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VBR/CSO Quarterly Training June 2013 Thomas Meadows TDVA Training Officer 615-441-3384 or [email protected] 2 Rating Hearing Loss Presented By David Jungquist Course Objectives To learn: • How to rate ear disabilities • Some basic factors of service connection for ear conditions Ratings of the Ear EAR REFERENCS Hearing Loss Definition Ear and Sense Organ Regulations. Paired Organ 38 CFR 3.385 38 CFR 4.85 to 4.87(a) 38 CFR 3.383 5 When is an exam required? • Hearing loss is claimed • Hearing loss is shown in the STR’s • There is no hearing loss for VA purposes in the STR’s AND there is a hearing shift in service or acoustic trauma is conceded AND there is a competent lay statement or medical evidence of hearing loss/tinnitus. Examinations • Must be conducted by State-licensed audiologist. • Must be conducted without the use of hearing aids. Examinations (Cont.) • Must include a controlled speech discrimination test (Maryland CNC). Expressed as percentage of correct responses. • Must include a puretone audiometry test. Measures the dB (decibel) (loudness) level at which a tone can be heard at various frequencies. The puretone threshold average is the sum of puretone thresholds at 1000, 2000, 3000 and 4000 Hz, divided by 4. Hearing loss Criteria 38 CFR 3.385 • A single reading of 40 dB or higher in the range 500 to 4000 Hz. • Three or more readings of 26 dB or higher in the range 500 to 4000 Hz • Maryland CNC Speech Recognition Scores of 93 or lower. Hearing loss is present if any one of the three criteria is met. The criteria apply to individual ears. Example 1 R L 500 1000 2000 3000 4000 20 25 30 30 25 15 20 30 30 30 Speech recognition: R 93% L 96% Does the audio test show hearing loss in the right ear, left ear, or both? Rating Hearing Loss Turn to the Hearing Tables, 38 CFR 4.85(h). Table VI or VI(a) is used to assign the Numeric Designation for each ear based on Puretone Threshold Average and Percent of Discrimination. Table VII is used to determine the evaluation by combining the numeric designations for both ears. Example 2 R L 1000 2000 3000 4000 30 50 75 85 40 50 55 60 Speech recognition: R 88% L 78% What is the evaluation? Average 60 51 Example 3 R L 1000 2000 3000 4000 60 65 70 80 40 40 70 90 Speech recognition: R 86% L 87% What is the evaluation? Average 69 60 Exceptional Patterns of Hearing Loss 38 CFR 4.86a If each of the four frequencies (1000-4000) is 55 dB or higher, use either Table VI or VIa, whichever results in the higher numeral. Exceptional Patterns of Hearing Loss 38 CFR 4.86b If the 1000 Hz reading is 30 dB or less AND the 2000 Hz reading is 70 dB or higher, use table VI or VIa, whichever results in the higher numeral, then elevate to next higher Roman numeral. Table VIa Note that Table VIa does not have speech discrimination (speech reception) scores. It is used under 4.86a OR 4.86b OR when the examiner certifies that the use of the speech discrimination test is not appropriate because of language difficulties, inconsistent discrimination scores, etc… Example 4 R L 1000 2000 3000 4000 25 75 85 105 60 85 105 105 Speech recognition: R 55% L 78% What is the evaluation? Average 73 89 Paired Extremities or Organs 38 CFR 3.383 provides compensation as if both ears were SC when • the hearing impairment in the SC ear would rate at least 10 percent, and • there is hearing impairment in the NSC ear that meets the VA definition for hearing loss (38 CFR 3.385) in the other ear. (NSC cause cannot be due to misconduct.) Example 5 R L 500 1000 2000 3000 4000 30 30 25 25 30 105 105 105 105 105 Average 28 105 Speech recognition: R 96% L 20% The left ear is SC due to acoustic trauma. Grant or denial for the right ear? What is the evaluation? Diseases of the Ear Follow along in the Rating Schedule, from DC 6200 to DC6260 Otitis Media DC 6200 Chronic suppurative otitis media (CSOM) is a perforated tympanic membrane with persistent drainage of pus from the middle ear. Mastoiditis is an infection of the mastoid bone of the skull. Cholesteatoma is a cyst located in the middle ear and skull bone (mastoid). Otitis Media DC 6200 Chronic suppurative otitis media (CSOM), mastoiditis, or cholesteatoma is rated 10 percent during suppuration, or with aural polyps. Rate hearing impairment or complications (labyrinthitis, tinnitus, facial nerve paralysis, or bone loss of skull) separately. Nonsuppurative Otitis Media DC 6201 Chronic nonsuppurative otitis media with effusion is rated on hearing impairment. Middle ear effusion is caused by a presence of fluid in the middle ear without an actual ear infection. Otitis Externa DC 6210 Otitis externa is an inflammation or infection of the external auditory canal and/or auricle. Rated 10 percent when there is swelling, dry and scaly or serous discharge, and itching requiring frequent and prolonged treatment. Peripheral Vestibular Disorders DC 6204 The peripheral vestibular system is comprised of structures within the inner ear which work with the brain to govern balance. 30 percent 10 percent Dizziness and occasional staggering Occasional dizziness Rate hearing impairment or suppuration separately and combine. Meniere’s Syndrome DC 6205 Meniere's disease is a syndrome characterized by episodes of spinning vertigo (sense of the room spinning), hearing loss, and tinnitus (ringing in the ear). Meniere’s Syndrome Rated 30, 60, or 100 percent based on frequency of vertigo and cerebellar gait, with or without tinnitus. OR Separately evaluate vertigo as a peripheral vestibular disorder, hearing impairment and tinnitus, whichever results in a higher evaluation. Ratings under DC 6205 cannot be combined with ratings for hearing impairment, tinnitus or vertigo. Loss of Auricle DC 6207 The auricle is the projecting outer portion of the ear, aka: pinna. 50 percent: 30 percent: 10 percent: Complete loss of both Complete loss of one Deformity of one, with loss of one third or more. Neoplasm DC 6208 and 6209 Neoplasm means tumor. Can be malignant or benign. If benign, rated under DC 6209 on impairment of function. If of the skin of the ear only, the rating will be for a skin disorder. Malignant Neoplasm of the Ear (Other than Skin) DC 6208 Rated 100 percent. A future exam will be conducted six months after the cessation of any surgical, x-ray, antineoplastic chemotherapy or other therapeutic procedure. If there has been no local recurrence or metastasis, the evaluation will be based on residuals, following due process procedures. Perforation of Tympanic Membrane DC 6211 The tympanic membrane (TM) is the eardrum. The rating is zero percent. This can sometimes be used as evidence of acoustic trauma. Recurrent Tinnitus DC 6260 The evaluation is 10 percent, whether the sound is perceived in one ear, both ears, or in the head. An evaluation for tinnitus can be combined with an evaluation for hearing loss, otitis media, or peripheral vestibular disorders. It can be combined with an other DC, except when the tinnitus supports an evaluation under that code (Such as Meniere’s). Questions?