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January 21, 2017

Rating Hearing Loss; M21-1MR, Part III, Subpart iv, Chapter 4, Section B;

Filed under: Uncategorized — Tags: , , , , — veteranclaims @ 7:26 pm

 

 

M21-1MR, Part III, Subpart iv, Chapter 4, Section B

Section B.  Conditions of the Organs of Special Sense

Overview

In this Section
This section contains the following topics:

 

Topic Topic Name See Page
10 General Information About Eye Conditions 4-B-2
11 Specific Eye Conditions 4-B-6
12 Hearing Impairment 4-B-10
13 Exhibit 1:  Examples of Rating Decisions for Diplopia 4-B-22

12.  Hearing Impairment

Introduction
This topic contains information about hearing impairment, including

 

  • determining impaired hearing as a disability
  • reviewing claims for hearing loss and/or tinnitus
  • considering the Duty Military Occupational Specialty (MOS) Noise Exposure Listing
  • requesting audiometric examinations and medical opinions
  • requesting medical opinions to determine causation of tinnitus
  • considering medical opinions in cases involving tinnitus
  • handling changed criteria or testing methods
  • applying revised hearing loss tables
  • reviewing for functional disturbances
  • granting service connection for functional hearing impairment
  • considering service connection for development of subsequent ear infection
  • determining the need for a reexamination
  • compensation payable for paired organs under 38 CFR 3.383, and
  • using the hearing loss calculator.

 

Change Date
June 5, 2012
a.  Determining Impaired Hearing as a Disability
Per 38 CFR 3.385, impaired hearing is considered a disability for VA purposes when

 

  • the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater
  • the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater, or
  • speech recognition scores using the Maryland CNC Test are less than 94 percent.

 

Notes:

  • Sensorineural hearing loss is considered an organic disease of the nervous system and is subject to presumptive service connection under 38 CFR 3.309(a).

 

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12.  Hearing Impairment, Continued

 

a.  Determining Impaired Hearing as a Disability (continued)
  • Be careful in determining whether older audiometry results show a disability under 38 CFR 3.385. Results today may indicate a different level of impairment than in the past because of changed equipment standards.

–    Audiometry results from before 1969 may have been in American Standards Association (ASA) units.

–    Current testing will be to standards set by the International Standards Organization (ISO) /American National Standards Institute (ANSI).

–    Test results should indicate the standard for the audiometry.

 

Important:  If you have older results that are in ASA units or the results date to a time when a ASA units may have been used, and you cannot determine what standard was used to obtain the readings, an audiologist opinion will be needed to interpret the results and convert any ASA test results to ISO/ANSI units.

 

Reference:  For more information on:

Continued on next page
12.  Hearing Impairment, Continued

b.  Reviewing Claims for Hearing Loss and/or Tinnitus
Review each claim for hearing loss and/or tinnitus for

 

  • sufficient evidence of a current audiological disability (including lay evidence), and
  • evidence documenting

–    hearing loss and/or tinnitus in service, or

–    an in-service event, injury, disease, or symptoms of a disease potentially related to an audiological disability.

 

If there is no documented evidence of an in-service disease, injury, or event with which the claimed condition could be associated, consider the Duty Military Occupational Specialty (MOS) Noise Exposure Listing to help determine the probability of the Veteran’s exposure to hazardous noise in service.

 

Veterans are not expected to be medical experts; therefore, claims must be read sympathetically.  A common example of sympathetically reading claims is when a Veteran files a claim for hearing loss and tinnitus is diagnosed at the examination.  If the examiner states that tinnitus is related to

noise exposure during the Veteran’s military service or hearing loss of the same etiology, the date of claim (for purposes of determining the effective date) will be the same as the date of claim for the hearing loss, if service connection is otherwise warranted.

 

Note:  If tinnitus is not specifically claimed, do not address tinnitus in the rating decision unless service connection can be granted.

 

Reference:  For more information on considering the Duty MOS Noise Exposure Listing, see M21-1MR, Part III, Subpart iv, 4.B.12.c.

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12.  Hearing Impairment, Continued

c.  Considering the Duty MOS Noise Exposure Listing
The Duty MOS Noise Exposure Listing, which has been reviewed and endorsed by each branch of service, is available at http://vbaw.vba.va.gov/bl/21/rating/docs/dutymosnoise.xls

 

Based on the Veteran’s records, review each duty MOS, Air Force Specialty Code, rating, or duty assignment documented on the Duty MOS Noise Exposure Listing to determine the probability of exposure to hazardous noise.

 

If the duty position is shown to have a “Highly Probable” or “Moderate” probability of hazardous noise exposure, concede exposure to hazardous noise for the purposes of establishing the in-service event.

 

Note:  The Duty MOS Noise Exposure Listing is not an exclusive means of establishing a Veteran’s in-service noise exposure.  Evaluate claims for service connection for hearing loss in light of the circumstances of the Veteran’s service and all available evidence, including treatment records and examination results.

 

Reference:  For more information on considering the circumstances of the Veteran’s service, see 38 U.S.C. 1154(a) and (b).

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12.  Hearing Impairment, Continued

d.  Requesting Audiometric Examinations and Medical Opinions
Request an audiometric examination whenever

 

  • service connection for hearing loss and/or tinnitus is at issue
  • there is sufficient evidence of a current audiological disability, and
  • there is documented evidence of

–    hearing loss in service, or

–    an event, injury, disease, or symptoms in service of a disease potentially related to an audiological disability, or

  • exposure to hazardous in-service noise is conceded based on the Duty MOS Noise Exposure Listing or by other means.

 

If there is sufficient evidence of a current disability, request a medical opinion with the audiometric examination to determine the relationship between current audiological disability and

 

  • an event, injury, disease, or symptoms in service potentially related to an audiological disability, or
  • exposure to hazardous in-service noise.

 

Notes:

  • If VA concedes in-service noise exposure, include the level of probability conceded, such as “highly probable” or “moderate,” in the information provided to the examiner in the body of the examination request.
  • If VA doesn’t concede in-service noise exposure, but an examination and opinion request are otherwise warranted (based on hearing loss claimed related to an event, injury, disease, or symptoms in service potentially related to an audiological disability, or other basis), provide the probable level of exposure to hazardous noise associated with the Veteran’s documented duty position in the examination request remarks.
  • In Noise and Military Service: Implications for Hearing Loss and Tinnitus (2006), the National Academy of Sciences reported that a delay of many years in the onset of noise-induced hearing loss following an earlier noise exposure is extremely unlikely.
  • Request a medical opinion regarding the significance of prior audiological findings if the evidence of record is unclear on any point.

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12.  Hearing Impairment, Continued

e.  Requesting Medical Opinions to Determine Causation of Tinnitus
A medical opinion regarding possible causation of tinnitus is not required to establish service connection if

 

  • service treatment records (STRs) show a complaint of tinnitus, and
  • the Veteran

–    claims service connection for tinnitus, and

–    has current complaints of tinnitus.

 

If … Then …
  • the STRs contain no record of tinnitus but VA can otherwise concede noise exposure or the occurrence of an event, injury, or illness in service, and
  • there is a complaint or claim of tinnitus
ask the audiologist to offer an opinion, if it is within the scope of his/her practice, about an association of tinnitus to

 

  • hearing loss, or
  • an event, injury, or illness in service.

 

Note:  Only ask the audiologist to offer an opinion about the association to hearing loss if hearing loss is also specifically claimed.

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12.  Hearing Impairment, Continued

f.  Considering Medical Opinions in Cases Involving Tinnitus
Use the table below when considering an examiner’s medical opinion in a case involving tinnitus.

 

If … Then …
the examiner states tinnitus is a symptom of hearing loss
  • evaluate tinnitus separately under diagnostic code 6260 if the hearing loss is determined to be SC and
  • establish service connection for tinnitus on a direct, not secondary, basis.

 

Note:  If the hearing loss is service connected, and the tinnitus is a symptom of the hearing loss, we concede that the hearing loss and tinnitus result from the same etiology.  Therefore, service connection is warranted for tinnitus on a direct basis in these cases.

  • the examiner

–    states tinnitus is not related to hearing loss, or

–    is unable to determine the etiology within reasonable certainty, or

  • there is no hearing loss
determine, based on all the evidence of record, whether or not the etiology of tinnitus requires further assessment by one of more additional examinations.

 

Note:  The type and need for any additional examination(s) will depend on the Veteran’s claim as to the cause of tinnitus.

Examples:

  • If the Veteran claims tinnitus due to hearing loss, and the examiner says they are not related, no further action is needed.
  • If Veteran claims tinnitus due to another condition (such as head injury, hypertension, etc., which would be outside the scope of the audiologist), it might be appropriate to request

–    a general medical, ears/nose/throat (ENT), or other examination, and

–    an opinion as to the causation of tinnitus.

Continued on next page
12.  Hearing Impairment, Continued

 

f.  Considering Medical Opinions in Cases Involving Tinnitus (continued)

 

If … Then …
the examiner states that tinnitus is related to noise exposure or an event, injury, or illness in service
  • evaluate all the evidence of record
  • determine if the examiner’s opinion is consistent with the evidence, and

 

If … Then …
the examiner’s opinion is consistent with the evidence or record grant service connection on a direct basis.
  • the examiner’s opinion is not consistent with the evidence of record, and
  • the evidence VA provided to the examiner was incorrect or insufficient
  • return the exam for clarification and
  • provide the examiner with all necessary information.

 

Note:  When the corrected exam is received, consider the opinion together with all other evidence of record to determine if service connection is warranted.

  • the examiner’s opinion is not consistent with the evidence of record, and
  • the information the Veteran provided to the examiner was also inconsistent with the record
consider the opinion together with all other evidence of record to determine whether service connection is warranted.

 

 

References:  For more information on

  • when to use lay evidence, see

–    M21-1MR, Part III, Subpart iv, 5.9.b

–    Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), and

–    Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir. 2007).

  • weighing evidence, see

–    M21-1MR, Part III, Subpart iv, 5.12

–    Coburn v. Nicholson, 19 Vet. App. 427 (2006)

–    Kowalski v. Nicholson, 19 Vet.App. 171 (2005), and

–    Reonal v. Brown, 5 Vet. App. 548 (1993).

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12.  Hearing Impairment, Continued

 

g.  Handling Changed Criteria or Testing Methods
If a decrease in evaluation is due to changed criteria or testing methods, rather than a change in hearing impairment, apply the old criteria and make no reduction.

 

Reference:  For more information on handling changed criteria or testing methods, see 38 CFR 3.951.

h.  Applying Revised Hearing Loss Tables
Veterans Health Administration (VHA) ceased converting audiology examinations to American Standards Association (ASA) standards after December 31, 1975.

 

Use the table below to apply revised hearing loss tables to claims of hearing loss.

 

If the examination results are dated … Then apply …
before January 1, 1976 the rating tables in effect prior to September 9, 1975.
from January 1, 1976, through December 17, 1987 evaluation tables VI and VII.

 

Note:  The evaluations used ISO/ANSI, W-22 word discrimination and speech reception threshold standards exclusively.

after December 18, 1987 evaluation tables VI and VIa.

 

Note:  Examiners use the speech discrimination or recognition ability of Maryland CNC with the results of the puretone auditory test.

i.  Reviewing for Functional Disturbances
If, following an examination at an audiology clinic, a drastic reduction in rating for a hearing impairment is in order, thoroughly review the claims folder for evidence of a psychiatric disease entity, which might be manifested in part by a nonorganic hearing impairment.

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12.  Hearing Impairment, Continued

j.  Granting Service Connection for Functional Hearing Impairment
Determine entitlement to service connection for a psychiatric disability, manifested in part by a hearing impairment, by the usual regulations pertaining to the grant of service connection.

 

It is anticipated the psychiatric disorder will be identifiable by manifestations other than those relating to hearing complaints alone.  Base the rating either on the organic hearing loss or the psychiatric disorder, but not both in combination.

 

Reference:  For more information on evaluating psychiatric disorders, see 38 CFR 4.126.

k.  Considering Service Connection for Development of Subsequent Ear Infection
If the disease of one ear, such as chronic catarrhal otitis media or otosclerosis, is held as the result of service, the subsequent development of similar pathology in the other ear must be held due to the same cause if

 

  • the time element is not manifestly excessive, a few years at most, and
  • there has been no intercurrent infection to cause the additional disability.

 

Note:  If there is continuous SC infection of the upper respiratory tract, the time cited for the purpose of service connecting infection of the second ear should be extended indefinitely.

l.  Determining the Need for Reexamination
Use the table below to determine whether reexamination is necessary.

 

Note:  A single examination is often sufficient to meet the qualifying conditions of permanence under 38 CFR 3.327.

 

If … Then …
the extent of hearing loss in an individual claim has been satisfactorily established by an examination do not routinely schedule reexamination.

Continued on next page
12.  Hearing Impairment, Continued

 

l.  Determining the Need for Reexamination (continued)

 

If … Then …
the Veteran has hearing loss evaluated 100 percent under diagnostic code 6100 with a numeric designation of XI & XI
  • permanency can be conceded, and
  • Special Monthly Compensation (SMC) granted unless extenuating circumstances are present.

 

Note:  If hearing loss is functional, such as psychogenic, schedule at least one future examination to ensure that permanency is established before granting SMC.

there is evidence that the hearing loss is likely to improve materially in the future
  • schedule a reexamination, and
  • include justification for such reexamination in the Reasons for Decision section of the rating decision.
the Veteran has had middle ear surgery
  • consider that hearing acuity will have reached a stable level one year after surgery, and
  • schedule reexamination for one year after such surgery under 38 CFR 3.327.
m.  Compensation Payable for Paired Organs Under 38 CFR 3.383
Even if only one ear is SC, compensation may be payable under 38 CFR 3.383 for the other ear, as if SC, if the Veteran’s hearing impairment

 

  • is compensable to a degree of 10 or more in the SC ear, and
  • meets the provisions of 38 CFR 3.385 in the non-SC ear.

 

Reference:  For more information on compensation payable for paired SC and non-SC organs, see

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12.  Hearing Impairment, Continued

n.  Using the Hearing Loss Calculator
The hearing loss calculator on the Compensation Service Intranet Rating Job Aids page generates stand-alone paragraphs for use in the Reasons for Decision section of the rating decision narrative.  The calculator determines the appropriate diagnostic code, evaluation, and narrative based on data input by the decision maker.

 

Important:  print the calculator worksheet and file it in the center of the claims folder or, for paperless claims, scan the worksheet into VirtualVA.

 

  • If the language generated by the calculator is in error, print the decision from the main calculator screen, place it and a screenshot of the calculator results in the claims folder, and use RBA 2000 to complete the decision.
  • If you do not use the calculator-generated text, you must notify the DENTT.VBAPHO@va.gov  mailbox with a detailed description of the error.

 

Reference:  For more information on the hearing loss calculator, see the user’s guide.

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