BVA9503538 DOCKET NO. 92-08 275 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for a low back disorder. 4. Entitlement to service connection for heart disease. 5. Entitlement to an increased (compensable) disability evaluation for left ear hearing loss. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R. M. Yonemoto, Counsel INTRODUCTION The veteran had active service from October 1964 to July 1991. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of December 1991 from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In addition to the issues addressed herein, the veteran's representative has also raised the issue of entitlement to service connection for an upper (thoracic) spine disorder. That issue has not been adjudicated by the RO and is not ripe for appellate review. It is not inextricably intertwined with the issues before us. Consequently, it is referred to the RO for appropriate action. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that the onset of his current low back disorder was in service. He notes that an X-ray film less than three months after his separation from service revealed degenerative joint disease. It is further argued that he has hearing loss in the right ear and tinnitus because of his continual exposure to aircraft noise in service, and that his tinnitus may not reasonably be disassociated from the neurosensory component of his service-connected left ear hearing loss. It is maintained that he was placed on limited duty in service because of a heart abnormality, and that the abnormality was the initial manifestation of his current heart disease. It is also asserted that his service-connected left ear hearing loss adversely affects him daily. DECISION OF THE BOARD In accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), we have reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on a review of the relevant evidence in this matter, and for the following reasons and bases, it is our decision that the claims for service connection for right ear hearing loss and heart disease are not well grounded; that the evidence supports the grant of service connection for tinnitus and degenerative joint disease of the sacroiliac joints and lumbar muscle strain; and that the preponderance of the evidence is against the claim for an increased (compensable) disability evaluation for left ear hearing loss. FINDINGS OF FACT 1. The veteran does not have a right ear hearing loss by VA standards. 2. The veteran's tinnitus may not be disassociated from the neurosensory component of his service-connected left ear hearing loss. 3. The veteran's degenerative joint disease of both sacroiliac joints was manifested to a compensable degree within one year following his discharge from active duty; he had low back complaints in service which have persisted to the present; low back strain is also currently diagnosed. 4. It is not shown that the veteran has heart disease. 5. The veteran has level I hearing in the left ear. CONCLUSIONS OF LAW 1. The veteran's claim for service connection for right ear hearing loss is not well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107(a) (West 1991); 38 C.F.R. §§ 3.303(b), 3.385 (1994). 2. The veteran's tinnitus is proximately due to or the result of his service-connected left ear hearing loss. 38 C.F.R. §§ 3.102, 3.310(a) (1994). 3. Degenerative joint disease of both sacroiliac joints is presumed to have been incurred in service, and low back strain was incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.303(b), 3.307, 3.309 (1994). 4. The veteran's claim for service connection for heart disease is not well grounded. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107(a) (West 1991); 38 C.F.R. §§ 3.303(b), 3.307, 3.309 (1994). 5. A compensable evaluation for left ear hearing loss is not warranted. 38 U.S.C.A. §§ 1155, 1160(a) (West 1991); 38 C.F.R. §§ 3.321(b)(2), 4.85 Part 4, Code 6100 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, we find that the veteran's claims, except for those concerning right ear hearing loss and heart disease, are well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, we find that those claims are plausible. We are also satisfied that all relevant facts have been properly developed to the extent possible and that there is no further "duty to assist" the veteran which is also mandated by § 5107(a). To establish service connection for a disability, the evidence must show that the disability was incurred in service or, if pre- existing, that it was aggravated therein. 38 U.S.C.A. §§ 1110, 1131 (West 1991). When certain chronic disorders, including degenerative joint disease and heart disease, become manifest to a compensable degree within one year after separation from service, they are presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1994). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1994). I. Entitlement to Service Connection for Right Ear Hearing Loss. The threshold question with this issue is does the veteran have a right ear hearing loss disability. If he does not, his claim for service connection for such disability is not well grounded. Rabideau v. Derwinski, 2 Vet.App. 141 (1992). If it is not well grounded, the appeal may proceed no further. In establishing service connection for hearing loss, the controlling regulation states: For the purpose of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, and 4,000 hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1,000, 2,000, 3,000, and 4,000 hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (effective November 1994). The veteran had a VA audiometric examination in October 1991 Pure tone air conduction test revealed threshold levels of 5, 5, 5, 10, and 15 decibels in the right ear at 500, 1,000, 2,000, 3,000, and 4,000 hertz, respectively. The speech reception score using the Maryland CNC Test reflected recognition ability of 94 percent correct for the right ear. These results were noted to provide the best estimate of the veteran's organic hearing. The audiologist concluded that the veteran had normal hearing in the right ear. A review of the October 1991 audiometry shows the veteran does not have a right ear hearing loss disability under any of the alternative criteria in the controlling regulation outlined above. Although he was noted to have elevated pure tone thresholds in the right ear in service, he does not meet the prerequisite for establishing service connection, i.e., current disability. Consequently, this claim is not well-grounded. II. Entitlement to Service Connection for Tinnitus. The service medical records show that the veteran had sensorineural hearing loss in the left ear. There was no clinical notation of tinnitus during service. In a questionnaire completed in connection with a flight examination in August 1983, the veteran denied having ringing in the ears. A questionnaire, dated in November 1987 shows that he again denied having tinnitus. In a medical report completed in connection with the retirement examination of March 1991, the veteran did not report having ringing in the ears. On a VA audiometric examination in October 1991, the veteran reported having a constant high-pitched tinnitus in the left ear that had been present for the previous 20 years. He complained of a high-pitched tinnitus during a VA compensation examination in October 1991. The diagnoses included continuous traumatic tinnitus. Service connection may be granted if it is shown that a disability is proximately due to or the result of a service- connected injury or disease. 38 C.F.R. § 3.310(a) (1994). When a reasonable doubt arises regarding service origin, or any other point, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102 (1994). In this case, we initially observe that service connection is in effect for left ear sensorineural hearing loss, and that the hearing loss is considered to be the result of noise exposure when the veteran was a pilot. Furthermore, a VA examiner expressed the opinion that the veteran's tinnitus was due to exposure to acoustic trauma. Accordingly, after reviewing the evidentiary picture in its entirety, we cannot reasonably disassociate the tinnitus from the neurosensory component of the veteran's service-connected left ear hearing loss. We, therefore, hold that service connection for tinnitus is warranted on a secondary basis. III. Entitlement to Service Connection for a Low Back Disorder. The veteran's examination for Officer Candidate School in June 1964 showed a slight pelvic tilt. It was noted that he had a postural scoliosis due to pelvic tilt. It was further reported that the veteran had a moderate left dorsal scoliosis and right shoulder droop that was associated with a pelvic tilt, and that leg length was equal, bilaterally. On an orthopedic consultation, the veteran had no symptoms relative to his back. Examination showed that the left hip was lower than the right. The right shoulder was lower than the left. He had good flexibility to touching the fingertips to the floor. There was no leg length discrepancy. A three-fourths inch lift under the left foot leveled the pelvis. The X-ray studies showed no structural changes. The diagnosis was postural scoliosis due to pelvic tilt. In August 1976, the veteran complained of lower back pain. It was noted that the pain was possibly due to lifting a piano while moving furniture. In a questionnaire completed in connection with a flight examination in August 1983, the veteran denied having backaches. A questionnaire, dated in November 1987, shows that he again denied having backaches. In a questionnaire attached to an annual flight physical examination report of March 1989, the veteran reported having backaches. An undated questionnaire reveals that the veteran had back pain with heavy lifting. The veteran's retirement examination in March 1991 disclosed a normal musculoskeletal system. The veteran was accorded a VA compensation examination in October 1991. At that time, he complained of backache and stiffness. He reported that he had been advised to exercise to strengthen the back muscles, that most of his problems occurred when walking any distances or standing, and that he experienced backache if he had to go shopping with his wife in a mall. Musculoskeletal examination revealed that he stood erect and had normal posture and lumbar lordosis. There was no tenderness or spasm of the paravertebral muscles. Some limitation of back motion was observed. Straight leg raising was to 90 degrees on each side without pain. He was able to squat down on his heels and rise up again. Heel and toe walking was normal. An X-ray film of the lumbosacral spine showed narrowing of both sacroiliac joints. The impressions were degenerative joint disease of both sacroiliac joints with normal lumbar spine and lumbar muscle strain. The veteran had complaints of low back pain in service. Within several months following his service retirement in July 1991, degenerative joint disease of both sacroiliac joints was established by X-ray findings. Thus, it may be presumed to have been incurred in service. On a VA examination in October 1991, the veteran complained of low back pain and stiffness, and exhibited limitation of back motion. The lumbar muscle strain diagnosed at that time may not reasonably be disassociated with the recurring low back complaints in service and the degenerative joint disease of the sacroiliac joints. The history reported by the veteran is consistent with the clinical data and reasonably reflects a chronic low back strain which is characterized by periods of acute exacerbation. Thus, service connection for low back strain is also warranted. IV. Entitlement to Service Connection for Heart Disease. The veteran's service entrance examination in July 1964 showed that he had a normal heart. A chest X-ray study was negative. In October 1978, the veteran was hospitalized for a disorder not pertinent herein. An electrocardiogram and a chest X-ray were within normal limits. A questionnaire, dated in September 1980, shows that the veteran's blood pressure was recently elevated. In October 1983, it was reported that there was no history of heart disease or high blood pressure, and that an electrocardiogram was within normal limits. The veteran's annual flight examination in September 1986 revealed a normal heart. His blood pressure readings were 160/96 in the recumbent position and 148/100 in the standing position. Repeat blood pressure checks of the left arm showed readings of 142/94 in the recumbent position and 144/108 in the standing position. The examiner concluded that the veteran had elevated blood pressure. A three-day blood pressure check in September 1986 disclosed that the systolic blood pressure ranged from 128 to 158 and the diastolic blood pressure ranged from 84 to 118. An undated aeromedical summary shows that the veteran recently had been detected to have hypertension, that three-day blood pressure and pulse checks were performed to rule out initial spurious elevated readings, and that once hypertension was confirmed, extensive physical examination and laboratory tests were performed. An electrocardiogram and a chest X-ray were found to be normal. In early October 1986, it was reported that the veteran had elevated blood pressure readings during a flight examination, that the remaining portion of the examination was within normal limits, and that an electrocardiogram was within normal limits. The service medical records further disclose that in mid-October 1986 the veteran was examined at a hypertension clinic. He had a regular heart rate and rhythm except for an occasional skipped heart beat. The assessment was controlled hypertension. A repeat electrocardiogram indicated 3 premature atrial contractions. In late October 1986, the veteran was seen at the clinic. He reported that coffee in the evening tended to make his heartbeat skip. Examination disclosed regular heart rate and rhythm except for occasional skipped heartbeat. The assessment was controlled hypertension. In early November and December 1986, examinations at the clinic showed regular heart rhythm and rate without skipped beats. The assessment was controlled hypertension. Examination at the hypertension clinic in January 1987 revealed abnormal rhythm. The heart was auscultated x 3 minutes. There was one premature heartbeat without murmurs. The impression was hypertension. About a month later, the veteran underwent a stress test, which revealed frequent premature ventricular contractions at rest and in recovery as well as retrogressive premature ventricular contractions with increase in heart rate. The impression was ventricular arrhythmias. In April 1987, it was noted that the February stress test was within normal limits and that an examination of the veteran's heart showed 2 premature ventricular contractions in one minute, but otherwise regular rate and rhythm. An examination of the heart in October 1987 disclosed regular rate and rhythm without murmurs. The assessment was hypertension. On the veteran's annual flight examination report of October 1987, it was noted that an electrocardiogram showed sinus bradycardia. Chest X-ray films were within normal limits. A consultation sheet of October 1987 discloses that the veteran had borderline electrocardiogram results and that there were a broad Q-wave in III and unchanged AVF which raised the possibility of, but were not diagnostic of, inferior myocardial infarction. He was referred to the internal medicine clinic where it was noted that the original electrocardiogram which first raised the question showed Q-waves in III and unchanged AVF in all previous electrocardiograms. Repeat electrocardiogram revealed normal sinus rhythm without suggestion of myocardial infarction. The impressions were normal cardiac evaluation, normal electrocardiogram, and adequately treated hypertension. A MUGA scan in November 1987 was within normal limits. An early November 1987 report from RoTech Diagnostic, Inc., shows that the veteran had occasional to frequent ventricular ectopic beats with four ventricular couplets. Another RoTech Diagnostic, Inc. report of mid-November 1987 discloses the impressions of preserved left ventricular function with estimated ejection fraction of 66 percent, no detected echocardiographic abnormalities, occasional premature ventricular contractions on telemetry, and normal Doppler studies of the mitral and aortic valves. On an annual flight examination in March 1989, an electrocardiogram showed normal sinus rhythm except for one isolated premature ventricular contraction, and it was noted that a complete cardiological workup during the previous year was within normal limits. Blood pressure readings were 128/76 in the recumbent position and 130/78 in the standing position. In August 1990, the veteran sought consultation for his premature ventricular contractions. The examiner reported that the veteran had a long history of premature ventricular contractions which, for the most part, were asymptomatic, and that the veteran's hypertension was well controlled on medication. An electrocardiogram revealed normal sinus rhythm and unifocal premature ventricular contractions, but was considered, otherwise, within normal limits. The assessment was well- controlled hypertension. The veteran's retirement examination in March 1991 revealed no heart abnormality A blood pressure reading of 136/92 was reported. A chest X-ray film showed that cardiac size was top normal. An electrocardiogram revealed sinus bradycardia which was asymptomatic. The veteran was accorded a VA compensation examination in October 1991. At that time, he stated that his heart condition was arrhythmia which had been diagnosed as premature ventricular contractions, and that he had never had any treatment for that condition. Cardiovascular examination revealed good heart size, rate and rhythm. No murmurs were noted. Heart tones were normal. No bruits were heard. The veteran's blood pressure was elevated. An electrocardiogram was within normal limits. The diagnoses included cardiac arrhythmia (premature ventricular contractions), not found on current electrocardiogram. In a rating decision of December 1991, the RO granted service connection for hypertension. The veteran had a VA cardiovascular examination in January 1994 to determine whether he had heart disease. On review of the claims folder, the examiner found that the veteran had been on medication for hypertension since 1986, that premature ventricular contractions were noted in 1987, and that the veteran had premature ventricular contractions including 4 couplets during a Holter monitor. The examiner further stated that the veteran had a negative stress test, negative MUGA, and negative echocardiogram, and that the veteran was returned to flight status. The veteran complained of ectopic beats. On examination, his blood pressure reading was 180/94. An electrocardiogram revealed sinus bradycardia with normal axis and no acute changes or ectopy. A chest X-ray showed that the veteran's heart size was at the upper limits of normal without any other abnormality. The diagnoses were hypertension and ventricular ectopy in benign status. A threshold requirement in establishing a well-grounded claim for service connection for a disability is that that disability must be shown to exist. 38 U.S.C.A. §§ 1110, 1131 (West 1991). Here, we note that during service the veteran exhibited several cardiovascular symptoms, including premature ventricular contractions, arrhythmias, elevated blood pressure and sinus bradycardia. However, heart disease was not diagnosed in service. On one occasion , studies were suggestive of inferior myocardial infarction, but this was not confirmed subsequently. The veteran had a comprehensive special VA cardiovascular examination in January 1994. Its clinical findings were not reflective of heart disease. Moreover, the laboratory studies he underwent at that time disclosed no evidence of heart disease. Without substantiating medical evidence, the veteran's argument that he has heart disease has no merit. Hanna v. Brown, 6 Vet.App. 507 (1994). In the absence of medical evidence showing that the veteran currently has the claimed disability, that is, heart disease, his claim for service connection for heart disease is not well grounded. It is noteworthy that service connection has been established for hypertension. Medical confirmation that the veteran has heart disease would be a basis for reopening his claim. V. Entitlement to an Increased (Compensable) Disability Evaluation for Left Ear Hearing Loss. The service medical records disclose that the veteran had defective hearing in the left ear during service. The retirement examination report of March 1991 reveals that an audiometric study showed threshold levels of 5, 10, 10, 10, 25, and 25 decibels in the right ear at 500, 1,000, 2,000, 3,000, 4,000, and 6,000 hertz, respectively. On VA audiometric examination in October 1991, pure tone air conduction studies revealed threshold levels of 5, 10, 50, and 50 decibels in the left ear at 1,000, 2,000, 3,000, and 4,000 hertz, respectively. The average threshold for those frequencies in the left ear was 28.75 decibels. Speech recognition ability in each ear was 94 percent correct. These results were certified to provide the best estimate of the veteran's organic hearing. The audiologist commented that the veteran had normal hearing in the right ear and a moderate hearing loss at 3,000 and 4,000 hertz in the left ear. It is asserted by the veteran that he should be entitled to a compensable disability evaluation for his service-connected left ear hearing loss. Evaluations of unilateral defective hearing range from noncompensable to 10 percent based on organic impairment of hearing acuity as measured by the results of controlled speech recognition tests together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1,000, 2,000, 3,000, and 4,000 cycles per second. To evaluate the degree of disability from defective hearing, the revised rating schedule establishes eleven auditory acuity levels from level I for essentially normal acuity through level XI for profound deafness. In situations where service connection has been granted only for defective hearing involving one ear, and the appellant does not have total deafness in both ears, the hearing acuity of the nonservice-connected ear is considered to be normal. In such situations, a maximum 10 percent evaluation is assignable where hearing in the service- connected ear is at level X or XI. 38 C.F.R. § 4.85, and Part 4, Codes 6100 to 6101. "[D]isability ratings for hearing impairment are 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 (1992). Here, such mechanical application of the rating schedule establishes that in his left ear the veteran has level I hearing, warranting a noncompensable rating under Code 6100. Additionally, consideration has been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, including § 4.40, whether or not they were raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet.App. 589 (1991). The evidence here does not show that the service-connected left ear hearing loss presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards, as is required for an extra- schedular evaluation under 38 C.F.R. § 3.321(b)(1) (1994). The left ear hearing loss has not been demonstrated to be so severe as to require frequent periods of hospitalization or to markedly interfere with the veteran's employment. As such, we conclude that the application of the regular schedular standards is warranted in this case. ORDER Service connection for tinnitus is granted. Service connection for degenerative joint disease of the sacroiliac joints and low back strain is granted. The claim for service connection for right ear hearing loss is dismissed. The claim for service connection for heart disease is dismissed. An increased (compensable) disability evaluation for left ear hearing loss is denied. GEORGE R. SENYK Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.