Citation Nr: 22015668 Decision Date: 03/18/22 Archive Date: 03/18/22 DOCKET NO. 17-28 642A DATE: March 18, 2022 ORDER Entitlement to an initial disability rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial compensable disability rating prior to June 26, 2017, and a disability rating in excess of 30 percent thereafter for service-connected tension headaches is denied. Entitlement to an initial compensable rating for left ear hearing loss is denied. REMANDED Entitlement to service connection for a low back disability, to include as secondary to service-connected Crohn's disease, is remanded. Entitlement to service connection for right ear hearing loss, to include as secondary to service-connected left ear hearing loss, is remanded. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Throughout the entire initial rating period on appeal the Veteran's service-connected PTSD has not resulted in occupational and social impairment with deficiencies in most areas of life. 2. Prior June 26, 2017, the Veteran's tension headaches disability was manifested by headache pain that was not prostrating occurring once or twice a week. 3. From June 26, 2017, the Veteran's tension headaches disability was manifested by characteristic prostrating attacks of headache pain occurring once a month; however, his headaches have not been productive of severe economic inadaptability. 4. Throughout the entire initial rating period on appeal the Veteran's left ear hearing disability was manifested by hearing acuity no worse than Level I impairment. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 50 percent for service-connected PTSD are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9411 (2021). 2. Prior to June 26, 2017, the criteria for a compensable disability rating for service-connected tension headaches are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8100 (2021). 3. From June 26, 2017, the criteria for an initial disability rating in excess of 30 percent for service-connected tension headaches are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8100 (2021). 4. The criteria for an initial compensable rating for service-connected left ear hearing loss are not met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.85, 4.86, Diagnostic Code 6100 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 2000 to October 2011. This matter comes before the Board of Veterans' Appeals (Board) from April 2013 and August 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In September 2019, the Board remanded the instant claims to afford the Veteran new VA examinations to ascertain the current severity of his PTSD and tension headaches disabilities, and to determine the likely etiology of his low back and right ear hearing loss disabilities. The Veteran underwent a VA examination in March 2020, May 2021, and October 2021; and the examination reports and opinions are of record and have been reviewed. The Board finds substantial compliance with its September 2019 remand in regard to the VA PTSD and headaches examinations. However, for reasons set forth in the Remand section, below, the Board finds there has not been substantial compliance with the remand regarding the low back and right ear hearing loss opinions. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand); Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). 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 the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability 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 low rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. 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 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different Diagnostic Codes is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several DC; however, the critical element in doing so is that none of the symptomatology is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The assignment of a particular diagnostic code (DC) is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One DC may be more appropriate than another based on such factors as an individual's relevant medical history, the DC, and the demonstrated symptomatology. Any change in a DC by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Where the veteran is appealing the rating for an already established service-connected condition, his or her present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). 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). 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). The claimant bears the burden of presenting and supporting his or her claim for benefits. 38 U.S.C. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). PTSD Rating Criteria for Psychiatric Disorders The RO assigned an initial 50 percent disability rating for the Veteran's PTSD under Diagnostic Code 9411 based on occupational and social impairment with reduced reliability and productivity. 38 C.F.R. § 4.130, Diagnostic Code 9411; Rating Decision dated May 2, 2017. The Veteran claims that a higher rating is warranted. Under the General Rating Formula for Mental Disorders, a 50 percent rating is warranted 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted if the evidence establishes there is 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 work like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating (total occupational and social impairment) is warranted 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. Id. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact a Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Board recognizes that the United States Court of Appeals for Veterans Claims (Court) in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA's general Rating Formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the Court further indicated that, without those examples, differentiating between rating evaluations would be extremely ambiguous. In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale, and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating in cases where the DSM-5 applies when the appeal was certified after August 4, 2014. Here, the Veteran's claim for service connection was submitted in October 2011, and his claim for an increased rating was certified to the Board in March 2018, and as such, only DSM-5 applies. Rating Analysis Turning to the record, the Board notes that during a VA social work evaluation in November 2011, the Veteran denied depressed mood, loss of interest or pleasure, and insomnia. During a PTSD screening, he endorsed flashbacks triggered by loud noises, avoidance efforts, poor concentration, hypervigilance, and exaggerated startle response, but denied recurrent nightmares, intrusive recollection of events, difficulty falling or staying asleep, irritability and anger. He endorsed memory problems daily and sleep problems. He said he avoided tobacco and drug use, and tried to avoid alcohol due to his Crohn's disease. He said he worked in logistics in the military but was currently unemployed. The Veteran said he earned a B.S. degree in criminal justice in 2010 and would be returning to college studies to obtain a master's degree in business administration (MBA). The Veteran said his strengths were his ability to get along with people, and he enjoyed giving back to the community, citing his involvement in Toys for Tots, charity work, and community involvement. On examination, the Veteran was alert and oriented in all spheres, his mood and affect were intact, his thought process was engaged, speech clear, and there were no cognitive deficiencies or delusional thoughts or content present. It was noted that the Veteran appeared to be well rounded, articulate, highly motivated, and focused. He denied depression and sadness. The Veteran denied suicidal ideation and past history of suicide attempts. See VA Social Work Initial Evaluation Note dated November 16, 2011. May 2012 VA treatment notes reflect that the Veteran denied depression, and anxiety. He endorsed insomnia but denied loss. The Veteran endorsed irritability, difficulty concentrating, anhedonia, fatigue, emotional numbing, and easy startle reflex to loud noises. He denied suicidal and homicidal ideations. He was negative for psychosis and mania. He said he had not been able to find work, and this was causing some stress with his wife. He said he missed the purpose he felt while in the Marine Corps. On examination, the Veteran was alert and oriented in all spheres; fairly groomed; and his speech was clear, coherent, and of regular rate. His mood and affect were depressed. His thought processes were goal directed, and his thought content was negative for delusions. He denied perceptual disturbances, and was negative for internal stimuli. His insight and judgment were fair. The diagnoses were major depressive disorder, anxiety, and possible PTSD. A May 2012 VA psychiatry note shows that the Veteran complained of anger, irritability, insomnia, depressed mood, poor attention and concentration, and lack of motivation. He found adjusting to civilian life very difficult and said he lacked a sense of purpose. He was worried about his father who was hospitalized following surgery. On examination, the Veteran was casually attired, well groomed, and had good personal hygiene. His mood and affect were mildly depressed. There were no gross memory or cognitive impairments. His speech reflected good articulation and fluency. His thought processes were well organized with no circumstantiality or thought blocking, and his thought content was devoid of paranoid thinking or suspiciousness. His insight and judgment were described as good. He was negative for delusions and audio/visual hallucinations. The Veteran denied suicidal and homicidal ideations. A statement received from the Veteran's spouse in July 2012 reflects that he was affected emotionally by the loss of his job in the Marine Corps due to health conditions, and that he was "trying hard" to complete his college degree. She said, "He spends hours [at] the computer doing heavy typing, papers, essays ..." August 2012 VA social work notes reflect that the Veteran was alert and oriented in all spheres, stable, and presented with euthymic mood and congruent affect. His though process and speech were linear. The Veteran had good hygiene. He denied any thoughts of self-harm. During an October 2012 VA outpatient appointment, the Veteran denied depression, anxiety, suicidal or homicidal ideation, and substance abuse. November 2012 VA psychiatry notes reflect diagnoses of major depressive disorder, anxiety, and PTSD. The Veteran said he had been employed for one year, and was having difficulty adjusting to civilian life. The Veteran was attending college, said he enjoyed going to school, and said he expected to graduate in May with an MBA. He said he felt depressed about being unemployed, his father's recent death, worrying about his mother who was homeless and had no income, and taking care of his children while his wife worked. He endorsed irritability, difficulty concentrating, lack of motivation, insomnia, being jumpy and on-guard, and anxiety. On examination, the Veteran was casually attired, well groomed, and had good hygiene. His speech reflected good articulation and fluency. His mood and affect were depressed. There were no gross memory or cognitive impairments. His thought processes were well organized, with no circumstantiality or thought blocking. His thought content was devoid of paranoid thinking or suspiciousness. He was negative for delusions. His insight and judgment were good. He denied suicidal and homicidal ideation. He was negative for audio/visual hallucinations. In January 2013, the Veteran was afforded a VA PTSD examination, at which time the VA examiner noted diagnoses of PTSD and major depressive disorder. In terms of social impairment, the examiner noted that the Veteran reported moving from Colombia with his parents at age nine, and he was raised by both parents. He characterized his childhood as good, but said being away in the Marine Corps for 12 years he was not close to his family. He said he had been married for ten years, and that his relationship with his spouse was "up and down" since leaving the service. He said he and his spouse have two children ages five and nine. He said he had friends from high school with whom he talked occasionally. His leisure activities included going to a gym, although he was unable to at the time of the examination because of symptoms of Crohn's disease. The Veteran denied psychiatric hospitalizations and suicide attempts. In terms of occupational impairment, the examiner noted that the Veteran was unemployed, and that the Veteran stated he had been unable to find employment since leaving the service, but that he had earned a bachelor's degree in criminal justice, and he was enrolled in college pursuing a master's degree in business administration. The examiner identified symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner noted that the Veteran reported having suicidal ideation "1 year ago," however, during the examination the Veteran was negative for suicidal ideation. The examiner concluded that the Veteran's PTSD and MDD resulted in occupational and social impairment with reduced reliability and productivity. The examiner determined that the Veteran was capable of handling his financial affairs. See VA PTSD examination report dated January 25, 2013. January 2013 VA psychiatry notes reflect that the Veteran endorsed difficulty concentrating, irritability, and insomnia. He noted a lack of motivation due to a recent flare-up of Crohn's disease. The Veteran said he continued to attend college, said he was doing well in school, and expected to graduate in May, earning an MBA. On examination, the Veteran was casually attired, well groomed, and had good hygiene. His speech reflected good articulation and fluency. His mood and affect were mildly depressed. There were no gross memory or cognitive impairments. His thought processes were well organized, with no circumstantiality or thought blocking. His thought content was devoid of paranoid thinking or suspiciousness. He was negative for delusions. His insight and judgment were good. He denied suicidal and homicidal ideation. He was negative for audio/visual hallucinations. An April 2013 VA psychiatry note shows that the Veteran reported depressed mood, insomnia, and poor concentration; and he was concerned about finding a job after graduation from a college MBA program in May. The Veteran was negative for suicidal and homicidal ideation. VA psychiatry notes dated June 2013 reflect that the Veteran reported having difficulty adjusting to civilian life after service, he was experiencing marital problems due to being unemployed since his separation from service in 2011, and financial pressures. He reported difficulty concentrating, lack of motivation, irritability, insomnia, and flashbacks triggered by events depicted in news reports. He said he had not slept more than three hours a day for two weeks. He said he graduated from college in May with an MBA but was feeling discouraged and mildly depressed about his chances of finding a job. He said his wife was working and he stayed at home with their children. On examination, the Veteran was casually attired, well groomed, and had good personal hygiene. His mood and affect were mildly depressed. There were no gross memory or cognitive impairments. His speech reflected good articulation and fluency. His thought processes were well organized, and he was negative for circumstantiality and thought blocking. His thought content was devoid of paranoid thinking and suspiciousness. He was negative for delusions and audio/visual hallucinations. His insight and judgment were good. The Veteran denied suicidal and homicidal ideations. The diagnoses were major depressive disorder, anxiety, and PTSD. In statements received in April 2014, the Veteran stated that he was taking medication for PTSD but still battling depression and "I still have issues trying to cope with my daily life." During a private outpatient appointment in June 2014 for Crohn's disease, the Veteran denied drinking alcohol over the past year. On examination, the Veteran was in no acute distress, he was well developed and well nourished. June 2014 VA psychiatry notes reflect that the Veteran reported being unemployed after working up to 70 hours a week over the past nine months in construction, and he was looking for a new job. He denied feeling depressed and denied suicidal thoughts, said he was worried about finances. The Veteran complained of poor sleep and flashbacks triggered by events depicted in the news. He said he had not slept more than three hours a day for two weeks. On examination, the Veteran was casually attired, well groomed, and had good personal hygiene. There were no gross memory or cognitive impairments. His speech reflected good articulation and fluency. His mood was neutral, and his affect was anxious. His thought processes were well organized, and he was negative for circumstantiality and thought blocking. His thought content was devoid of paranoid thinking and suspiciousness. He was negative for delusions and audio/visual hallucinations. His insight and judgment were good. August 2014 and October 2014 private treatment notes reflect that the Veteran denied a history of depression and sleep disorders. He denied use of alcohol and a history of drug or alcohol addiction. VA psychiatry notes from August to October 2014 reflect that the Veteran reported being separate from his wife for financial reasons. He was living with his mother and his wife, and their two young children were living with her parents, which was causing marital stress, but he said that was improving. He noted his graduation from a college MBA program, and said he was working part time supervising construction while looking for a job in logistics. He expressed frustration at not being able to find a different job after graduation. He endorsed insomnia at night and tiredness and lethargy during the day, although he said that was improving. On examination, the Veteran was casually attired, well groomed, and had good personal hygiene. There were no gross memory or cognitive impairments. His speech reflected good articulation and fluency. His mood and affect were mildly depressed. His thought processes were well organized, and he was negative for circumstantiality and thought blocking. His thought content was devoid of paranoid thinking and suspiciousness. He was negative for delusions and audio/visual hallucinations. His insight and judgment were good. The Veteran denied a history of suicidal ideation and current suicidal ideation and homicidal ideation. December 2014 VA outpatient notes reflect that the Veteran denied depression, anxiety, and suicidal ideation. On examination, the Veteran's affect was appropriate, and he answered questions appropriately. Private treatment notes from December 2014 show that the Veteran denied a history of depression and sleep disorders. He denied use of alcohol over the past year and a history of drug or alcohol addiction. January 2015 VA psychiatry notes reflect the Veteran's endorsement of irregular sleep, being more withdrawn, no friends, and less interest in things he used to enjoy. He said he missed being in the military. On examination, the Veteran was oriented in all spheres, he was well groomed, calm, and cooperative. His mood was mildly depressed, and his affect was full and appropriate. He denied suicidal ideation. His long and short term memory were intact. The diagnosis was depressive disorder. May 2015 private treatment notes reflecting examination for shoulder pain show that the Veteran denied a history of depression and sleeping disorders. He denied use of alcohol and a history of drug or alcohol addiction. May 2015 VA treatment notes reflect that the Veteran was alert and oriented in all spheres. July 2015 VA alcohol and depression screenings were negative. In August 2015, the Veteran underwent a psychological evaluation by non-VA psychologist W.A., Psy.D. In the evaluation report, W.A. noted that she interviewed the Veteran and his spouse, the Veteran completed cognitive and personality assessments, and she reviewed a copy of the Veteran's DD Form 214 he provided. It was noted that the Veteran was not taking psychiatric medications as prescribed, and he was not at that time receiving treatment for PTSD. The diagnoses were PTSD, panic disorder, depressive disorder, and alcohol abuse. The Veteran endorsed hypervigilance, exaggerated startle response, recurrent intrusive thoughts, recurrent nightmares, persistent avoidance of thoughts and conversations about traumatic experiences, cognitive responses to trauma cues in reaction to smells of gunpowder and burned rubber, markedly diminished interest and participation in significant social activities, anhedonia, feelings of detachment from others, and restricted range of effect, insomnia, irritability, and angry outbursts. The Veteran's spouse said she perceived her husband to be "angry all the time," explaining that he is "angry at everything." The Veteran said he had concentration and cognitive difficulties, including diminished ability to think and indecisiveness, and W.A. noted that concentration problems were "markedly apparent during the interview." W.A. noted that the Veteran's responses to the Montreal Cognitive Assessment indicated significant cognitive difficulties. The Veteran endorsed having suicidal ideation at times. He denied homicidal ideation. The Veteran endorsed anxiety attacks occurring approximately once to twice weekly of uncertain duration, and he avoided situations which might spark an anxiety attack. In terms of social impairment, the examiner noted that the Veteran reported avoiding being "involved with a lot of people," had no emotional close relationships, and his spouse said the Veteran tended to keep to himself. The Veteran said he and his spouse have two children, ages seven and twelve, who resided at home. His spouse said the Veteran was short-tempered at times, citing his "Marine Corps mentality" as the cause. The Veteran denied difficulties with anger; however, his spouse described verbal outbursts by the Veteran and said he would "throw things around." She described an incident three months earlier in which the Veteran "nearly left his vehicle" after another person spat on a vehicle window. At the time of the evaluation, the Veteran said he was not residing in the marital home to avoid conflict with his spouse and was living with his mother. The Veteran said he drank during weekends and experienced blackouts, and his spouse said he would consume a large bottle of wine alone. He denied a history of drug use. In terms of occupational impairment, the examiner noted that the Veteran reported that he completed college classwork during military service through on-line courses, earning an associate degree in 2008, and a bachelor's degree in 2010. The Veteran said he was a sergeant in the Marine Corps and has difficulty with authority figures in work environments. He said differences in accommodating the demands of his job caused frustration for him. After separation from service, the Veteran said he was employed by two construction companies over a period of 18 months, with employment ending in both instances due to being laid off. He said he worked alone while in construction and noted that he had trouble accommodating a civilian work ethic. Thereafter, he worked for another construction company but left due to limited pay, and was then unemployed while he earned an MBA, attending classes and receiving his diploma in 2013. He said he was able to tolerate the classroom setting because there were few individuals present. He said he disliked group projects because he had difficulties being in contact with others he did not know and being in public environments where his student group would meet. At the time of the evaluation, the Veteran said he was working for a telecommunications company. W.A. noted that the Veteran's Minnesota Multiphasic Personality Inventory (MMPI-2) profile was valid for interpretation and explained what the profile indicated generally among those whose profiles were evaluated but did not specify the characteristics particular to the Veteran. On examination, the Veteran was oriented to all spheres. His speech was unusually soft but normal in terms of content. His mood was "okay," and his affect was somewhat blunted, but stable and appropriate for the discussion at all times during the evaluation. Form of thought was remarkable for circumstantiality. His thought content was within normal limits. Suicidal and homicidal ideation were not present. He was negative for perceptual abnormalities. W.A. concluded that the Veteran's "impulse control, as demonstrated by his history of alcohol abuse, irritability, and angry outbursts, appeared to fall below normal limits. See Private Psychological Evaluation by W.A., Psy.D. dated August 1, 2015. May 2016 private treatment notes reflect that the Veteran denied drinking alcohol over the past year. August 2016 private treatment notes show that the Veteran was oriented to time, place, and person. He was adequately groomed, and his mood and affect were appropriate. He denied a history of depression, sleeping disorders, drug or alcohol addiction, and he denied current use of alcohol. On examination, the Veteran was oriented to time, place, and person, he was in no acute distress, and he was adequately groomed. His mood and affect were appropriate. March 2019 private treatment notes reflect that the Veteran denied a history of depression, a history of drug or alcohol addiction, and he denied drinking alcohol over the past year. He denied sleeping disorders. On examination, the Veteran was oriented to time, place, and person. He was adequately groomed. His mood and affect were appropriate. Treatment notes from an October 2019 VA outpatient appointment reflect that the Veteran endorsed occasional nightmares and flashbacks, but he denied suicidal thoughts. He denied a need for psychiatric treatment. The Veteran's mood and affect were normal. His PHQ-2 depression screening score was "0" which was negative. A PTSD screening score was "0" which was negative. November 2019 private treatment notes reflect that the Veteran denied a history of depression, drug or alcohol addiction, and he denied current use of alcohol. He denied sleeping disorders. On examination, the Veteran was oriented to time, place, and person. He was adequately groomed. His mood and affect were appropriate. A March 2020 VA social work note shows that the Veteran endorsed anxiety and depression symptoms. The Veteran said he was last seen in 2015 for psychiatric treatment and wanted to restart treatment. He reported that he was easily bothered and socially isolated himself. He said he continued to have adjustment difficulties after discharge from the Marine Corps. He said he felt isolated, and became easily annoyed and irritable nearly every day. He said he had been married 17 years, was currently separated, and working full time. He went to a gym for recreation. He endorsed unstable sleep patterns but said he had normal focus and concentration. He denied use of alcohol and tobacco. On examination, the Veteran was oriented to person, place, time, and situation. His speech was clear and coherent and of normal rate, tone, and volume. His mood was apathetic, and his affect was constricted. His thought process was organized, and goal directed. He was negative for delusions. His insight was described as "aware but blames others," and his judgment was good. His attention and concentration were intact. His recent and remote memory were good. He denied suicidal and homicidal ideation. A PHQ-9 depression screening indicated moderately severe depression. The diagnosis was major depressive disorder and possible PTSD. In March 2020, the Veteran underwent a VA PTSD examination, at which time the VA examiner diagnosed PTSD. In terms of social impairment, the examiner noted that the Veteran reported that he and his spouse were separated but they were trying to work on their relationship. He said that although he had some friends, he tended to not want to "hang out" with them, instead keeping to himself. He said that over the past year he had experienced more feelings of depression and anxiety, and stress over eating right to avoid undue symptoms of Crohn's disease. In terms of occupational impairment, the examiner noted that the Veteran said he was working in logistics for a company and that his position allowed him the ability to work alone and not interact with many people, which he described as preferable to him because he sometimes he has difficulty and discomfort being around and interacting with others. On examination, the Veteran was appropriately dressed and groomed, and his attention to hygiene was excellent. His affect and mood were relatively flat. He had good eye contact with the examiner, a rapport was easily established, and his level of engagement with the examiner was described as good. The Veteran denied any suicidal or homicidal ideation, behavior, plan, or intent. The examiner identified symptoms of depressed mood and anxiety. The examiner concluded that the Veteran's PTSD resulted in 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. The examiner determined that the Veteran is capable of handling his financial affairs. See VA PTSD examination report dated March 11, 2020. In April 2020, the Veteran submitted a VA PTSD examination completed by non-VA psychologist, W.A., Psy.D., who noted that she reviewed the Veteran's DD Form 214, rating documentation, and W.A.'s August 2015 evaluation. She recorded diagnoses of PTSD, other specified depressive disorder, and panic disorder, noting that the disorders have overlapping symptoms. W.A. noted that the Veteran reported discontinuing his prescribed psychotropic medications. In terms of social impairment, W.A. noted that the Veteran reported ongoing social isolation and detachment that continued since service. He said he had no close relationships, was anticipating divorce from his wife, and that he is somewhat distanced from his son. In terms of occupational impairment, W.A. noted that the Veteran said he had problems with authority figures, and tended to become agitated and nervous in meetings in occupational and educational settings, he was socially distanced from coworkers, and had overly high expectations from subordinates. He described a pattern of road rage involving verbal outbursts, gesturing, tailgating and cutting off other drivers, and verbal outbursts that resulted in withdrawal. W.A. said the Veteran was unable to describe his typical mood state, consistent with alexithymia, anhedonia, sleep disturbances, and concentration problems that he reported. The Veteran reported fatigue and loss of energy, cognitive difficulties, including the diminished ability to think and indecisiveness. The Veteran reported recurrent thoughts of death, including periodic suicidal ideation, although he denied a history of suicide attempts. W.A. noted that the Veteran reported he continued to experience anxiety attacks, "six or seven times a month." W.A. identified symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; flattened affect; circumstantial, circumlocutory or stereotyped speech; impaired judgment; disturbances of motivation and mood; difficulty establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; and suicidal ideation, and concluded that the Veteran's disorders resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. W.A. determined that the Veteran is capable of handling his financial affairs. See VA PTSD examination report completed by W.A., Psy.D. dated March 11, 2020. In an August 2020 statement from the Veteran's spouse, she said the Veteran was unable to find or keep a job for more than six months because of altercations with superiors. She described how the Veteran's erratic behavior, irritability, anger outbursts, and an inability to express affection resulted in disengagement and deteriorated relationships with her, their son, and the Veteran's friends. She also described the Veteran's aggressive physical behavior during nightmares and how he had to leave an amusement park during a firework display because they reminded him of explosions in Iraq. M.P. said the Veteran took his PTSD medication for a short time and then discontinued them. She said the Veteran suffered from hallucinations and frequent panic attacks, he lacked judgment, and had contemplated suicide. During an October 2020 VA outpatient visit, the Veteran reported insomnia and said he was getting only four to five hours of sleep. He described his mood as "not good," and said he was feeling anxious and irritable. He said he experienced panic attacks three to four times a week. On examination, the Veteran was casually dressed, his hygiene was fair, and he was well groomed. He was alert and oriented to person, place, and time. His mood was depressed, and his affect was congruent with his mood. His speech was of normal volume and rate. His thought processes were organized, and goal directed. He was negative for delusions. There was no evidence of obsessive thoughts or phobias. He denied audio/visual hallucinations. His insight and judgment were good. He denied suicidal and homicidal thoughts. He denied a history of suicide attempt. The assessment was depression, anxiety, and PTSD related symptoms. March 2021 VA psychiatry notes reflect that the Veteran reported experiencing depression and nightmares. He reported his motivation "is there." He said he drank alcohol here and there, but did not smoke cigarettes. He endorsed panic attacks depending on the stressor. On examination, his speech was clear and coherent. His thought process was organized. He was negative for delusions. He was negative for psychosis. He denied suicidal and homicidal thoughts. The diagnostic impression was PTSD and general anxiety disorder. April 2021 VA psychiatry notes show that the Veteran reported experiencing depression and anxiety. He described his motivation as "so-so." He said he walked and ran at times. He said he smoked one to two cigarettes, and drank alcohol here and there. He was negative for psychosis. He denied suicidal thoughts. On examination, his speech was clear and coherent, and his thought process was organized. The diagnostic impression was PTSD and general anxiety disorder. VA psychiatry notes dated May 2021 reflect that the Veteran was feeling less depressed, his sleep had improved, and his mood was more stable but varied. He said he felt anxious at times but was negative for panic attacks. He was negative for suicidal thoughts. On examination, the Veteran's speech was normal, his mood was euthymic, and his affect was congruent with mood. His thought process was goal directed. His thought content was negative for delusions. His insight was intact, and his judgment was good. The diagnoses PTSD and unspecified affective mood disorder. In a December 2021 statement, the Veteran said, "I have been suffering with this condition for years. Extreme anxiety, depression, manic and suicidal thoughts are some of the symptoms/episodes I still experience on a daily basis." In January 2022, the Veteran underwent a psychological evaluation by non-VA psychologist, W.A., Psy.D. In the evaluation report, W.A. noted that she interviewed the Veteran, who "described a pattern of intensifying social isolation and distancing, which he attributed in part to the COVID-19 pandemic." In terms of social impairment, the examiner noted that the Veteran reported that his marriage was "on and off," although he was spending less time at his mother's home. He said his relationships with his children were "a little bit better" because of his presence at home. He noted that he had not had contact with his mother or his aunt since prior to the Thanksgiving holiday. The Veteran described what W.A. characterized as a pattern of road rage involving verbal outbursts, gesturing, tailgating other drivers, and cutting off other drivers; and a pattern of withdrawal at home in response to his anger. The Veteran reported that he consumed alcohol which exacerbated his Crohn's disease. In terms of occupational impairment, the examiner noted that the Veteran reported that he has held five to six jobs since his August 2015 evaluation by W.A., and that he tended to hold jobs for three to four months at a time due to intolerance of coworkers. He said he left his most recent job in October 2021. On examination, the Veteran was initially difficult to engage but eventually warmed to the interview process. His speech was unusually soft but normal in terms of content. His affect was somewhat blunted but stable and appropriate for the topic of discussion at all times. Form of thought was remarkable for circumstantiality. Thought content during the evaluation fell within normal limits despite the Veteran's existential concerns of feeling useless and questioned his reason for being. The Veteran was negative for suicidal and homicidal ideation, and perceptual abnormalities consistent with psychosis. W.A. opined that the Veteran's impulse control, as demonstrated by his history of irritability and angry outbursts, appeared to fall below normal limits. W.A. reported that the Veteran scored 78 on a PCL-5 self-evaluation of PTSD symptoms, and a PHQ-9 self-evaluation for depression score of 26 indicated "severe major depression," and a GAD-7 anxiety evaluation score of 18 indicated "severe anxiety." W.A. concluded that the Veteran is capable of managing his financial affairs. See Private Psychological Evaluation by W.A., Psy.D. dated January 17, 2022. On review of the evidence, both lay and medical, the Board finds that the criteria for a rating higher than 50 percent are not met or approximated for the entire rating period. Objective evaluations throughout the rating period consistently revealed that the Veteran was appropriately dressed and groomed, alert and oriented in all spheres, possessed normal speech, and his judgment and insight were unimpaired. Also, there is no evidence of impaired thought processes or communication, no psychosis, no irrelevant, illogical or obscure speech, no obsessive or ritualistic behavior that interferes with routine activities, no near-continuous panic or depression, and no unprovoked irritability with periods of violence. Though at times the Veteran endorsed diminished memory and concentration, and the August 2015 non-VA psychologist reported that significant cognitive difficulties were indicated, the record overall predominantly reflects objective evidence of unimpaired memory, concentration, and cognitive abilities on examination by VA clinicians or examiners throughout the rating period. Notably, the Veteran reported that he completed a graduate college course during the rating period and was awarded an MBA. While the Veteran described discomfort interacting with other students during his MBA coursework, he nonetheless said he enjoyed attending class, he completed the curriculum, and he received his diploma, which suggest an absence of occupational and social impairment with deficiencies in most areas. While the Veteran's spouse described angry outbursts, there is no evidence that the Veteran has at any time engaged in periods of violence. Regarding the spouse's report of hallucinations experienced by the Veteran, the Board notes that although she may be competent to report such symptoms if directly observable, her observations must be weighed against the entire record, which overwhelmingly demonstrates that on objective examination the Veteran was negative for hallucinations, delusions, and other perceptual abnormalities before and subsequent to her August 2020 report. Additionally, while the Veteran endorsed panic attacks during the rating period, there is no evidence that he experienced near-continuous panic as contemplated by a 70 percent rating. Although the Veteran's treatment records and lay statements during the rating period reflect infrequent endorsements of suicidal ideation, more often than not he denied suicidal ideation or endorsed such symptoms infrequently. The Board recognizes that suicidal ideation is a symptom contemplated by a higher 70 percent or 100 percent disability rating under Diagnostic Code 9411. See Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). In Bankhead, the Court held that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas. Under the specific facts of Bankhead, the claimant was noted to have had recurrent suicidal thoughts and behaviors of varying severity, frequency, and duration throughout the relevant period on appeal. Id. at 19-23. Here, however, the record demonstrates that, more often than not, the Veteran denied suicidal ideation during the appeal period and thus is not shown to be recurrent in nature. As discussed above, the listed symptoms in the rating schedule are meant to be examples of the types of symptoms that an individual at a corresponding level of impairment might experience, and the Board need not find one, or even all, the symptoms listed; the focus is on the level of occupational and social impairment produced. Mauerhan, 16 Vet. App. at 442. On the current record, suicidal ideation in and of itself does not rise to the level of occupational and social impairment with deficiencies in most areas of life as contemplated by the criteria for a higher rating of 70 percent. To the extent that the Veteran contends that his PTSD symptoms are more severe than currently rated, while the Veteran and/or his spouse may be competent to report observable symptoms, see Layno, supra, the Board assigns more probative value to the Veteran's treatment records, which predominantly reflect that he denied suicidal ideation and was entirely negative for hallucinations and other perceptual abnormalities throughout the rating period. As such, the Board assigns more probative weight to the lay history made for treatment purposes than to subsequent statements made for compensation purposes. Harvey v. Brown, 6 Vet. App. 390, 394 (1994). Thus, when taking into consideration the lay assertions of the Veteran and his spouse, as well as the treatment records and VA and non-VA examinations throughout the rating period, at no time do the Veteran's PTSD symptoms more nearly approximate the criteria for a rating higher than 50 percent throughout the rating period on appeal. In sum, the Board concludes that the evidence weighs against a finding that the severity, frequency, or duration of the Veteran's psychological symptoms rise to the level contemplated by a 70 percent rating. Consequently, a higher rating under Diagnostic Code 9411 is not warranted. See 38 C.F.R. § 4.130. Tension Headaches Rating Criteria for Headaches The Veteran's tension headaches disability is rated pursuant to Diagnostic Code 8100, with an initial noncompensable evaluation assigned November 1, 2011 to June 26, 2017, and a 30 percent rating assigned thereafter. The Veteran asserts that his tension headaches are worse than the assigned initial ratings. Under Diagnostic Code 8100, migraine headaches with less frequent attacks than the criteria for a 10 percent rating are rated as non-compensable. Migraine headaches with characteristic prostrating attacks averaging one in two months over the last several months are rated 10 percent disabling. Migraine headaches with characteristic prostrating attacks occurring on an average once a month over last several months are rated 30 percent disabling. Migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability are rated 50 percent disabling. Although the rating criteria do not define "prostrating," according to Dorland's Illustrated Medical dictionary, 32nd Edition (2012), pg. 1531, "prostration" is defined as "extreme exhaustion or powerlessness." Further, "severe economic inadaptability" is also not defined in VA law. See Pierce v. Principi, 18 Vet. App. 440, 446 (2004). In addition, the Court has held that nothing in DC 8100 requires that the claimant be completely unable to work to qualify for a 50 percent rating. Id. It was explained by the Court that if "economic inadaptability" were read to import unemployability, the appellant, should he or she meet the economic-inadaptability criterion, would then be eligible for a TDIU rather than just a 50 percent rating. Id. citing 38 C.F.R. § 4.16. In Pierce, the Court discussed the notion that consideration must also be given as to whether the disability was capable of producing severe economic inadaptability, regardless of whether the condition was actually causing such inadaptability. See Pierce, 18 Vet. App. at 446. In this regard, VA conceded that the words "productive of" could be read to mean either "producing" or "capable of producing." Id. at 446-447. Analysis Turning to the record, the Board notes that VA treatment notes dated November 2011 reflect that the Veteran denied headaches. October 2012 VA treatment notes reflect that the Veteran denied headaches. In a May 2012 statement, the Veteran said he suffered from migraines. In a July 2012 statement, the Veteran's spouse said the Veteran complained of migraines during the day. During a VA examination in January 2013, the Veteran reported experiencing headaches for approximately two years. He described pulsating or throbbing pain in the occipital region of his head, both sides, with pain sometimes mild and sometimes severe, occurring once or twice a week and lasting less than a day. He said the severe headaches were not prostrating and tended to occur once a week. He said taking acetaminophen alleviated his headaches, even the severe ones. He endorsed changes in vision during headaches. He denied prostrating attacks of headache pain. The diagnosis was tension headaches. The examiner opined that the Veteran's headaches did not impact his ability to work. See VA Headaches examination dated January 25, 2013. VA treatment notes dated April 2013 reflect that the Veteran denied headaches. VA treatment notes dated June 2013 reflect that the Veteran denied headaches. In his April 2014 Notice of Disagreement, the Veteran endorsed severe migraines, which he characterized as a side effect of medication. VA and private treatment notes dated June 2014 reflect that the Veteran denied headaches. VA treatment notes dated August 2014 reflect that the Veteran denied a history of headaches. Private treatment notes dated October 2014 and December 2014 show that the Veteran denied a history of headaches. During a private outpatient appointment in May 2015, the Veteran denied a history of headaches. Private treatment notes dated August 2016 show that the Veteran denied a history of headaches. In his June 2017 appeal to the Board, the Veteran said he suffered from migraines "that are hard to cope with." See Appeal to the Board of Veterans' Appeals received June 26, 2017. During a private outpatient appointment in March 2019 for shoulder pain, the Veteran denied a history of headaches. During a second such appointment in November 2019, the Veteran again denied a history of headaches. March 2020 VA treatment notes reflect that the Veteran denied headaches, although it was noted that his past use of the medication Sildenafil caused headaches. During a VA examination in March 2020, the Veteran reported the gradual onset of headaches in 2006 after deployment and said the headaches have grown worse. He described pulsating or throbbing pain in the occipital region of his head, both sides and lasting one to two days. He said he took ibuprofen for headache pain. He endorsed nausea, sensitivity to light, sensitivity to sound, and changes in vision during headaches. He endorsed prostrating attacks of headache pain once a month but denied very prostrating and prolonged attacks productive of severe economic inadaptability. The diagnosis was tension headaches. The examiner opined that the Veteran's headaches did not impact his ability to work. See VA Headaches examination dated March 13, 2020. October 2020 VA treatment notes reflect that the Veteran reported that his past use of the medication Cialis caused headaches. Upon review of the evidence of record, both lay and medical, the Board finds that a compensable rating for the initial rating period prior to June 26, 2017, is not more nearly approximated. The record predominantly reflects that the Veteran denied headaches and a history of headaches except during the January 2013 VA examination, at which time he described headaches that involved vision changes occurring once or twice a week lasting less than a day but denied prostrating attacks of headache pain. Subsequent to the examination, the Veteran endorsed severe migraines in his 2014 Notice of Disagreement but provided no additional information and thereafter again consistently denied headaches and a history of headaches during medical appointments. Additionally, the Board finds that rating in excess of 30 percent is not more nearly approximated for the initial rating period from June 26, 2017. In his June 2017 appeal, the Veteran stated that he has migraines "that are hard to cope with." Moreover, during the March 2020 VA examination, the Veteran endorsed prostrating attacks of headache pain once a month that involved nausea, sensitivity to light, sensitivity to sound, and vision changes, but denied very prostrating and prolonged attacks productive of severe economic inadaptability. These symptoms nearly approximate characteristic prostrating attacks as contemplated by the 30 percent rating criteria. That notwithstanding, the Board finds that the Veteran's tension headaches disability is not productive of severe economic inadaptability as required for the next higher 50 percent rating. In other words, there is no indication that the Veteran's headaches have caused severe economic inadaptability. The evidence does not show that special accommodations have been made to the Veteran's job or tasks as a result of his tension headaches disability. In sum, and although the Veteran has reported periods of unemployment due to his PTSD disability, the evidence does not suggest that severe economic inadaptability (solely due to his tension headaches disability) is present. To the extent that the Veteran contends that his headache symptoms are more severe than currently rated, while the Veteran and/or his spouse may be competent to report observable symptoms, see Layno, supra, here, the Veteran's headaches, the Board assigns more probative value to the Veteran's treatment records, which predominantly reflect that he denied headaches and a history of headaches throughout the rating period. As such, the Board assigns more probative weight to the lay history made for treatment purposes than to subsequent statements made for compensation purposes. Harvey, supra. As such, the Board finds that for the initial appeal period prior to June 26, 2017, the criteria for a compensable rating for tension headaches are not met, and thereafter, the criteria for an initial rating in excess of 30 percent for tension headaches are not met. As such, the appeal must be denied. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1, 4.7, 4.124a, Diagnostic Code 8100. Left Ear Hearing Loss The Veteran's left ear hearing loss is rated pursuant to 38 C.F.R. § 4.85, DC 6100, with an initial noncompensable evaluation assigned November 1, 2011. The Veteran asserts that his left ear hearing acuity is worse than the assigned rating. 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 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, Diagnostic Code 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. Rating Analysis Turning to the record, the Board observes that the Veteran's treatment records include an April 2012 VA audiological consultation that does not include puretone data. July 2015 and April 2017 private audiology evaluations do not include Maryland CNC speech discrimination evaluations. As such these evaluations will not be considered in adjudicating the Veteran's claim. 38 C.F.R. § 4.85. Additionally, an October 2019 VA audiological assessment reflects puretone data in terms of decibel ranges rather than specific decibel readings, and the speech discrimination results are noted as "excellent" rather than as percentages, rendering them unusable in the rating tables provided under 38 C.F.R. § 4.85, DC 6100. Thus, the January 2013 and the May 2021 VA examination audiometric testing results discussed below are the most probative evidence of record as to the severity of the Veteran's left ear hearing loss during the period on appeal. The January 2013 VA audiological examination that reflects left ear puretone thresholds of 5 decibels, 15 decibels, 50 decibels, 35 decibels, and 20 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. The puretone threshold average (the average of puretone thresholds from 1000 through 4000 Hertz) was 30 decibels for the left ear. The Veteran's speech discrimination score using the Maryland CNC Test was 100 percent for the left ear. See VA examination report dated January 29, 2013. The January 2013 audiometric results do not demonstrate an exceptional pattern of hearing under 38 C.F.R. § 4.86. Accordingly, under Table VI, the Veteran has a Level I hearing acuity in the left ear. 38 C.F.R. § 4.85. The non-service-connected right ear is assigned a Level I hearing acuity subject to 38 C.F.R. § 4.85(f). The point where designation I and I meet in Table VII yields a 0 percent, or noncompensable, disability rating. See 38 C.F.R. § 4.85, Table VII. A May 2021 VA audiological examination that reflects left ear puretone thresholds of 20 decibels, 25 decibels, 55 decibels, 60 decibels, and 40 decibels at 500, 1000, 2000, 3000, and 4000 Hertz respectively. The puretone threshold average (the average of puretone thresholds from 1000 through 4000 Hertz) was 45 decibels for the left ear. The Veteran's speech discrimination score using the Maryland CNC Test was 100 percent for the left ear. See VA examination report dated May 20, 2021. The May 2021 audiometric results do not demonstrate an exceptional pattern of hearing under 38 C.F.R. § 4.86. Accordingly, under Table VI, the Veteran has a Level I hearing acuity in the left ear. 38 C.F.R. § 4.85. The non-service-connected right ear is assigned a Level I hearing acuity subject to 38 C.F.R. § 4.85(f). The point where designation I and I meet in Table VII yields a 0 percent, or noncompensable, disability rating. See 38 C.F.R. § 4.85, Table VII. The Board notes the Court has held that, "in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report." Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). Here, the January 2013 VA examiner indicated that the Veteran's hearing loss impacted the ordinary conditions of his daily life, including the ability to work, and the Veteran reported, "he has difficulty understanding in background noise." The May 2021 VA examiner indicated that the Veteran's hearing loss impacted the ordinary conditions of his daily life, including the ability to work, and the Veteran reported, "Cannot hear, getting worse in left ear, cannot understand what is being said." To the extent that the Veteran contends that his hearing loss is more severe than currently rated, the Board observes that the Veteran, while competent to report observable symptoms such as difficulty hearing, see Layno, supra, is not competent to opine that his left ear hearing acuity is of sufficient severity to warrant a compensable rating under VA's tables for rating hearing loss disabilities, as such an opinion requires medical expertise (training in evaluating hearing impairment), which he has not been shown to have. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board acknowledges the Veteran's reports of difficulty hearing, but even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a compensable rating are not met. See Lendenmann, supra. The rating schedule contemplates impairment under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Furthermore, pursuant to Martinak, the functional effects caused by the Veteran's left ear hearing loss were considered and addressed in the April 2019 VA examination. See Martinak, 21 Vet. App. at 455. While the Board is sympathetic to the Veteran's contentions, the VA rating criteria are definitive and provide for a precise result based on audiometric test results. The Veteran's subjective report of difficulty hearing cannot be the basis for a compensable rating. The Board must apply the law as promulgated and is bound by VA regulations. See Owings v. Brown, 8 Vet. App. 17, 23 (1995) (providing that the Board must apply the law as it exists and is not permitted to award benefits based on sympathy for a particular appellant). As the law is dispositive of the issue on appeal, the claim must be denied because of the absence of legal merit or entitlement under the law. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Accordingly, for the reasons set forth above, the appeal is denied. 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). REASONS FOR REMAND Although the Board regrets the additional delay, remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. Once VA undertakes the effort to provide an examination or medical opinion when developing a service-connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Low Back Disability The Board finds deficiencies in the March 2020 VA nexus opinion. In opining that the Veteran's low back disorder was less likely than not related to service, the VA examiner did not consider the Veteran's lay statements regarding the onset of low back symptoms during service. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (finding a medical examination inadequate where the examiner impermissibly ignored the appellant's lay assertions regarding onset of symptoms or injury during service). Instead, the examiner relied heavily on the absence of evidence of low back symptoms in the Veteran's service treatment records as the rationale for the negative nexus opinion. Id. Accordingly, remand is necessary to obtain an addendum nexus opinion addressing the etiology of the Veteran's low back disability. See Barr, supra; Stegall, supra. Right Hearing Loss The Veteran is currently diagnosed with right ear hearing loss for VA purposes. See, e.g., VA examination dated May 20, 2021. However, the Veteran's right ear hearing loss has not been shown to be related to service. In a May 2021 VA opinion, the VA examiner, while acknowledging the Veteran's military noise exposure during service, concluded that absent evidence of hearing loss during service, it is unlikely that the Veteran's current right ear hearing loss is related to service. However, the absence of evidence in the Veteran's service treatment records, alone, may not serve as the basis for a negative opinion as to direct service connection. Dalton, 21 Vet. App. at 39-40. Further, the fact that a clinical diagnosis was not rendered during service is not fatal to the claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Additionally, the May 2021 VA examiner refuted the medical plausibility of delayed onset hearing loss based heavily on an Institute of Medicine (IOM) study indicating that delayed onset hearing loss due to previous noise exposure is unlikely to occur. See VA examination dated May 20, 2021 at pg. 5. The Board observes that the Court has directed attention to the fact that language of the IOM report may also support a theory of service connection involving delayed onset of a veteran's perception of hearing loss such that a VA examiner's citation of the report should contemplate all pertinent aspects of the report's findings. If a VA examiner relies on a medical treatise or literature, and there is any inconsistency within the evidence or with the conclusions drawn, the Board must address these inconsistencies. McCray v. Wilkie, 31 Vet. App. 243 (2019). Here, the VA examiner contemplated only the IOM report's negative findings. Lastly, it appears that VA, in requesting the secondary service opinion pursuant to the Board's September 2019 remand, specified only that the VA examiner address causation and not aggravation of right ear hearing loss by the Veteran's service-connected hearing loss. See Examination Scheduling Request dated March 4, 2020. The result is that the opinion addresses only the causation prong. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (opinion regarding secondary service connection is inadequate if it does not address both causation and aggravation of the nonservice-connected condition). Moreover, the May 2021 examiner merely noted in regard to causation "No, no hearing loss at separation in right ear" without any supporting rationale. 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). Accordingly, remand is necessary to obtain addendum opinions addressing direct and secondary service connection of the Veteran's right ear hearing loss. See Barr, supra; Stegall, supra. TDIU The issue of unemployability has been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A non-VA psychologist has indicated that the Veteran's PTSD symptoms have resulted in his being unemployed. See, e.g., Private Psychological Evaluation by W.A., Psy.D. dated January 17, 2022. The Veteran submitted a TDIU application form in 2014, but entitlement to a TDIU was denied in a January 2015 rating decision. March 2020 treatment records note that the Veteran was working full time, and the January 2022 private psychological evaluation indicates that the Veteran has held a number of jobs since 2014. Therefore, further development of this claim is needed, to include requesting that the Veteran submit an updated TDIU application form on remand. The matters are REMANDED for the following actions: 1. Ensure that all outstanding VA treatment records are associated with the claims file. 2. Provide the Veteran with an application for entitlement to TDIU (Veteran's Application for Increased Compensation Based on Unemployability, VA Form 21-8940) and request that he complete and return the application to help ensure that VA has all pertinent information regarding his educational background and employment history. Allow a reasonable time for reply. 3. Then, obtain an addendum opinion from the same VA examiner who conducted the March 2020 VA back examination, if available, as to the etiology of the Veteran's low back disability. If the same examiner is unavailable, request an addendum opinion from an appropriately qualified VA clinician. Access to the Veteran's electronic claims file, which shall include a copy of this Remand, must be made available to the examiner for review, and be reviewed, in connection with the examination. *The examiner's review of the body of this Remand is recommended to assist in avoiding errors that have resulted in deficiencies in the March 2020 opinion regarding direct service connection. *The need for another examination(s) is left to the discretion of the medical professional offering the addendum opinion. Should an examination(s) be necessary, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner is asked to respond to the following: (a) Identify all currently diagnosed low back disabilities that have been present at any point since the commencement of the claim period in October 2011. (b) Provide an opinion as to whether it is at least as likely as not (approximately 50 percent or higher probability) that the currently diagnosed low back disability(s) onset during service, manifested within one year after service separation, or is otherwise etiologically related to service. The examiner must address the Veteran's lay assertions regarding the onset of low back symptoms during service. The examiner must provide a complete rationale for all opinions proffered/provided. 4. Obtain addendum opinions from the same VA examiner who conducted the May 2021 VA hearing loss examination, if available, as to the etiology of the Veteran's right ear hearing loss. If the same examiner is unavailable, request an addendum opinion from an appropriately qualified VA clinician. Access to the Veteran's electronic claims file, which shall include a copy of this Remand, must be made available to the examiner for review, and be reviewed, in connection with the examination. *The examiner's review of the body of this Remand is recommended to assist in avoiding errors that have resulted in deficiencies in the May 2021 opinion regarding direct service connection. *The need for another examination(s) is left to the discretion of the medical professional offering the addendum opinion. Should an examination(s) be necessary, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner is asked to respond to the following: (a) Identify all currently diagnosed right ear hearing loss disorders that have been present at any point since the commencement of the claim period in October 2011. (b) Provide an opinion as to whether it is at least as likely as not (approximately 50 percent or higher probability) that the currently diagnosed right ear hearing loss disorder(s) onset during service, manifested within one year after service separation, or is otherwise etiologically related to service, to include military noise exposure previously conceded by VA. (c) Provide an opinion as to whether it is at least as likely as not (approximately 50 percent probability or greater) that the right ear hearing loss was CAUSED or AGGRAVATED by the service-connected left ear hearing loss. Note: Both causation AND aggravation must be addressed by the examiner's opinion. *Any increase/aggravation is sufficient; permanent aggravation is NOT required. See Ward v. Wilkie, 31 Vet. App. 233, 239-240 (2019) (permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease). The examiner must discuss the IOM Report on noise exposure in the military which states that it is "unlikely" that the onset of hearing loss begins years after noise exposure occurs, but also states that "an individual's awareness of the effects of noise on hearing may be delayed considerably after the noise exposure." The examiner must provide a complete rationale for all opinions provided. 5. Thereafter, ensure that the examiner has substantially responded to the questions posed by the Board, and if not, take corrective action. 6. Then, readjudicate the remanded claims. L. Chu Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell, 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.