Citation Nr: 0706913 Decision Date: 03/08/07 Archive Date: 03/20/07 DOCKET NO. 94-15 475 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to service connection for bilateral hearing loss. WITNESS AT HEARINGS ON APPEAL The veteran ATTORNEY FOR THE BOARD D. M. Casula, Counsel INTRODUCTION The veteran had active service from January 1955 to January 1957. This matter comes before the Board of Veterans' Appeals (Board) from a March 1993 rating decision of the above Regional Office (RO) of the Department of Veterans Affairs (VA) which, in pertinent part, denied service connection for bilateral hearing loss. In July 1996 and October 1998, a Veterans Law Judge, who is no longer with the Board, remanded this issue to the RO for further development. In June 2000, the veteran advised the Board that he was no longer represented by the Oregon Department of Veterans' Affairs and, since then, he has proceeded on the record representing himself in the appeal. By July 2000 decision, the Board determined that the claim for bilateral hearing loss was well grounded, and remanded the hearing loss claim for additional evidentiary development, pursuant to Stegall v. West, 11 Vet. App. 268 (1998). In November 2005, the Board again remanded the claim for service connection for bilateral hearing loss for additional evidentiary development pursuant to Stegall. FINDING OF FACT The preponderance of the competent and probative medical evidence of record is against a finding that the veteran's bilateral hearing loss is etiologically related to service. CONCLUSION OF LAW Bilateral hearing loss was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2006). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim, (2) that VA will seek to provide, and (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in his possession that pertains to the claim, in accordance with 38 C.F.R. § 3.159(b)(1). The U.S. Court of Appeals for Veterans Claims (Court) has held that VCAA notice should be provided to a claimant before the initial RO decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if VCAA notice is provided after the initial decision, such a timing error can be cured by subsequent readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental SOC (SSOC). Mayfield v. Nicholson, No. 02-1077 (Vet. App. Dec. 21, 2006). The Board finds that the VCAA notice requirements have been satisfied with respect to the veteran's claim, as he was sent a notice letter in December 2005, in which he was informed of VA's duty to assist him in substantiating his claim under the VCAA, and the effect of this duty upon his claim. Thus, the Board concludes that the notification received by the veteran adequately complied with the VCAA and subsequent interpretive authority, and that he has not been prejudiced by the notice and assistance provided by the RO. In addition, it appears that all pertinent obtainable evidence identified by the veteran relative to his claims has been obtained and associated with the claims file, and that neither he nor his (then) representative has identified any other pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. The Board notes that, in prior remands, the RO was instructed to contact VA examiners who had provided medical opinions and ask that they provide the rationale for their respective opinions regarding the significance of the veteran's in- service noise exposure in the development of his current hearing disability. Only one such VA examiner was accounted for, the Ph.D. in March 1998, who was found to have retired. The Board notes that since VA has obtained a VA opinion, by an appropriate hearing specialist, which includes complete review of the veteran's claims file, and a decision with supporting rationale, there is no indication that further attempts to obtain rationales from the VA examiners who rendered opinions more than seven years ago would provide any additional benefits to the veteran. For reasons explained below, there are other weaknesses with those medical opinions, which have rendered them less probative and persuasive. More recently, in an SSOC dated in September 2006, he was provided with an additional 60 days to submit more evidence. It is therefore the Board's conclusion that the veteran has been provided with every opportunity to submit evidence and argument in support of his claim, and to respond to VA notices. See Mayfield, supra. Accordingly, we find that VA has satisfied its duty to assist the veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claim under the VCAA. Therefore, no useful purpose would be served in remanding this matter for yet more development. Such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). In addition to the foregoing harmless-error analysis, to whatever extent the recent decision of the Court in Dingess v. Nicholson, 19 Vet. App. 473 (2006), requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date, the Board finds no prejudice to the veteran in proceeding with the present decision. The September 2006 SSOC specifically explained the Dingess precedent. II. Factual Background Service medical records show that, on the pre-induction examination in December 1954, the veteran's ears were clinically evaluated as normal. Bilateral hearing was reported as 15/15 to whispered voice and no entry was made in the summary of defects and diagnoses. The January 1957 examination for separation shows the veteran's ears were clinically evaluated as normal. Bilateral hearing was reported as 15/15 to spoken and whispered voice. Results of audiometric testing showed hearing thresholds in decibels of 0, 0, -5, and -5, in the right ear, and -5, -5, -5, and 5, in the left ear, at 500, 1,000, 2,000, and 4,000 hertz (Hz), respectively. VA audiometric readings prior to June 30, 1966, and service department audiometric readings prior to October 31, 1967, must be converted from American Standards Association (ASA) units to International Standard Organization (ISO/ANSI) units. Thus, on evaluation, pure tone threshold levels, in decibels, converted from ASA to ISO/ANSI units, were as follows: 15, 15, 10, and10, on the right and 10, 10, 10, 10, on the left, at 500, 1000, 2000, and 4000 Hertz. There was no entry in the summary of defects and diagnoses. Service records show that the veteran was assigned to an anti-aircraft artillery (AAA) unit. His military occupational specialty (MOS) was AAA Gun Crewman. The veteran's initial claim for dental benefits was supplemented in September 1958 with a claim that included "left ear condition 1956". He reported treatment at a military infirmary in "1956". He did not report for a VA examination of the left ear or respond to a RO request for evidence. The RO then requested additional service medical records regarding the reported treatment for an "ear condition" in the left ear at the time and location the veteran had reported. In November 1958, the service department responded that no additional records were found. A May 1992 ENT consultation noted the veteran's complaint of decreased right ear hearing of 17 years, without significant change, and fluctuating left ear hearing loss for a year. It was noted he had a history of previous noise exposure, tinnitus, and occasional vertigo, but no history of otologic trauma. The assessment was hearing loss. A June 1992 VA treatment record showed that the veteran reported having "hearing loss". The summary of his hospitalization from May to June 1992 shows the diagnoses included hearing loss and it was noted he was extremely hard of hearing. VA treatment records showed that in a June 1992 audiological consultation request, the veteran was reported to have a history of long-term hearing impairment in the right ear and recent fluctuating hearing loss in the left ear. Audiological testing in July 1992 showed moderate to profound loss probably mixed in the right ear and mild to profound sensorineural loss in the left ear. It was noted that he was in the rehabilitation program, and was unable to hear and understand counseling and medication instructions. Additional treatment records from audiology in August 1992 showed that he had significant hearing loss. On VA general medical examination in August 1992, the examiner noted a profound low frequency hearing defect on examination of the ears. The diagnoses included profound hearing deficit. On an August 1992 VA examination for ear disease, the veteran reported increasing hearing loss especially in the right ear for about 18 years, and that it decreased in the left ear about two years before. He had constant, variable bilateral tinnitus. He complained that he was exposed to much gunfire while in the Army. The diagnoses were bilateral hearing loss and secondary, constant bilateral tinnitus. The worksheet for the VA audiology examination in September 1992 showed that the veteran reported a history of dizziness without vertigo or nausea, constant tinnitus, and fluctuating hearing loss. He said the tinnitus, noticed on the right side, began when the dizzy spells began. Audiometric testing showed right ear decibel thresholds (at frequencies of 500, 1000, 2000, 3000, and 4000 Hz) of 70, 75, 80, 105+, and 105+. Left ear decibel thresholds at these same frequencies were 50, 60, 90, 105+, and 105+. Speech discrimination was 86 percent in the right ear and 66 percent in the left ear. An ENG report in September 1992 showed the veteran reported fluctuating left ear hearing loss documented over the previous two months. The examination impression was significant unilateral weakness on the left. A November 1992 ENT clinic report noted fluctuating hearing loss and gait difficulty that was assessed as rule out multiple sclerosis versus autoimmune disorder, bilateral Meniere's disease. Received from the veteran in February 1993, was a claim for service connection for hearing loss and tinnitus. He said that both had begun in military service when he was exposed to firing of anti-aircraft guns without any hearing protection, and not advised of potential damage. He said in service he was told that the problem would disappear, and that he believed this since his symptoms were mild or intermittent. The veteran recalled that the ringing became louder around 1976 and later involved the left ear. He said that recently he was plagued with additional inner ear problems that he identified as a constant feeling of dizziness and loss of balance. He recalled complaining about his problems when he was given an audiology examination in service. He asserted that these problems were the result of noise damage during his military service. A March 1993 VA tympanogram report showed complaints of subjective vertigo and increased hearing loss. The test results indicated a possible developing middle ear problem. A magnetic resonance imaging (MRI) of the head in March 1993 showing left basal ganglia lacunar infarct, moderately severe supratentorial and infratentorial atrophy, and no findings to confirm demyelinating process or acoustic neuroma. In a statement dated in December 1993, the veteran reported he was a "big guns repair mechanic" for his entire period of service and had "constant exposure to heavy firing". In his March 1994 substantive appeal (VA Form 9), the veteran indicated he began suffering from tinnitus in service. He claimed that his records showed he was a loader and then a gun mechanic on 90 mm anti-aircraft guns. He averred he was not issued protective devices and was not advised on ways to protect his hearing. VA medical records show that in March 1994 the veteran was seen in the ENT clinic and it was noted that he had severe Meniere's disease with a profound hearing loss in the left ear and a severe hearing loss in the right ear. In June 1994, the veteran testified at a hearing at the RO. He elaborated on his previously stated contentions and recollections regarding exposure to weapons firing in service. He recalled having his hearing tested before he left the service. He also elaborated on the extent of shooting he engaged in after service, and his recollections of conversations with physicians regarding his hearing problem. He felt that Menieres was the result of his military experience but noted a VA physician, had told him he had the disorder but did not know what caused it. Also, received in June 1994 from the veteran was information regarding tinnitus, Meniere's disease, and hearing loss found in the Mayo Clinic Family Health Book and the Health Reference Center. He also submitted additional information from OSHA and from the American Academy of Family Physicians on tinnitus and acoustic trauma. He added additional information including research from the Health Reference Center that included a government agency report on the prevalence of hearing loss in certain age groups that was once found in World War II artillery personnel. He also provided information regarding Meniere's disease and hearing loss from Disability Evaluation Under Social Security, a handbook for physicians. In a report dated in April 1995, J.B., M.A., a hearing, speech and language therapist, concluded that the veteran had a profound bilateral sensorineural hearing loss and chronic tinnitus. The therapist opined that the gradual and progressive nature of his hearing loss and tinnitus in his mid-to-late fifties suggested noise-induced hearing loss rather than such loss associated with aging. The therapist noted that she based her decision on research which substantiates such a link, rather than on specific reference to the veteran's history of noise exposure. She further indicates that an audiologist, with expertise in noise exposure, should be consulted and that there should be further investigation into the true actual levels of noise the veteran was exposed to and there should be a clear chronological interpretation of his past medical history. Congressional correspondence that VA received in 1996 included a lengthy statement from the veteran wherein he argued, in essence, the hearing evaluation in service at separation was on account of his complaints and that this evidence was "suppressed". He asserted the test would not have been completed had he not made a complaint about tinnitus. He argued further that it is not his fault if reports from military service were not written or are missing. In July 1996, the Board remanded this matter to the RO, requesting that the veteran identify relevant treatment sources, and that the veteran be scheduled for a complete audiological examination to determine the nature, etiology, and severity of any bilateral hearing loss or tinnitus. On VA ear disease examination in December 1996, the veteran reported a history of exposure to antiaircraft artillery fire without ear protection in service, that he suffered bilateral hearing loss and tinnitus since that time, and that the hearing loss continued to progress since his discharge from service. The veteran reported ongoing disequilibrium and unsteadiness for many years but had not had frank dizziness or true vertigo. The diagnoses were severe to profound bilateral sensorineural hearing loss and moderate to severe, constant bilateral tinnitus. The companion audiology examination in December 1996 showed that the veteran reported a history of noise exposure from recreational shooting after military service until the 1970's, and the onset of tinnitus in 1955-1956. The summary showed severe to profound sensorineural hearing loss. Received in February 1997, were two buddy statements submitted by the veteran. The veteran's service comrades, V.N. and A.N., recalled no ear protectors being used and they also did not recall being warned about hearing problems. The veteran submitted an August 1994 report for the Social Security Administration (SSA), from a private ENT doctor, M.B, M.D. Dr. M.B. reported that the veteran appeared to suffer from Meniere's disease that resulted in a disabling bilateral sensorineural hearing loss and a fluctuating type of dizziness. Dr. M.B. indicated that the veteran had 80 to 90 percent hearing impairment, and that he first succeeded the threshold (presumably SSA's threshold) of hearing impairment in March 1993, and that his hearing had worsened since that time. The veteran claimed in a letter received in April 1997 that Dr. M.B.'s findings were rendered exclusively from VA medical records. In November 1997, the same ear disease examiner who conducted the VA examination in December 1996, rendered an addendum. The VA examiner noted that the claims file was made available a week prior to the date of the dictated report. The examiner noted that the limited service medical records made no mention of hearing loss, tinnitus or inner ear difficulties, and that the January 1957 examination whispered voice and the audiometer recording indicated normal hearing. he examiner stated that while it was reasonable to argue that the amount and type of noise exposure the veteran experienced in service might have resulted in some hearing loss or tinnitus, it was in no way imaginable that the experience would relate to his later progression of hearing loss and tinnitus, and the presently described balance difficulties. It was the examiner's conclusion that, based upon the service record, the veteran's present difficulties could not be causally related to his period of active military service. In November 1997, the same audiologist from December 1996 reviewed the veteran's claims folder and issued a report. The audiologist opined that it was highly likely that the veteran's hearing loss and tinnitus were partially attributable to his noise exposure during service. But, the audiologist felt that it was impossible to state the exact degree of hearing loss that was due to military noise exposure since the veteran did not have audiometry results immediately following service. It was the audiologist's opinion that because of the veteran's age at the time of the 1992 VA audiogram, it was possible that a mild portion of his hearing loss was related to presbycusis. She recommended further consultation as to whether the hearing deterioration in the left ear could be attributed to Meniere's disease and to further "speculate" as to the amount of noise-induced hearing loss. In summary, the audiologist stated that she could not determine whether the veteran had Meniere's disease and, if so, to what degree it affected his hearing. In February 1998, the RO requested an opinion from one of the clinicians named by the audiologist. In March 1998, another VA clinician (a Ph.D.) responded stating that as noted on a previous ear, nose, and throat examination, the veteran had normal hearing when he left the military service. In June 1998 the veteran again testified at a hearing at the RO. His testimony contained an elaboration of the previous history of noise exposure. He responded to the question regarding the Board's request for additional evidence by stating it was all in his records and he did not have any. In letters dated in June and July 1998 to the RO, the veteran advised that he changed his mind regarding another examination. He asserted that there was sufficient evidence to confirm his disorders. He argued that VA knew that no doctor could make a definitive statement linking the cause to military service. In response a VA letter informed him of the action that would be taken in light of his request to return the case to the Board. However, in late July 1998, the veteran wrote to the RO that he would accept another examination. An August 1998 statement from a person who recalled that on his military separation examination he was not tested by audiometrics or whisper method even though being exposed to intense noise during duty in Vietnam. The writer presumed that since he did not request such testing, it was not given as a standard practice on separation from the military. As a result of the Board remand in 1998, the RO obtained a record of SSA action, which the veteran stated, was based exclusively on VA outpatient medical records. There was information regarding his condition obtained in 1992 that noted the hearing in his right ear left him sometime in 1975, and that the left ear problem began in the latter part of 1990. He said that he had experienced balance problems since the first of the year. A SSA psychology evaluation in late 1992 contained essentially the same history. The SSA decisions in 1994 and 1995 found the veteran had severe impairment due to hearing loss and Meniere's disease. The RO sent the veteran requests seeking relevant evidence regarding Meniere's disease and other claimed disorders, as well as authorization for the release of such information. The veteran's letter dated in November 1998 in response stated that he had no additional information, but referred to the SSA decision, and advised that he did not recall a physician who treated him in the mid 1970s for hearing loss. He then wrote the next month for an explanation regarding the need for certain examinations the Board requested. He wrote to the VA Secretary early in 1999 stating that he saw no reason for reexamination since Meniere's disease and other disorders were well documented in the record. On VA ear disease examination in March 1999, the veteran recalled his exposure to artillery noise in service, going on sick call at one point because of "roaring tinnitus and hearing loss" in the left ear, and complaining of tinnitus at separation from service. The examiner indicated that the veteran's discharge audiogram was not located, but he was "told" that he discharge audiogram was normal. The pertinent impression after examination was profound bilateral sensorineural hearing loss with constant bilateral tinnitus and vertigo. In the March 1999 VA examination report, the examiner further opined that the veteran had some characteristics of progressive Meniere's disease. The episodic nature and fluctuating hearing loss were characteristic, but the lack of demonstrable auditory recruitment, and rather consistent presence of frank otalgia were not. The examiner noted that it would "hardly be possible for someone assigned to 90 mm anti-aircraft gun duty in that time frame to escape without some hearing loss and tinnitus", but that he was not able to find definitive documentation for the service years including audiometry and specialist evaluation of problems that would bear on the current inquiry, and was not able to find such documentation for the period just after separation from service. The examiner opined that it was virtually certain that the cause of some of the tinnitus was service, and that it was "possible" that some hearing loss was concussion induced. The examiner stated that the onset of the vertigo- hearing loss-tinnitus syndrome, possibly Meniere's, could not be documented with available records for the service years. The examiner believed that to better clarify the present diagnosis would require neurological consultation and neuropsychological testing. The VA audiology examination performed in March 1999 showed the veteran once again recalled tinnitus during service. According to the record, he reported dizziness and vertigo, but he could not recall the specific onset of dizziness or left ear hearing loss. He said the right ear hearing loss was initially noticed in the 1970's. The examiner reported moderately severe to profound loss of hearing sensitivity in the right ear, profound loss of hearing sensitivity in the left ear, and poor speech recognition and constant tinnitus in both ears. The VA ear disease examination addendum dated in September 1999 (completed by the same examiner from March) noted that several volumes of materials in the claims file were reviewed, which included the induction and separation examinations. The examiner questioned the validity of the separation examination, citing three reasons for this, including the examiner's opinion that the thresholds listed on the separation examination would be unusual in any adult and essentially impossible for someone who had been exposed to basic training in artillery fire. It was the examiner's belief, in essence, that no valid conclusion could be drawn from the military discharge examination since the reported hearing level unlikely represented actual hearing at the time. The examiner noted that the reference to acute hearing loss had no real significance in these evaluations, and that while the tendency for fluctuation of sensorineural hearing loss in Meniere's syndrome and other conditions is recognized, the veteran's case involved profound loss that was essentially irreversible and had no significant acute component. The examiner indicated that tinnitus fluctuated in many individuals but that did not change the chronic nature of tinnitus. The examiner noted that service records showed no reference to ears or hearing, and that while the veteran reported a visit to a naval facility for his ears in 1956, documentation of that could not be found. The VA examiner in September 1999 also attached a referral memorandum for a neurology consultation regarding Meniere's disease and hearing loss, summarized the pertinent information from the available record. The record reflects that examinations were scheduled and that the veteran did not appear for them. The messages from a VA medical center indicate the veteran's request to reschedule had twice been accommodated but that he "refused to be seen" at the VA facility. The message indicates his most important question was what would happen if he refused to be examined. In a November 1999 report of contact, the RO was advised that the veteran asked for the examinations to be rescheduled at a VA facility in Arizona, where he resided for the winter months. In a December 1999 letter to the RO, the veteran asked to have the examinations rescheduled in Arizona and to have the RO explain what would happen if he refused further examination. In January 2000, the veteran wrote the RO that it had been decided that further examination was "not in my best interest" and that he declined further examination unless there was a VA regulation that "compels me to be examined". He asked the RO to provide the details of such a regulation if it existed. In another letter dated in January 2000, he asked for a copy of the January 1957 audiometry findings which he believed the RO Decision Review Officer had forgotten to send him. He quoted legal definitions of "withholding of evidence" and "fraudulent concealment". The RO letter in March 2000 acknowledged the recent correspondence regarding the processing time in his appeal and advised that action would be taken on the evidence available. The veteran was reminded of his recent decision not to undergo a scheduled examination and advised regarding the duty to assist. The veteran then supplemented the record in April 2000 with 19 pieces of correspondence variously dated from 1998 to 2000 that he determined were missing from his claims file. In March 2000, the RO issued a supplemental statement of the case (SSOC) that noted the veteran had declined further examination. He did not advise the Board through more recent correspondence that he intended to change his decision regarding further examination. Responding in April 2000, the veteran asserted that service records were "fraudulently concealed" from him and VA examiners. Once again in June 2000 he argued regarding the significance of the hearing evaluation at separation from military service and the concealment of this evidence. In July 2000, the Board issued a decision which, in pertinent part, found the claim for service connection for bilateral hearing loss to be well grounded. The Board then remanded that issue for further evidentiary development, including obtaining information from the veteran regarding any treatment for his hearing loss. The Board also directed the RO to contact VA examiners who had provided medical opinions and ask that they provide the rationale for their respective opinions regarding the significance of the veteran's in- service noise exposure in the development of his current hearing disability. Finally, the Board directed that the veteran's claims folder be reviewed, by a hearing disorder specialist if available, to include an examination if necessary. In a September 2000 Report of Contact, the RO reported that the Portland VAMC was contacted and revealed that the VA Ph.D. who rendered an opinion in March 1998 was no longer with them due to retirement. By September 2000 rating decision, the RO granted service connection for tinnitus. In November 2001, pursuant to the veteran's request, the Board sent to him copies of his audiology examination in January 1957 and of his separation physical examination. In August 2004, the veteran submitted additional argument and evidence in the form of a June 1997 medical statement of Dr. N, a specialist in otology. Dr. N commented that it certainly seemed like the veteran had a tremendous amount of noise exposure in the past. Dr. N explained that a temporary threshold shift was indicative of inner ear damage, but was temporary and would normally recover completely or almost so, unless further noise exposure were to occur. Dr. N stated that the only reason he could imagine that the veteran would have tinnitus at the time of discharge without evidence of hearing loss was that perhaps the spectrum of hearing tested (frequencies) was limited and did not include injured frequencies. Dr. N stated that this was speculation and there was no way to prove it, but that this was somewhat of an indicator of problems to come later. In December 2004, additional medical information obtained from the National Center for Biotechnology Information (NCBI), National Institutes of Heath (NIH) website, was added to the file. This information pertaining generally to acoustic trauma and noise exposure and Meniere's disease, essentially indicating that post-traumatic Meniere's disease could manifest several years later. In November 2005, the Board issued a decision (denying service connection for Meniere's disease) and a remand of the claim of entitlement to service connection for bilateral hearing loss, pursuant to Stegall v. West, 11 Vet. Appellant 268 (1998). In the remand, the Board requested further evidentiary development, including obtaining information from the veteran regarding any treatment for his hearing loss. The Board also directed the RO to contact VA examiners who had provided medical opinions and ask that they provide the rationale for their respective opinions regarding the significance of the veteran's in-service noise exposure in the development of his current hearing disability. Finally, the Board directed that the veteran's claims folder be reviewed, by a hearing disorder specialist if available, to include an examination if necessary. On VA examination in May 2006, the examiner (who is Board certified in otolaryngology), noted that he was supplied with all of the veteran's medical records and claims file and reviewed these before dictating the VA examination report. The examiner noted that in service the veteran was attached to artillery or anti-aircraft and was involved with firing weapons, and that , according to the veteran's report, did not involve using ear protection much of the time. The examiner also noted that the veteran's separation examination showed he had normal hearing in both ears at the time of discharge. The examiner did not believe the medical literature related Meniere's disease to an noise exposure and from all the records it was not sure that the veteran even had Meniere's disease. The examiner opined that the veteran's Meniere's disease (if he indeed had it) and his hearing loss were "more likely than not not" related to his military service. The examiner indicated that, since there was documentation on the veteran's separation examination of normal hearing at the time of discharge, and since the preponderance of the evidence is that the hearing loss due to acoustic trauma is not a progressive form of hearing loss, and since the veteran had developed a lot of hearing loss over the 40 years since his military service, "certainly the evidence is more likely than not that the hearing loss [the veteran] has is not related to his military experience". Finally, the examiner noted that the veteran was not examined or interviewed at that time, and the examiner did not feel that examination or further testing would shed an more light on this situation. The examiner also noted that further evaluation or physical examination by him would not be helpful or have any bearing on his conclusions. III. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection for certain chronic diseases, including sensorineural hearing loss (as an organic disease of the nervous system) will be presumed if such disease becomes manifest to a compensable degree within the first year following active service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the purpose of applying the laws administered by VA, impaired hearing is considered a "disability" when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hz is 40 decibels or greater; or when the auditory thresholds for at least three of the above frequencies are 26 decibels or higher; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To do so, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992), Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Gilbert, supra. And equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The veteran contends that his bilateral hearing loss was caused by noise exposure during service. He claims that his hearing problems started in service as a result of exposure to noise from the firing of anti-aircraft artillery guns. Service records confirm that the veteran was assigned to an anti-aircraft artillery unit, and his military occupational specialty (MOS) was AAA Gun Crewman. A review of the record shows that VA has essentially conceded his exposure to noise in service. (Although the Board notes that the veteran has also reported a history of noise exposure from recreational shooting after military service until the 1970's.) In addition, audiograms confirm that the veteran does have current bilateral hearing loss disability, for VA purposes. 38 C.F.R. § 3.385. What is at issue is whether the veteran's bilateral hearing loss is related in anyway to his active military service. Service medical records show that the veteran had essentially normal hearing upon discharge from service. Although he filed a claim for a "left ear condition 1956" in 1958, he failed to report for a VA examination at the time. The first medical evidence of any hearing loss was dated in 1992, at which time the veteran complained of decreased right ear hearing for 17 years and fluctuating left ear hearing loss for a year. With regard to a medical link between the veteran's current hearing loss disability and his exposure to noise in service, the Board notes that there have been several medical opinions rendered during the course of this appeal. However, after weighing the medical opinions, to determine the probative value of each opinion, the Board concludes that the preponderance of the competent medical evidence of record is against establishing a link between the veteran's hearing loss and exposure to noise in service. The Board notes that there are three medical opinions of record which tend to support the veteran's claim. In a report dated in April 1995, J.B., M.A., a hearing, speech and language therapist, opined that the gradual and progressive nature of the veteran's hearing loss and tinnitus in his mid- to-late fifties suggested noise-induced hearing loss rather than such loss associated with aging. The problem with this opinion is that the therapist based her decision on research which substantiates such a link, rather than on specific reference to the veteran's history of noise exposure. She further indicates that an audiologist, with expertise in noise exposure, should be consulted and that there should be further investigation into the true actual levels of noise the veteran was exposed to and there should be a clear chronological interpretation of his past medical history. The Board assigns this opinion less probative value because there is no indication that the therapist had access to the veteran's entire claims file (and she concedes as much at the end of her opinion), and Factors for assessing the probative value of a medical opinion include the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Similarly, the November 1997 audiologist's opinion tends to support the veteran's claim. The audiologist opined that it was highly likely that the veteran's hearing loss and tinnitus were partially attributable to his noise exposure during service. But, the audiologist felt that it was impossible to state the exact degree of hearing loss that was due to military noise exposure since the veteran did not have audiometry results immediately following service. The audiologist opined that because of the veteran's age in 1992, it was possible that a mild portion of his hearing loss was related to presbycusis. She recommended further consultation as to whether the hearing deterioration in the left ear could be attributed to Meniere's disease and to further "speculate" as to the amount of noise-induced hearing loss. Although the audiologist did have access to the veteran's claims folder, the Board notes that she has failed to provide a definitive opinion, with supporting rationale; rather she indicated that further consultation was needed. Thus, for these reasons, the Board also assigns less probative value to this opinion. The veteran also submitted a June 1997 private medical statement, in which Dr. N, a specialist in otology, commented that it seemed like the veteran had a tremendous amount of noise exposure in the past. Dr. N opined that the only reason the veteran would have tinnitus at the time of discharge without evidence of hearing loss was that perhaps the spectrum of hearing tested (frequencies) was limited and did not include injured frequencies. Dr. N stated that this was speculation, but that this was somewhat of an indicator of problems to come later. Thus, this opinion, while tending to support the veteran's claim, does not provide a definitive opinion as to whether the veteran's hearing loss is related to noise exposure in service. Finally, the Board notes that in the March 1999 VA examination report (along with the September 1999 addendum), a VA physician, noted that it would "hardly be possible for someone assigned to 90 mm anti-aircraft gun duty in that time frame to escape without some hearing loss and tinnitus", and opined it was "possible" that some hearing loss was concussion induced. By September 1999, the VA physician had reviewed the veteran's claims file and claimed that the thresholds listed on the separation examination would be unusual in any adult and essentially impossible for someone who had been exposed to basic training in artillery fire. It was the examiner's belief, in essence, that no valid conclusion could be drawn from the military discharge examination since the reported hearing level unlikely represented actual hearing at the time. The examiner noted that the veteran's case involves profound loss that is essentially irreversible and has no significant acute component. The Board finds this opinion to be more persuasive than the two aforementioned medical opinions, but less persuasive and probative than the VA examiner's opinion from May 2005, primarily because the VA examiner did not render a definitive opinion; rather he used the word "possible" when referring to the issue of whether the veteran's hearing loss was noise-induced, and the VA examiner essentially found that no valid conclusion could be drawn. The Board also notes that the VA examiner in March 1999/September 1999 also attached a referral memorandum for a neurology consultation regarding Meniere's disease and hearing loss. While it appears that such neurological examination was not completed, the Board finds that such examination is not necessary to decide this claim as (explained below) the veteran's claims file underwent review by a VA otolaryngologist in 2005, who rendered a decision, with supporting rationale, after reviewing the veteran's entire claims file. With regard to the other medical evidence of record that goes against the veteran's claim, the Board initially notes that this evidence as a whole is more persuasive and probative than the medical opinions cited above. First, these two opinions are definitive, supported by rationale, are based on a review of the claims file, and are both rendered by VA physicians, one of which is Board certified in otolaryngology. An opinion may be reduced in probative value even where, as here, the statement comes from someone with medical training, if the medical issue requires special knowledge. See, e.g., Black v. Brown, 10 Vet. App. 279 (1997); see also Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). This evidence includes a November 1997 addendum by a VA physician, who, after reviewing the claims file, stated that, while it is reasonable to argue that the amount and type of noise exposure the veteran experienced in service might have resulted in some hearing loss, it is in no way imaginable that the experience would relate to his later progression of hearing loss . The examiner concluded that the veteran's present difficulties could not be causally related to his period of active military service. Also, there is the May 2006 VA examination in which the examiner opined that the veteran's Meniere's disease (if he indeed had it) and his hearing loss were "more likely than not not" related to his military service. The examiner indicated that since there was documentation on the veteran's separation examination of normal hearing at the time of discharge, and since the preponderance of the evidence is that the hearing loss due to acoustic trauma is not a progressive form of hearing loss, and since the veteran had developed a lot of hearing loss over the 40 years since his military service, "certainly the evidence is more likely than not that the hearing loss [the veteran] has is not related to his military experience". The Board finds this opinion to be the most probative and persuasive on the issue of whether the veteran's bilateral hearing loss may be related to service, as it included a review of the entire claims file prior to rendering an opinion, and included a clear, definitive opinion, with supporting rationale, references to the veteran's specific history and the medical bases for the opinion. In summary, after reviewing all the medical evidence of record, both positive and negative, the Board concludes that the preponderance of the medical evidence of record and the weight of the competent medical evidence of record does not support a causal relationship between service and the veteran's current bilateral hearing loss. And, although the veteran has sincerely contended that his bilateral hearing loss is related to noise exposure in service, he is a layperson and as such is competent to report his exposure to noise in service (which has been noted through the history of this appeal), but is not competent to render a medical opinion on diagnosis or etiology of a condition such as hearing loss. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). As the preponderance of the evidence is against the claim, the benefit-of-the- doubt rule does not apply, and the claim for service connection for bilateral hearing loss must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. ORDER Service connection for bilateral hearing loss is denied. __________________________ ANDREW J. MULLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs