Department of Veterans Affairs M21-1, Part III, Subpart ivVeterans Benefits Administration April 9, 2019 Washington, DC 20420

Key Changes

Changes Included in This Revision

The table below describes the changes included in this revision of Veterans Benefits Manual M21-1, Part III, “General Claims Process,” Subpart iv, “General Rating Process.”

Note: Minor editorial changes have been made to improve clarity and readability update incorrect or obsolete references, and bring the document into conformance with M21-1 standards.

Reason(s) for Notable Change CitationTo remove specific reference to completion of the audiological disability benefits questionnaire (DBQ) by a private physician, since this DBQ has not been released specifically for private use. Any privately completed DBQs should be reviewed in the same manner as other private medical evidence.

M21-1, Part III, Subpart iv, Chapter 4, Section D, Topic 2, Block f (III.iv.4.D.2.f)

To revise the note concerning applicability of Jandreau v. Nicholson, 492 F.3d. 1372 (Fed. Cir. 2007) because the note mischaracterizes proper policy and procedures for considering lay evidence.

To add a note reflecting that proper consideration of lay evidence is necessary for tinnitus claims.

To add an example of proper consideration of continuity and lay evidence in tinnitus claims.

To add references to proper policy and procedures for considering lay evidence.

III.iv.4.D.3.b

To update the discussion of evaluation criteria for Meniere’s disease to replace the word “or” with “and” for consistency with 38 CFR 4.87.

III.iv.4.D.4.d

Reason(s) for Change CitationTo clarify that symptoms need not be specifically correlated to a disease when assessing evidence for an in-service event, injury, or disease.

III.iv.4.D.1.a

To eliminate redundancy from Step 2 and 3 and clarify that the review of evidence is targeted toward noise exposure, not acoustic trauma, since noise exposure and acoustic trauma are not synonymous.

To reword the note to eliminate redundancy but not otherwise substantively change the guidance.

III.iv.4.D.1.c

To clarify that procedures pertaining to timing of examination requests should be followed when requesting hearing loss

III.iv.4.D.1.d

examinations. To delete information quoted from a 2006 National Academy of

Sciences report since the information is old and is relevant to medical determinations regarding etiology of hearing loss but is not relevant to decisions about when an examination is or is not appropriate, which is the subject matter of this block.

To delete certain prescriptive job titles, such as “Rating Veterans Service Representative” and “Decision Review Officer,” when necessary, as outlining position descriptions falls under the direction and purview of the Office of Field Operations.  Per Compensation Service leadership, such references have been removed from M21-1 where their inclusion does not meaningfully impact the procedures described.

III.iv.4.D.2.g and i

Authority By Direction of the Under Secretary for Benefits

Signature

Beth Murphy, DirectorCompensation Service

Distribution LOCAL REPRODUCTION AUTHORIZED

Section D. Conditions of the Auditory System

Overview

In This Section This section contains the following topics:

Topic Topic Name1 Rating Principles for Conditions of the Auditory System2 Hearing Loss3 Tinnitus4 Peripheral Vestibular and Other Ear Disorders

1. Rating Principles for Conditions of the Auditory System

Introduction This topic contains information about rating principles for conditions of the auditory system, including

service connection (SC) for hearing loss and tinnitus considering the Duty Military Occupational Specialty (MOS) Noise

Exposure Listing and combat duties considering National Guard and Reserve duty for hearing loss and/or

tinnitus claims, and requesting audiometric examinations and medical opinions.

Change Date February 2, 2018April 9, 2019

a. SC for Hearing Loss and Tinnitus

Review each claim for direct service connection (SC) for hearing loss and/or tinnitus for

sufficient evidence of a current audiological disability, or lay evidence of difficulty hearing, 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.

Important: A claim for hearing loss is acceptable lay evidence that the claimant is

stating that he/she experiences difficulty hearing. A claim for tinnitus is acceptable lay evidence that the claimant is stating

that he/she experiences symptoms associated with tinnitus, such as ringing in the ears.

Sensorineural hearing loss and tinnitus are considered organic diseases of the nervous system and areis subject to presumptive SC under 38 CFR 3.309(a).

References: For more information on decreased hearing thresholds on audiometry testing in service as evidence of

an in-service event, injury, or disease see Hensley v. Brown, 5 Vet.App. 155 (1993), and

tinnitus as a presumptive disability under 38 CFR 3.309(a), see - Fountain v. McDonald, 27 Vet.App. 258 (2015), and- M21-1, Part III, Subpart iv, 4.N.1.d.

b. Considering the Duty MOS Noise Exposure

The Duty Military Occupational Specialty (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 .

Listing and Combat Duties 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.

When the duty position is shown to have a high, moderate, or low probability of hazardous noise exposure, concede exposure to hazardous noise for the purposes of establishing an event in service.

In addition, aAlso review the Veteran’s records for evidence that the Veteran engaged in combat with the enemy in active service during a period of war, campaign, or expedition. If the evidence establishes that the Veteran was engaged in combat, concede exposure to hazardous noise for the purposes of establishing an event in service.

Notes: The Duty MOS Noise Exposure Listing is not an exclusive means of

establishing a Veteran’s in-service noise exposure. Evaluate claims for SC for hearing loss in light of the circumstances of the Veteran’s service and all available evidence, including treatment records and examination results.

When hazardous noise exposure is conceded based on the Veteran engaging in combat, accept satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, even if there is no official record of such incurrence or aggravation in such service. Resolve every reasonable doubt in favor of the Veteran, unless there is clear and convincing evidence to the contrary.

References: For more information on considering the circumstances of the Veteran’s service, see

- 38 U.S.C. 1154(a) and (b) , and- 38 CFR 3.304(d)

considering combat service for purposes of conceding in-service noise exposure and determining service incurrence of a disability, see Reeves v. Shinseki, 682 F.3d 988 (Fed.Cir. 2012), and

requesting audiometric examinations and opinions, see M21-1, Part III, Subpart iv, 4.D.1.d.

c. Considering National Guard and Reserve Duty for Hearing Loss and/or Tinnitus Claims

Claims for SC of hearing loss and/or tinnitus due to service in the National Guard or Reserves should be considered under the same criteria as any claim for SC of hearing loss and/or tinnitus. The condition must be causally related to service.

First, consider SC on the basis of a potential relationship to periods of active duty or active duty for training (ADT).

When SC for hearing loss and/or tinnitus may not be directly related to a period of active duty or extended ADT, entitlement to SC may still be established if there has been a decrease in auditory acuity due to military duties as a member of the National Guard or Reserves.

SC for hearing loss and/or tinnitus can be established for inactive duty for training (IADT) if the condition can be linked to an injury during IADT as shown by the nature of service, MOS, lay evidence, or other competent evidence.

Follow the procedures in the table below when developing for evidence of a decrease in auditory acuity due to National Guard or Reserve duty service and deciding whether an examination and/or medical opinion is warranted.

Step Action1 Obtain National Guard or Reserve medical records documenting

the auditory baseline.2 Consider the type of MOS and military duties performed during

National Guard or Reserve service. Follow the guidance in M21-1, Part III, Subpart iv, 4.D.1.b.

Note: For purposes of hearing loss or tinnitus during IADT, the MOS or other evidence establishing noise exposure serves as the injury during IADT required for SC eligibility, per M21-1, Part IV, Subpart ii, 2.B.1.m. Review the entire evidentiary record for noise exposure to ascertain both in-service and post-service exposure to hazardous noise.

3 Review the entire evidentiary record for acoustic traumanoise exposure to ascertain both in-service and post-service exposure to acoustic traumahazardous noise.

Note: Although the National Guard or Reserve service records should show auditory threshold shifts during National Guard or Reserve service, the service records do not need to meet the criteria in 38 CFR 3.385 to warrantmeet the threshold for an examination and/or medical opinion if all other requirements for ordering examinations and medical opinions in M21-1, Part I, 1.C.3 are metsatisfied.

References: For more information on when evidence of decreased hearing on in-service audiometry testing, not

constituting a disability as defined in 38 CFR 3.385 , can support direct SC for hearing loss, see Hensley v. Brown, 5 Vet.App. 155 (1993)

requesting records, see M21-1, Part I, 1.C updating Department of Veterans Affairs (VA) systems for active service

based on multiple periods of ADT or IADT, see M21-1, Part III, Subpart ii, 3.C.7.e

duty status and eligibility of members of the Reserves, see M21-1, Part III, Subpart ii, 6.A.3

duty status and eligibility of personnel in the National Guard service, see M21-1, Part III, Subpart ii, 6.A.4

applying the presumption of soundness for ADT, see M21-1, Part IV, Subpart ii, 2.B.1.l, and

examination requests, see M21-1, Part III, Subpart iv, 3.A.

d. Requesting Audiometric Examinations and Medical Opinions

Where the question of SC is at issue, request an audiometric examination and/or medical opinion when necessary under 38 CFR 3.159(c)(4).

Competent evidence of a current diagnosis or symptoms could include records or lay evidence of difficulty hearing or tinnitus. A claim for hearing loss is acceptable lay evidence that the claimant is stating that he/she experiences difficulty hearing.

Establishment of an event, injury, or disease in service is fact-specific. Even if there is documentation of an in-service illness, injury, or event involving the ears or hearing, the Duty MOS Noise Exposure listing and evidence of combat service should still be considered. - When noise exposure is conceded based on the Duty MOS Noise

Exposure Listing, include the level of probability conceded (high, moderate, low) in the information provided to the examiner in the body of the examination request.

- If noise exposure is conceded based on engagement in combat with the enemy, include this detail in the information provided to the examiner in the body of the examination request.

- If an examination and/or opinion are otherwise necessary based on an event, injury, or disease, also include the probable level of exposure to hazardous noise associated with the Veteran’s documented duty position in the examination request remarks.

In most instances when noise exposure is conceded as a result of MOS, combat, or event in service this will also satisfy the indication of association between service and current disability for the purposes of finding an examination necessary.

Notes: An examination should be requested when a claim for hearing loss is

received and there is evidence of an event, injury or disease in service. Follow the procedures in M21-1, Part I, 1.C.3.k with reference to the timing of the examination request.

A decision not to order an examination must be supported with adequate reasons and bases in the rating decision.

Request a medical opinion regarding the significance of prior audiological findings if the evidence of record is unclear on any point, such as when there is no evidence of calibrated audiometry testing in the record. Older records frequently contain whispered voice tests which cannot be considered as reliable evidence that hearing loss did or did not occur.

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.

References: For more information on when an exam is necessary under the duty to assist, see M21-1, Part I, 1.C.3 use of the duty MOS to determine if there was in-service hazardous noise

exposure, see M21-1, Part III, Subpart iv, 4.D.1.b

considering a decrease in hearing thresholds on audiometry in service not meeting the definition of a hearing loss disability in 38 CFR 3.385 as evidence of an event, injury or disease, see Hensley v. Brown, 5 Vet.App. 155 (1993)

medical opinions and the Hearing Loss and Tinnitus Disability Benefits Questionnaire, see M21-1, Part III, Subpart iv, 3.A.7.h

qualification requirements of examiners for hearing loss and tinnitus examinations, see M21-1, Part III, Subpart iv, 3.D.2.k

hearing loss and tinnitus examination report review, see M21-1, Part III, Subpart iv, 3.D.4.d, and

requesting medical opinions for tinnitus claims, see M21-1, Part III, Subpart iv, 4.D.3.b.

2. Hearing Loss

Introduction This topic contains general information about hearing loss, including

sympathetic reading of hearing loss claims regulatory definition of impaired hearing changes in audiological testing methods applying past versions of hearing loss criteria handling changed criteria or testing methods modified performance intensity function testing evaluating exceptional patterns of hearing impairment evaluating hearing loss when speech discrimination scores are not

appropriate or cannot be obtained using Veterans Benefits Management System – Rating (VBMS-R) decision

tools in hearing impairment claims audiometric values above 105 decibels bone conduction results hearing impairment due to Meniere’s Disease compensation payable for paired organs under 38 USC 3.383 earlier effective date of increase for hearing loss, and determining the need for reexamination.

Change Date February 2, 2018April 9, 2019

a. Sympathetic Reading of Hearing Loss Claims

Claims, particularly those from unrepresented claimants, must be read sympathetically. In some cases, a claim that appears to raise only the issue of SC or an increased evaluation for hearing loss will, by reason of its wording, also require consideration of SC for tinnitus.

In cases where the claim is phrased as a claim for SC or increased evaluation for “hearing loss” (or similar wording) and other lay or medical evidence raises the issue of tinnitus and establishes entitlement to SC, consider the issue of tinnitus as within scope of the claim for hearing loss.

Where SC is established for tinnitus, use the date of the hearing-related claim for effective date purposes.

Although the phrase “hearing loss” denotes diminished hearing acuity, a claimant without medical training might interpret extraneous sounds in the ear(s) or head (tinnitus) creating interference with normal hearing as “hearing loss.” Because of this ambiguity, it is not clear that a claim phrased as being for “hearing loss” without further specific explanation, is intended to request adjudication only of hearing loss and not of tinnitus.

References to “hearing impairment” or even just “hearing” are also ambiguous as to whether they concern reduced hearing acuity only or tinnitus as well.

References: For more information on sympathetic reading doctrine and issues within the scope of a claim, see

- 38 CFR 3.155(d)(2) - M21-1 Part III, Subpart iv, 6.B.1.c, and- M21-1 Part IV, Subpart ii, 2.A.1.a, and

sympathetic reading of tinnitus claims, see M21-1, Part III, Subpart iv, 4.D.3.a.

b. Regulatory Definition of Impaired Hearing

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, or 4000 Hertz (Hz) is 40 decibels or greater

the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater, or

speech recognition scores using the Maryland Consonant-Vowel Nucleus-Consonant (CNC) Test are less than 94 percent.

Reference: For more information on the impact of changes in audiological testing methods, see M21-1, Part III, Subpart iv, 4.D.2.c.

c. Changes in Audiological Testing Methods

Equipment and testing standards for hearing loss have undergone past changes.

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

Current testing standards are set by the International Standards Organization (ISO) /American National Standards Institute (ANSI).

Test results should indicate the standard for the audiometry, but - if a military audiogram was performed prior to 1969 and does not

specifically state it was conducted according to ISO/ANSI standards, assume the results are ASA, and

- unless otherwise specified, assume audiograms performed from 1969 and later were conducted according to ISO or ANSI standards.

Veterans Health Administration (VHA) examinations for compensation purposes routinely converted ISO/ANSI results to ASA units until the end of 1975 because the regulatory standard for evaluating hearing loss was not changed to require ISO/ANSI units until September 9, 1975.

In order to facilitate data comparison for VA purposes under 38 CFR 3.385, ASA standards noted in service treatment records (STRs) dated prior to 1969 must be converted to ISO/ANSI standards.

Important: 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.

If the audiometric results were reported in standards set forth by ASA, or the

results date to a time when ASA units may have been used and you cannot determine what standards were used to obtain the readings, an audiologist opinion is necessary to interpret the results and convert any ASA test results to ISO/ANSI units for application of 38 CFR 3.385 in disability determinations.

References: For more information on applying past versions of hearing loss tables, see M21-1, Part III, Subpart iv,

4.D.2.d, and obtaining medical opinions, see M21-1, Part III, Subpart iv, 3.A.7.

d. Applying Past Versions of Hearing Loss Criteria

In some cases, it may be necessary to consider past legal criteria for evaluating hearing loss. Such cases may include

unresolved pending claims, and claims where a past decision denying SC – or establishing an evaluation –

for hearing loss must be revised due to clear and unmistakable error.

The document here contains all versions of hearing loss evaluation tables from Extension 8-B of the 1945 Schedule for Rating Disabilities to the amendment of 38 CFR 4.85(b), effective June 10, 1999.

References: For more information on applying the law when criteria changes during a pending claim, see

VAOPGRPREC 3-2000, and standards for old audiometry, see M21-1, Part III, Subpart iv, 4.D.2.c.

e. Handling Changed Criteria or Testing Methods

If there is a change in evaluation criteria (including a required change in testing methods) and applying the current facts to the changed criteria would support a lower evaluation but there has not been an improvement in the degree of hearing loss (or tinnitus), the existing evaluation may not be reduced.

Reference: For more information on preservation of disability ratings, see 38 CFR 3.951(a).

f. Modified Performance Intensity Function Testing

Per 38 CFR 4.85, Maryland CNC testing is required to evaluate speech discrimination for VA compensation purposes. As a part of the Maryland CNC testing, when results are 92 percent or less following the preliminary administration of the test, a performance intensity function test must be performed.

Performance intensity function testing involves conducting three repetitions of speech recognition testing.

When an examination is performed by a VA or contract examiner, assume

that the performance intensity function testing has been completed unless there is a clear indication to the contrary.

When a treatment record or a disability benefits questionnaire (DBQ) completed by a private examinerprivate medical evidence is reviewed for rating purposes, if speech recognition scores are 92 percent or less, ensure that performance intensity function testing was conducted. Indicators that performance intensity function testing was conducted include (but are not limited to)- findings of three repetitions of speech recognition testing, wherein the

maximum score must be used, or- a treating provider’s notation that performance intensity function testing

was performed along with a report of the maximum speech recognition score.

g. Evaluating Exceptional Patterns of Hearing Impairment

Consideration should be made as to whether current audiometric readings demonstrate an exceptional pattern of hearing impairment. An exceptional pattern of hearing impairment is shown if

the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hz) is 55 decibels or more, or

the puretone threshold is 30 decibels or less at 1000 Hz and 70 decibels or more at 2000 Hz.

When an exceptional pattern of hearing impairment is shown, the Rating Veterans Service Representative (RVSR)rating activity will determine the Roman numeral designation for hearing impairment using either Table VI or VIA, in 38 CFR 4.85 (h),whichever results in the higher numeral.

Important: When the puretone threshold is 30 decibels or less at 1000 Hz and 70 decibels or more at 2000 Hz, the Roman numeral obtained by using the appropriate table will be elevated to the next higher Roman numeral.

Reference: For more information on evaluating hearing loss based on exceptional patterns of hearing impairment, see 38 CFR 4.86.

h. Evaluating Hearing Loss When Speech Discrimination Scores Are Not Appropriate or Cannot Be Obtained

When an examiner certifies that speech discrimination scores are not appropriate or cannot be obtained, typically indicated with a “cannot test (CNT)” designation on examination, in accordance with 38 CFR 4.85(c) use Table VIA in 38 CFR 4.85(h).

Example: An examiner indicates that speech discrimination scores are not appropriate due to inconsistent results.

i. Using VBMS-R Decision Tools

The Veterans Benefits Management System – Rating (VBMS-R) includes embedded calculators for hearing loss and tinnitus and ear diseases to help RVSRs and Decision Review Officersdecision makers assign correct

in Hearing Impairment Claims

evaluations and generate required narrative explanation. The calculator output is placed in the rating Narrative.

For the purpose of assigning a disability percentage for hearing loss always enter air conduction results into the hearing loss calculator.

References: For more information on VBMS-R, see the VBMS-R User Guide (also available within the

application and accessible by selecting “Help”), and the prohibition against using bone conduction results, see M21-1, Part III,

Subpart iv, 4.D.2.k.

j. Audiometric Values Above 105 Decibels

If audiometric testing results contain a value above 105 decibels, enter the value into the hearing loss calculator at no higher than 105 decibels for the purpose of determining the puretone threshold average as directed by VA’s Handbook of Standard Procedures and Best Practices for Audiology Compensation and Pension Examinations.

Example: Findings of loss of 115 decibels at the 4000 Hz frequency level will be entered as 105 decibels into the hearing loss calculator.

k. Bone Conduction Results

The Hearing Loss and Tinnitus Disability Benefits Questionnaire specifies when examiners will measure bone conduction results.

Bone conduction is used for diagnostic purposes only. Do not enter it into the hearing loss calculator regardless of the type of hearing loss and regardless of whether the evidence may contain an examiner’s comment that bone conduction results are a better indicator of a particular individual’s hearing loss.

References: For more information on the Hearing Loss and Tinnitus Disability Benefits Questionnaire, see the

D isability B enefits Q uestionnaires Switchboard special monthly compensation (SMC) based on deafness having absence

of air and bone conduction, see M21-1, Part IV, Subpart ii, 2.H.4.h, and hearing loss and tinnitus examination report review, see M21-1, Part III,

Subpart iv, 3.D.4.d.

l. Hearing Impairment Due to Meniere’s Disease

Meniere’s disease is characterized by episodic attacks with subsequent subsiding of symptoms following the attack. A Veteran may be totally deaf during the attack with return to normal hearing when the attack ends. Therefore, in evaluating hearing impairment under 38 CFR 4.87, diagnostic code ( DC ) 6205 , the puretone thresholds or speech discrimination percentages are not required to meet the provisions of 38 CFR 3.385 as hearing impairment associated with Meniere’s disease is often transient.

Important: In some cases, hearing loss may not recede following an attack of Meniere’s disease and instead results in a permanent loss of hearing that meets the definition of hearing impairment under 38 CFR 3.385. In such circumstances, award benefits under the DC that results in the highest percentage for the Veteran.

Reference: For more information on evaluating Meniere’s disease, see M21-1, Part III, Subpart iv, 4.D.4.d and e.

m. Compensation Payable for Paired Organs Under 38 CFR 3.383

Even if only one ear is service-connected (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 percent or more in the SC ear, and meets the provisions of 38 CFR 3.385 in the nonservice-connected (NSC)

ear.

Important: When the above entitling criteria do not apply for the NSC ear, the hearing in the NSC ear should be considered normal for purposes of computing the SC disability rating.

Reference: For more information on compensation payable for paired SC and NSC organs, see M21-1, Part III, Subpart iv, 6.B.3, and M21-1, Part IV, Subpart ii, 2.K.1.

n. Earlier Effective Date of Increase for Hearing Loss

Assignment of effective date in claims for increased evaluation for hearing loss is controlled by 38 CFR 3.400(o).

38 CFR 4.85 pertaining to evaluation of hearing impairment does not control the effective date of a claim for increased evaluation.

An increased evaluation for hearing loss may be assigned from a date prior to the date the Veteran received a VA audiological examination when evidence dated prior to the examination demonstrates that an increase in disability actually occurred, and the hearing loss demonstrated prior to the date of the examination is consistent with the findings shown by the examination.

Note: This will generally require a medical opinion indicating that evidence prior to the date of the examination is consistent with the results of the later, compliant VA examination upon which that increase was shown.

References: For more information on effective dates for increased evaluations for hearing loss when required tests were not

performed on prior examinations, see Swain v. McDonald, 27 Vet.App. 219 (2015), and

claims for increase, see M21-1, Part III, Subpart iv, 5.C.5.

o. 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.

the Veteran has hearing loss evaluated 100 percent under 38 CFR 4.87, DC 6100 with a numeric designation of XI & XI

permanency can be conceded, and SMC awarded 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 awarding 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 part 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.

3. Tinnitus

Introduction This topic contains general information about tinnitus, including

sympathetic reading of tinnitus claims requesting medical opinions for tinnitus interpreting medical opinions involving tinnitus, and applying liberalizing provisions for tinnitus.

Change Date February 2, 2018April 9, 2019

a. Sympathetic Reading of Tinnitus Claims

In cases where only tinnitus is claimed but the evidence shows the presence of hearing loss that may be related to an in-service event or injury or due to some other SC condition, solicit a claim for SC for hearing loss.

If, upon solicitation, a claimant submits a claim for SC for hearing loss and the evidence of record supports SC, use the date the claim for SC for hearing loss was received for effective date purposes.

Similarly, where only tinnitus is claimed but SC has been previously granted for hearing loss, and the evidence of record shows that the hearing loss may have worsened, solicit a claim for reevaluation of hearing loss. For effective date purposes the date of claim will be the date of filing after solicitation, not the date of claim for tinnitus.

By contrast to the guidance in M21-1, Part III, Subpart iv, 4.D.2.a, a claim for SC that is phrased as being for “tinnitus” generally should not be interpreted as raising a claim for SC (or an increased evaluation) for hearing loss.

This is because tinnitus has a specific definition (a subjectively perceived sound in one ear, both ears, or in the head) so a claim asserting that specific condition is generally unambiguous.

Important: Although claims for SC for tinnitus are not automatically or routinely going to raise an additional claim for SC for hearing loss, rarely there may be ambiguities that will require consideration of a claim for hearing loss in circumstances parallel to those addressed in M21-1, Part III, Subpart iv, 4.D.2.a.

Example: An original claim describes the disability claimed only as “tinnitus.” However, a statement submitted in connection with the claim reads “ringing in the ears (tinnitus); problems understanding what people are saying since tanker duty in service.” The additional statement is reasonably read as meaning that the Veteran’s claim for benefits is also premised on problems hearing since service.

References: For more information on sympathetic reading doctrine and issues within the scope of a claim, see

- 38 CFR 3.155(d) - M21-1 Part III, Subpart iv, 6.B.1.c, and- M21-1 Part IV, Subpart ii, 2.A.1.a

reviewing claims for SC for hearing loss in which tinnitus is identified but not claimed, see M21-1 Part III, Subpart iv, 4.D.2.a

the duty to investigate SC for an unclaimed primary disability when a secondary relationship to a claimed disability is shown, see - M21-1, Part III, Subpart iv, 5.C.3.f, and- Delisio v. Shinseki, 25. Vet.App. 45 (2011), and

soliciting claims for unclaimed, chronic disabilities, see M21-1, Part IV, Subpart ii, 2.A.1.e.

b. Requesting Medical Opinions for Tinnitus

A medical opinion is not required to establish direct SC for claimed tinnitus if

STRs document the original complaints and/or diagnosis of tinnitus there is current medical evidence of a diagnosis of tinnitus or the Veteran

competently and credibly reports current tinnitus, and the Veteran claims continuity of tinnitus since service or there are records

or other competent and credible evidence of continuity of tinnitus diagnosis or symptomatology.

Exception: An opinion may be necessary in the fact pattern above if evidence suggests a superseding post-service cause of current tinnitus.

A tinnitus examination may also be necessary if the STRs do not document tinnitus but

there is evidence establishing noise exposure or another in-service event, injury, or disease (for example ear infections, use of ototoxic medication, head injury, barotrauma, or other tympanic trauma) that is medically accepted as a potential cause of tinnitus, and

there is a competent diagnosis or competent report of current tinnitus.

Notes: Under Jandreau v. Nicholson, 492 F.3d. 1372 (Fed. Cir. 2007), a layperson

may provide a competent diagnosis of a condition when a layperson is competent to identify a medical condition. A diagnosis of Tinnitus is a medical condition determination; that a layperson is not competent to render a diagnosis without appropriate medical training and/or background. A layperson is competent to testify to what he/she experiences or perceives – namely the perception of sounds in his/her own ear(s) or head. Accordingly, this is lay testimony and therefore is NOT sufficient, in and of itself, to establish a medically-confirmed diagnosis of tinnitus for the purposes of awarding SC. identify in himself/herself because the condition

is defined by what the person experiences or perceives – namely subjective perception of sounds in his/her own ear(s) or head. Therefore, a layperson may establish the diagnosis of tinnitus at any point in time from service to present. However, consider credibility and weight of the evidence in deciding whether to accept lay testimony as proving tinnitusevidence of an event, injury, or disease in service or a presently disability.

The Hearing Loss and Tinnitus Disability Benefits Questionnaire tinnitus-only examination includes a number of options for examiner opinions on etiology. The examination may be conducted by an audiologist or non-audiologist clinician.

Only ask the audiologist to offer an opinion about the association to hearing loss if hearing loss is concurrently claimed or already SC.

Give consideration to relevant lay evidence describing in-service complaints, a current disability, and/or a link between an in-service event and a current disability.

Example: A Veteran submits a claim for tinnitus six years after discharge. STRs show one instance of tinnitus. The Veteran did not submit a lay statement of continuity. There is no post service medical evidence of continuity concerning tinnitus or tinnitus symptoms.

An examination and medical opinion are needed. Though tinnitus is a condition listed under 38 CFR 3.309(a), it is

sometimes acute and transitory. In most cases, the cause of tinnitus is unknown. Tinnitus can be associated with hearing loss, exposure to loud noise, ear disease, head injury (traumatic brain injury), cerebrovascular disease, tumors, certain medications, and many other medical conditions.

In accordance with 38 CFR 3.303(b), continuity of symptomatology is required when the condition noted during service is not, in fact, shown to be chronic or where 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. Because the chronicity in this example is not adequately supported, granting this claim without an examination would be premature.

Adversely, because the threshold for ordering an audiological examination is very low, denying this claim without an examination would be inappropriate. For this example, an examination and medical opinion must be ordered.

References: For more information on requesting examinations in audiological claims, see M21-1, Part III,

Subpart iv, 4.D.1.a-d, and assessing lay evidence to establish the occurrence of an in-service event or

injury, see- M21-1, Part I, 1.C.3.e- M21-1, Part III, Subpart iv, 5.A.6- 38 CFR 3.304(d) , and- Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

c. Interpreting Medical Opinions 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 38 CFR 4.87, DC 6260 if the hearing loss is determined to be SC, and

establish SC for tinnitus on a direct, not secondary, basis.

Notes: If the hearing loss is SC, and the tinnitus is a

symptom of the hearing loss, we concede that the hearing loss and tinnitus result from the same etiology. Therefore, SC is warranted for tinnitus on a direct basis in these cases.

Under 38 CFR 4.87, DC 6260, a single 10-percent disability evaluation should be assigned for tinnitus, regardless of whether tinnitus is perceived as unilateral, bilateral, or in the head. Separate evaluations for tinnitus for each ear cannot be assigned.

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, and so on, 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.

the examiner states that tinnitus is related to

evaluate all the evidence of record determine if the examiner’s opinion is

noise exposure or an event, injury, or illness in service

consistent with the evidence, and

If … Then …the examiner’s opinion is consistent with the evidence of record

award SC 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 SC 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 SC is warranted.

References: For more information on when to use lay evidence, see

- M21-1, Part III, Subpart iv, 5.A.6- Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006)- Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir. 2007), and

weighing evidence, see- M21-1, Part III, Subpart iv, 5.A.9- 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).

d. Applying Liberalizing Provisions for Tinnitus

38 CFR 4.87, DC 6260 was revised effective June 10, 1999. In the standard for a 10-percent evaluation for tinnitus, the change substituted the word “recurrent” for “persistent.” It also deleted language indicating that compensable tinnitus must be a manifestation of “head injury, concussion, or

acoustic trauma.”

The regulatory revision to this DC was liberalizing. Therefore the provisions of 38 CFR 3.114(a) are applicable when assigning an effective date.

Reference: For more information on assigning effective dates based on liberalizing changes in law, see M21-1, Part III, Subpart iv, 5.C.7.f.

4. Peripheral Vestibular and Other Ear Disorders

Introduction This topic contains general information about peripheral vestibular and other ear disorders, including

definitions of dizziness, vertigo, pre-syncope, and disequilibrium SC of vertigo peripheral vestibular disorders Meniere’s Disease cerebellar gait in Meniere’s Disease, and ear infections.

Change Date February 2, 2018April 9, 2019

a. Definitions: Dizziness, Vertigo, Pre-syncope, and Disequilibrium

Dizziness is a sensation or perception of unsteadiness, imbalance, or potential unconsciousness.

Vertigo is a sensation of rotation or spinning movement – either the self or surrounding objects – when there is no actual movement. Vertigo is best understood as a variety of dizziness where the feeling of unsteadiness or imbalance is due to the sense of spinning.

Presyncope is a feeling of losing consciousness or blacking out. The terms lightheadness and faintness are essentially synonymous although lightheadedness may also be used to describe a feeling of disconnectedness between the head and body rather than actual impending unconsciousness.

Disequilibrium means loss of equilibrium (balance, stability, physical orientation). A disability causing disequilibrium is manifested by symptoms that fall under the umbrella of dizziness (including vertigo or presyncope).

b. SC of Vertigo

Vertigo is generally considered a symptom of another disability, such as a peripheral vestibular disorder or a brain disorder. However SC can be granted for vertigo as provided in M21-1, Part III, Subpart iv, 4.N.1.e.

c. Peripheral Vestibular Disorders

38 CFR 4.87, DC 6204 provides 10-percent and 30-percent evaluations for peripheral vestibular disorders based on dizziness and/or staggering.

A note following the diagnostic criteria states “objective findings supporting the diagnosis of vestibular disequilibrium are required before a compensable evaluation can be assigned …” [Emphasis Added]

Important: The note in the diagnostic criteria does not mean that the

subjective perceptions that define dizziness must be objectively measured or observed for a 10-percent evaluation to be assigned. It means that the diagnosis of the current chronic disorder manifested by vestibular disequilibrium must be supported by objective findings (or have been supported by such findings when the current disorder was SC).

Objective findings include quantitative testing such as electronystagmography (ENG) and auditory brainstem evoked response (ABR) but are not limited to such tests. A variety of clinical examination maneuvers also are used to test for disequilibrium and positive results to examination maneuvers are also considered objective evidence in support of the diagnosis of vestibular disequilibrium.

The important consideration is whether the evidentiary record shows that objective examination results or other tests were cited in supported the diagnosis of the peripheral vestibular disorder manifested by disequilibrium.

Reference: For more information on evaluating vertigo as a symptom of traumatic brain injury (TBI) and the prohibition against evaluating vertigo separately from TBI, see M21-1, Part III, Subpart iv, 4.N.2.h.

d. Meniere’s Disease

Meniere’s Disease (endolymphatic hydrops) is to be rated

under the criteria in 38 CFR 4.87, DC 6205 which consider frequency of attacks of symptoms including hearing loss (with or without tinnitus) and vertigo andor cerebellar gait), or

by assigning separate evaluations for hearing impairment (38 CFR 4.85, DC 6100), tinnitus (38 CFR 4.87, DC 6210), and vertigo (rating vertigo as a peripheral vestibular disorder under 38 CFR 4.87, DC 6204).

Use whichever approach results in a higher evaluation. Do not separately assign an evaluation under 38 CFR 4.87, DC 6205 and a rating for hearing loss, tinnitus, or vertigo.

Reference: For information on assessment of hearing impairment when evaluating Meniere’s Disease under 38 CFR 4.87, DC 6205 , see M21-1, Part III, Subpart iv, 4.D.2.l.

e. Cerebellar Gait in Meniere’s Disease

The 60-percent and 100-percent criteria in 38 CFR 4.87, DC 6205 for Meniere’s Disease refer to cerebellar gait.

A cerebellar gait is a wide-based gait with lateral veering, a slow, jerky and irregular cadence, variable stride length, variability of foot placement from step to step, postural adjustments and propensity to lose balance. In the context of Meniere’s Ddisease the term alludes to staggering associated with vertigo.

f. Ear Infections

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.