audiological evaluation is inadequate for rating purposes. Additionally, as M.N.'s assertion that the Veteran has no history of balance disorders or vertigo is inconsistent with the prior record, the May 2018 opinion is assigned no probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-02 (2008). A September 2018 VA social work assessment reflects that the Veteran said when he is out in the community, extra noises drown out in his head. He gets frustrated because he perceives that he must yell for people to hear him, and when he does this people think he's yelling at them and they become upset. During an April 2019 VA mental health outpatient appointment, the Veteran said his hearing loss caused problems in his interactions with people because they become upset with him over his difficulty understanding them. He described difficulties hearing the television and when he increases the TV volume his family becomes upset with him. He said he experienced difficulties communicating with his children and grandchildren. Treatment notes from a June 2019 VA otolaryngology consultation show that the Veteran continued to wear hearing aids. He said he hears "OK" one-on-one, but when more than one person is talking, he has trouble understanding. On examination, the Veteran's external auditory canals were normal, and his tympanic membranes were without effusion or signs of infection. The Veteran underwent a VA audiological examination in February 2020. The diagnoses included right and left ear sensorineural hearing loss, and tinnitus. The Veteran reported that he has severe difficulty hearing and communicating at all times, that he was unable to hear much, even when using a hearing aid, and his hearing loss impacted his relationship with his children. The audiometric data indicates right ear puretone thresholds of 70 decibels, 75 decibels, 80 decibels, 90 decibels, and 95 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Left ear audiometric data indicates left ear puretone thresholds at 70 decibels, 80 decibels, 95 decibels, 100 decibels, and 100 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. Puretone threshold averages (the average of puretone thresholds from 1000 through 4000 Hertz) were 85 decibels for the right ear and 94 decibels for the left ear. The Veteran's right ear speech discrimination was noted as 12 percent; his left ear speech discrimination was noted as 14 percent. Regarding the functional impacted of the Veteran's hearing loss, the examiner noted that the Veteran has severe difficulty hearing and communicating at all times during daily and work activities. See VA hearing loss examination dated February 12, 2020. A puretone threshold average of 85 decibels in the right ear and 94 decibels in the left ear with speech discrimination at 12 percent and 14 percent in the right and left ears respectively is assigned numeric designations of XI for the right ear and XI for the left ear. The point where designations XI and XI meet in Table VII yield a 100 percent maximum schedular disability rating. See 38 C.F.R. § 4.85, DC 6100. The Board notes that while the February 2020 puretone thresholds reflect an exceptional pattern of hearing impairment, bilaterally, see 38 C.F.R. § 4.86(a), Table VIa does not provide a schedular rating higher than 100 percent. See 38 C.F.R. § 4.85, DC 6100. The Veteran underwent a VA ear conditions examination in February 2021. The Veteran reported that he believed his vertigo caused his falls, he avoided using stairs and long steps or going anywhere for fear of falling, and he avoided taking walks. Additionally, the Veteran's spouse assisted him in steadying himself. See VA ear conditions examination dated February 4, 2021. The examiner opined that vertigo is a symptom not a diagnosis, yet ultimately rendered a diagnosis of vertigo. While the language used by the examiner is conflicting, the examiner's likely intention of stating that vertigo may be a symptom of hearing loss is reflected in his specific diagnosis of vertigo, his statement that the Veteran "has vertigo," and his opinion that the Veteran's bilateral hearing loss caused vertigo. See VA medical opinion dated February 4, 2021 at pg. 4. The February 2021 VA medical opinion is competent, credible and probative: It was authored by a licensed doctor who reviewed the Veteran's claims file and was therefore familiar with the Veteran's symptoms, diagnoses, and treatment of his hearing loss and vertigo; the opinion was based on examination and interview of the Veteran and review of the evidence of record as well as the Veteran's lay statements. The opinion is consistent with the medical evidence of record and contains clear conclusions with supporting data connected by a reasoned medical explanation. See Nieves-Rodriguez, 22 Vet. App. at 301-02. Accordingly, the Board finds the February 2021 medical opinion highly probative, competent, and persuasive medical evidence in this case. On review, the Board has considered the Veteran's reports of difficulty hearing, including in noisy environments and group situations. Such statements are competent inasmuch as they reflect observable symptoms of hearing loss. See Layno, 6 Vet. App. at 469. The Board finds that the functional effects of the Veteran's bilateral hearing loss, including difficulty hearing other people, impaired communication, and poor social interactions are contemplated by the schedular criteria, including the criteria reflecting exceptional hearing patterns, because they describe consequences of decreased hearing ability. As the Court discussed in Doucette, such difficulties are contemplated by the schedular rating criteria for hearing loss. Indeed, in Doucette, the Court held "that the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday work environment, as these are precisely the effects that VA's audiometric tests are designed to measure. Thus, when a claimant's hearing loss results in an inability to hear or understand speech or to hear other sounds in various contexts, those effects are contemplated by the schedular rating criteria." Doucette, 28 Vet. App. at 369. The Board acknowledges that throughout the initial rating period, the evidence shows a significant decrease in bilateral hearing acuity as reflected in the puretone data and speech recognition scores. However, the Veteran is in receipt of increased schedular ratings based on this additional loss of hearing acuity as reflected in the staged ratings commencing November 24, 2008 (10 percent), September 16, 2010 (20 percent), August 20, 2011 (30 percent), October 23, 2017 (50 percent), and February 12, 2020 (100 percent). Therefore, the Board finds that the Veteran's symptomatology is contemplated by the rating criteria which are adequate to rate the disability and that related factors such as marked interference with employment and frequent hospitalizations due to hearing loss are not shown. The Board notes that notwithstanding the Veteran's hearing difficulties, as reflected in his lay statements discussed above, he maintains communication with his spouse, children, and grandchildren, and there is no indication of significant impairment resulting from his hearing loss affecting his ability to perform the activities of daily living. Furthermore, while his hearing acuity has significantly decreased since the commencement of the rating period in 2008, the Veteran has indicated his biggest challenge to communication is that he must ask people to repeat themselves. A veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the ratings of the individual disabilities does not capture all the service-connected disability experienced. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Here, the Board does not find any symptomatology described due to the Veteran's bilateral hearing loss disability that is not contemplated by the rating schedule which assigns ratings based on decreased hearing ability. The Veteran's hearing loss has not required burdensome medical care or similar impairment in daily life. While the Veteran's hearing loss requires the use of hearing aids, and his impression of their effectiveness has varied, the devices have not been shown to otherwise interfere with his daily functioning or impairment in any significant way. The record does not reflect an exceptional circumstance such as marked interference with employment or frequent periods of hospitalization due to the Veteran's bilateral hearing loss. 38 C.F.R. § 3.321. Notably, over the many years that this claim has been pending, including two appeals to the Court and numerous Board remands, neither the Veteran nor his representative have submitted evidence that tends to demonstrate such exceptional circumstances. See Fagan, supra. The Court in Doucette observed that a hearing loss claimant could provide evidence of symptoms that may warrant an extraschedular rating. Id. at 371. The Veteran has, throughout the rating period, reported dizziness and unsteadiness, symptoms the February 2021 VA examiner attributed to a vestibular disorder characterized as vertigo. On this basis, VA granted service connection for vertigo and assigned a separate 30 percent rating for the disorder under Diagnostic Code 6204 from the commencement of the rating period. See Rating Decision dated August 20, 2019. While the February 2021 VA opinion reflects that the Veteran's vertigo was proximately caused by his hearing loss, the examiner attributed the Veteran's dizziness and unsteadiness to the vestibular disorder vertigo, not hearing loss. To the extent that the Veteran has attributed symptoms of vertigo to hearing loss, see Correspondence received September 17, 2010, he is certainly competent, as a lay person, to report observable symptoms. See Layno, 6 Vet. App. at 469-70. (1994). However, the Veteran is not competent to provide an actual diagnosis or an etiological opinion, as it requires specific medical knowledge and training which he is not shown to possess. Additionally, VA regulations provide that when a Veteran has multiple service-connected disabilities and none are rated compensable, a 10 percent rating may be assigned when it is shown that the disabilities clearly interfere with normal employability. This rating may not be combined with any other. 38 C.F.R. § 3.324. Here, however, at least two of the Veteran's service-connected disabilities, bilateral hearing loss and vertigo, have been rated compensable from the commencement of the period on appeal. As such, he is not eligible for a separate 10 percent rating based on multiple uncompensated disabilities at any time during the period on appeal. 38 C.F.R. § 3.324. In sum, the evidence is against a finding that the Veteran's bilateral hearing loss disability causes average impairment of earning capacity beyond the ratings currently in effect, and an extraschedular rating for bilateral hearing loss is not warranted. 38 C.F.R. § 3.321(b)(1); see Thun, supra; see Doucette, supra. The Board finds that the preponderance of the evidence is against the claim of entitlement to an increased rating for service-connected bilateral hearing loss on an extraschedular basis, and that claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020). Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017). TDIU Entitlement VA will grant TDIU benefits when the evidence shows that the veteran is precluded, by reason of service-connected disabilities, from securing and following substantially gainful employment consistent with a veteran's education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Here, the Board, in its December 2019 remand determined that a claim for entitlement to a TDIU was raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453, 54 (2009) (holding that a request for a TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation). The Board instructed the AOJ to provide the Veteran with a TDIU application form (VA Form 21-8940), which it did in December 2019, inviting the Veteran to submit the completed form. See VA correspondence dated December 27, 2019. In its July 2020 remand, the Board again instructed the AOJ to provide the Veteran with a TDIU application form, and the AOJ did so, again inviting the Veteran to submit the completed form. See VA correspondence dated August 5, 2020. To date, the Veteran has not completed and returned the VA Form 21-8940. Furthermore, the record simply does not contain enough information for the Board to find equipoise that the Veteran's service-connected disabilities preclude substantially gainful employment and there is conflicting evidence regarding the Veteran's work and educational background a completed VA Form 21-8940 could serve to clarify. The Veteran's failure to provide the necessary information for adjudication of a TDIU deprives the Board of information as to the Veteran's work history and educational background, which is necessary for adjudication of a claim for entitlement to a TDIU. The Board emphasizes that the duty to assist is a two-way street. Due to the Veteran's failure to provide VA with necessary information to adjudicate his claim despite multiple attempts to obtain such information, there is no further duty to assist. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Veteran has failed to cooperate with VA's attempts to develop the claim for entitlement to a TDIU, and the record that is before the Board does not demonstrate that the Veteran's service-connected disabilities preclude him from securing or following a substantially gainful occupation. Thus, the claim for TDIU must be denied. B. G. LeMoine Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell, 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.