This topic contains information on specific eye conditions, including
considering the etiology of amblyopia
considering impairments of both visual acuity and visual field
considering glaucoma
evaluating preoperative versus postoperative cataracts
evaluating dry eye syndrome
examination requirements for diplopia
evaluating diplopia together with impairment of visual acuity or visual field, and
guidance related to retinitis pigmentosa.
Change Date
May 7, 2015December 11, 2015
a. Ascertaining the Etiology of Amblyopia
Ascertain the etiology of amblyopia in each individual case since a diagnosis may refer to either developmental or acquired causes of lost visual acuity.
b. Considering Impairments of Both Visual Acuity and Visual Field
When there are impairments of both visual acuity and visual field
determine for each eye the percentage evaluation for visual acuity and for visual field loss (expressed as a level of visual acuity under 38 CFR 4.79, DC 6080), and
combine the evaluations under 38 CFR 4.25.
The combined evaluation for visual impairment can then be combined with any other disabilities that are present.
Example
Situation:
Corrected visual acuity is 20/40 in the right eye and 20/70 in the left eye, warranting a 10-percent evaluation.
Visual field loss in right eye is remaining field 38 degrees (equivalent to visual acuity 20/70) and loss in left eye is remaining field 28 degrees (equivalent to visual acuity 20/100), warranting a 30-percent evaluation.
Result: Under 38 CFR 4.25, combine the 30-percent evaluation for visual field loss with the 10-percent evaluation for visual acuity, which results in a 40-percent combined evaluation for bilateral visual impairment.
c. Considering Glaucoma
Glaucoma is recognized as an organic disease of the nervous system and is subject to presumptive SC under 38 CFR 3.309(a).
Consider glaucoma, manifested to a compensable degree within one year of separation from an entitling period of service, to be SC on a presumptive basis unless there is
affirmative evidence to the contrary, or
evidence that a recognized cause of the condition (also known as an intercurrent cause) was incurred between the date of separation from service and the onset of the disability.
Notes:
Angle-closure glaucoma is evaluated on the basis of either visual impairment or incapacitating episodes, whichever results in a higher evaluation. For VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other health care provider.
When evaluating glaucoma, assign a minimum evaluation of 10 percent if the evidence shows that continuous medication is required.
d. Evaluating Preoperative Versus Postoperative Cataracts
38 CFR 4.79, DC 6027, requires that preoperative cataracts are to be evaluated based on visual impairment. If cataracts are postoperative in nature, evaluate based on visual impairment if a replacement lens is present (known as pseudophakia). If there is no replacement lens, evaluate based on aphakia under 38 CFR 4.79, DC 6029.
e. Evaluating Dry Eye Syndrome
Keratoconjunctivitis sicca, more commonly known as dry eye, occurs when the surface of the eye becomes dry due to lack of quality tears. Evaluation and selection of an analogous DC for dry eye syndrome is dependent on the symptoms noted and etiology. Dry eye syndrome may be due to a variety of causes to include
an underlying disease, such as diabetes mellitus or rheumatoid arthritis
medications, such as certain hypertensive and antidepressant medications, non-steroidal anti-inflammatory drugs, decongestants, or antihistamines, and
environmental exposures such as wind, high altitude, dry air, sun, or prolonged eye concentration.
Treatment for dry eyes ranges from use of over-the-counter artificial tear
drops to surgery, prescription medications, blocking of ducts, or special
contact lenses.
The disability picture present with dry eye syndrome varies and, therefore, an appropriate analogous DC must be selected. Appropriate DCs may include 38 CFR 4.79, DCs 6013, 6018, or 6025, depending upon the nature and symptomatology.
Important: Elective procedures, such as laser eye surgery (e.g., LASIK), without unusual results or additional disability attributed to elective procedures are not eligible for SC. Dry eye syndrome is a common result of laser eye surgery, and thus would not be eligible for SC if the etiology of the dry eye syndrome is due solely to an elective procedure. Notes:
Minimal symptomatology only requiring treatment by non-prescription eye drops would typically only warrant a zero percent evaluation under 38 CFR 4.79, DCs 6013, 6018, or 6025, as it clearly does not approximate the criteria required for a compensable evaluation.
Depending on the etiology of the dry eye syndrome, it may also be appropriate to evaluate as a symptom under part of the evaluation of the underlying condition.
References: For more information on the
principles of service connection, see 38 CFR 3.303, and
usual effects of medical and surgical treatment in service having the effect of ameliorating disease, see 38 CFR 3.306(b)(1).
f. Examination Requirements for Diplopia
38 CFR 4.78 requires use of Goldmann Bowl kinetic perimeter testing for examination of muscle function. However, the Tangent Screen is sufficient for rating purposes if the following criteria are met
The test must be performed at a distance of one meter with a 7.5 millimeter (mm) diameter round white test target to evaluate the central 30 degrees and/or a 3.75 mm diameter round white test target at a distance of one-half meter to evaluate beyond the central 30 degrees (up to 60 degrees).
The light falling on the Tangent Screen should be seven foot candles.
The output must be recorded on a Goldmann Perimeter Chart (recording sheet).
A diagnosis of diplopia that reflects the disease or injury that is the cause of the diplopia must be of record.
g. Evaluating Diplopia Together With Impairment of Visual Acuity or Visual Field
When the affected field with diplopia extends beyond more than one quadrant or range of degrees, evaluate diplopia based on the quadrant and degree range that provides the higher (or highest) evaluation. When diplopia exists in two separate areas of the same eye, increase the equivalent visual acuity under 38 CFR 4.79, DC 6090 to the next poorer level of visual acuity, but not to exceed 5/200.
Follow the steps in the table below when assigning an evaluation to visual impairment when a claimant has both
diplopia, and
a ratable impairment of visual acuity or loss of visual field in either eye.
Step
Action
1
Assign a level of visual acuity for diplopia for only one eye under DC 6090.
2
If the visual acuity level assignable for diplopia is …
Then assign a level of corrected visual acuity for the poorer eye (or affected eye, if only one is SC) that is …
20/70 or 20/100
one step poorer than it would otherwise warrant, not to exceed 5/200.
20/200 or 15/200
two steps poorer than it would otherwise warrant, not to exceed 5/200.
5/200
three steps poorer than it would otherwise warrant, not to exceed 5/200.
3
Determine the evaluation for visual impairment under 38 CFR 4.79, DC 6065 or 6066 by using the
adjusted visual acuity of the poorer eye (or affected eye, if only one is SC), and
corrected visual acuity for the better eye (or visual acuity of 20/40 for the other eye, if only one eye is SC).
Example:
The Veteran has an SC evaluation for diplopia.
Diplopia in both eyes is in the 31 to 40 degree range of upward vision and in the 31 to 40 degree range of lateral vision.
The diplopia in the upward vision is equivalent to visual acuity of 20/40, while the diplopia in the lateral vision is equivalent to visual acuity of 20/70.
Result:
Based on 38 CFR 4.78(b)(2) and (3), the overall equivalent visual acuity for diplopia is 20/100, which is one step poorer than the diplopia (in this case, the lateral) that provides the higher evaluation.
The overall evaluation for diplopia is, therefore, 10 percent, based on visual acuity of 20/100 for one eye and 20/40 for the other eye (diplopia is only taken into consideration for one eye).
Note: Diplopia that is occasional or that is correctable with corrective lenses is evaluated at zero percent.
Reference: For examples of rating decisions for diplopia, see M21-1, Part III, Subpart iv, 4.B.4.
h. Guidance Related to Retinitis Pigmentosa
SC may be awarded for diseases of congenital, developmental, or familial origin that either first manifest themselves during service or that preexist service and progress at an abnormally high rate during service so as to demonstrate aggravation.
If no other cause is shown for retinitis pigmentosa, consider it to be hereditary, and determine SC based on whether or not there has been aggravation of this preexisting condition during service.
3. 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 and combat duties
considering National Guard and Reserve duty for hearing loss and/or tinnitus claims
requesting audiometric examinations and medical opinions
when a medical opinion is necessary to determine onset or etiology of tinnitus
considering medical opinions in cases involving tinnitus
handling changed criteria or testing methods
general guidelines for assigning an effective date for an increased evaluation for hearing loss
evidence requirements to assign an earlier effective date of increase for hearing loss
applying past versions of hearing loss criteria
considering SC for development of subsequent ear infection in an NSC ear when the other ear is SC
evaluating exceptional patterns of hearing impairment
evaluating hearing loss when speech discrimination scores are not appropriate or cannot be obtained
considering hearing impairment due to Meniere’s disease
determining the need for a reexamination
compensation payable for paired organs under 38 CFR 3.383
using VBMS-R decision tools in hearing impairment claims
entering audiometric values above 105 decibels into the VBMS-R hearing loss calculator, and
applying liberalizing rule provisions when assigning effective dates for tinnitus.
Change Date
October 23, 2015December 11, 2015
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, 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.
Notes:
Sensorineural hearing loss is considered an organic disease of the nervous system and is subject to presumptive SC under 38 CFR 3.309(a).
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 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: If the audiometric results wereyou have older results that are reported in standards set forth by ASA units, or the results date to a time when ASA units may have been used, and you cannot determine what standards wereas used to obtain the readings, an audiologist opinion will be needed 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 dertiminations.
References: For more information on
applying past versions of hearing loss tables, see M21-1, Part III, Subpart iv, 4.B.3.jk
diseases found to represent organic diseases of the nervous system, see M21-1, Part IV, Subpart ii, 2.B.2.b, and
obtaining medical opinions, see M21-1, Part III, Subpart iv, 3.A.7.
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.
Claims, particularly those from unrepresented claimants, must be read sympathetically. Although a claim for “hearing loss” denotes diminished hearing acuity, a lay claimant might interpret extraneous sounds (tinnitus) creating interference with normal hearing as “hearing loss.” References to “hearing impairment” and “hearing” are even more ambiguous. In cases where the claim is phrased as above but the claimant: 1) makes later contentions specifically about tinnitus, 2) submits evidence of tinnitus or 3) reports tinnitus at a hearing exam or if the examiner diagnoses tinnitus and associates that with the Veteran’s service or another SC disability, treat the hearing-related claim to include a claim for tinnitus. Where SC is established for tinnitus, use the date of the hearing-related claim for effective date purposes.
Note: If tinnitus is not specifically claimed, do not address tinnitus in the rating decision unless SC can be awarded.
References: For more information on
sympathetic reading doctrine generally, see
M21-1 Part III, Subpart iv, 6.B.1.c, and
M21-1 Part IV, Subpart ii, 2.A.1.a, and
application of the sympathetic reading doctrine in mental disorders cases, see
M21-1 Part III, Subpart iv, 4.H.1.a-b, and
M21-1 Part III, Subpart iv, 4.H.6.
c. Considering the Duty MOS Noise Exposure Listing and Combat Duties
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.
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 an event in service.
In addition, also 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
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).
d. 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 duites 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
Action
1
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. Per M21-1, Part III, Subpart iv, 4.B.3.c, the MOS must provide exposure to acoustic trauma capable of causing hearing loss or tinnitus. Note: For purposes of hearing loss or tinnitus during IADT, the MOS providing exposure to acoustic trauma capable of causing hearing loss or tinnitus serves as the injury during IADT required for SC eligibility, per M21-1, Part IV, Subpart ii, 2.B.1.k.
3
Review the entire evidentiary record for acoustic trauma to ascertain both in-service and post-service exposure to acoustic trauma.
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 meet 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 met. References: For more information on
requesting records, see M21-1, Part 1, 1.C
duty status and eligibility of personnel in the National Guard service, see M21-1, Part III, Subpart ii, 6.3
determining Veteran status and eligibility for benefits, see M21-1, Part III, Subpart ii, 6
applying the presumption of soundness for ADT, see M21-1, Part IV, Subpart ii, 2.B.1.j
requirements for IADT to be considered active service, see M21-1, Part IV, Subpart ii, 2.B.1.k, and
examination requests, see M21-1, Part III, Subpart iv, 3.A.
de. 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).
Notes:
Competent evidence of a current diagnosis of symptoms could include records or lay evidence of difficulty hearing or tinnitus.
Establishment of an event, injury, or disease in service is fact-specific. If there is no 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 will be considered.
If noise exposure is conceded based on the Duty MOS Noise Exposure Listing, 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 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 noise exposure is not conceded but an examination and/or opinion are otherwise necessary based on another event, injury, disease, provide the probable level of exposure to hazardous noise associated with the Veteran’s documented duty position in the examination request remarks.
If the evidentiary threshold for finding a VA examination necessary under 38 CFR 3.159(c)(4) has been met, a duty MOS consistent with a lower probability of hazardous noise exposure than “Highly Probable” or “Moderate” does not preclude a VA examination.
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.
For claims received from a reservist on account of active or inactive duty for training, review service treatment records (STRs) should be reviewed to determine the auditory acuity of the individual prior to, and during, his/her period of service. Entitlement may be awarded if there has been a decrease in auditory acuity due to acoustic trauma as a result of military duties.
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.B.3.c, and
medical opinions and the Hearing Loss and Tinnitus Disability Benefits Questionnaire (DBQ), see M21-1, Part III, Subpart iv, 3.A.7.hg.
ef. When a Medical Opinion Is Necessary to Determine Onset or Etiology of 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. Tinnitus is a medical condition that a layperson is competent to 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 tinnitus in service or presently.
The Hearing Loss and Tinnitus DBQ 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.
fg. 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 38 CFR 4.87, DC 6260 if the hearing loss is determined to be SC, and
establish service connectionSC 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 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 of record
award SC on a direct basis.
the examiner’s opinion is not consistent with the evidence of record, 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, 5.6
Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), and
Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir. 2007).
weighing evidence, see
M21-1, Part III, Subpart iv, 5. 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).
gh. 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).
hi. General Guidelines for Assigning an Effective Date for an Increased Evaluation for Hearing Loss
In claims for increased evaluation for hearing loss, the effective date is still controlled by 38 CFR 3.400(o). The effective date will be
will be no earlier than the date of claim or date entitlement arose, whichever is later, or
one year prior to the date of claim, if it is factually ascertainable that an increase in disability had occurred from such date.
ij. Evidence Requirements to Assign an Earlier Effective Date of Increase for Hearing Loss
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.
Reference: For more information on effective dates on increased evaluations for hearing loss when required tests were not performed on prior examinations, see Swain v. Mcdonald, 27 Vet. App. 219 (2015).
jk. 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 linked 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:
standards for old audiometry, see M21-1, Part III, Subpart iv, 4.B.3.a.
kl. Considering SC for Development of Subsequent Ear Infection in an NSC Ear When the Other Ear Is SC
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.
lm. 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) 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.
mn. 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.
no. Considering 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, 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.
op. 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.
pq. 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 percent or more in the SC ear, and
meets the provisions of 38 CFR 3.385 in the 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.a, and
M21-1, Part IV, Subpart ii, 2.K.1.
qr. Using VBMS-R Decision Tools in Hearing Impairment Claims
VBMS-R includes embedded calculators for hearing loss and tinnitus and ear diseases to help RVSRs and Decision Review Officers (DROs) assign correct evaluations and generate required narrative explanation. The calculator output is placed in the rating Narrative.
References: For more information on
VBMS-R, see the VBMS-R User Guide (also available within the application and accessible by selecting “Help”), and
VBMS, see the VBMS Resources page.
rs. Entering Audiometric Values Above 105 Decibels Into the VBMS-R Hearing Loss Calculator
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.
st. Applying Liberalizing Rule Provisions When Assigning Effective Dates 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.
4. Exhibit 1: Examples of Rating Decisions for Diplopia
Introduction
This exhibit contains three examples of rating decisions for diplopia.
Change Date
August 3, 2011
a. Example 1
Situation: The Veteran filed an original claim for bilateral impairment of visual acuity on June 1, 2009. VA examination reveals the best distant vision obtainable after correction is 20/200 (6/60) in the right eye and 20/70 (6/21) in the left eye. Diplopia secondary to thyroid myopathy has been diagnosed and is within 24 degrees in the upward quadrant. Diplopia within 24 degrees in the upward quadrant is ratable as 20/70 (6/21) under DC 6090.
Rationale: Because the evaluation for diplopia is 20/70, evaluate visual acuity in the poorer eye (right) as 15/200 per 38 CFR 4.78, one step poorer than it would otherwise warrant.
Coded Conclusion:
1. SC (VE INC)
6066
Visual impairment secondary to thyroid myopathy, bilateral, with diplopia
40 percent from 06/01/2009
b. Example 2
Situation: The same facts as in Example 1, except the diplopia exists within 24 degrees in the downward quadrant. Diplopia within 24 degrees in the downward quadrant is ratable as 15/200 (4.5/60) under DC 6090.
Rationale: Because the evaluation for diplopia is 15/200, evaluate visual acuity in the poorer eye (right) as 10/200 per 38 CFR 4.78, two steps poorer than it would otherwise warrant.
Coded Conclusion:
1. SC (VE INC)
6066
Visual impairment secondary to thyroid myopathy, bilateral, with diplopia
50 percent from 06/01/2009
c. Example 3
Situation: The Veteran is SC for impairment of the visual field in the right eye secondary to trauma. The average contraction of the visual field is to 50 degrees, and is ratable equivalent to 20/50 (6/15) at 10 percent. Diplopia has been diagnosed secondary to trauma and exists within 20 degrees in the central area. Diplopia within 20 degrees in the central area is ratable as 5/200 (1.5/60).
Rationale: Since the evaluation for diplopia is 5/200, evaluate the visual field impairment in the SC eye (right) as 20/200 per 38 CFR 4.78, three steps poorer than it would otherwise warrant.
Result: Assign a 20-percent evaluation under 38 CFR 4.79, DC 6090-6066 for diplopia with impairment of the visual field, right eye. Do not assign a separate 10-percent evaluation for contraction of the visual field.
Coded Conclusion:
1. SC (VE INC)
6090-6066
Diplopia secondary to trauma, with impairment of visual field, right eye
