Citation Nr: 1400692 Decision Date: 01/08/14 Archive Date: 01/23/14 DOCKET NO. 10-40 225 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for a variously diagnosed psychiatric disability, including as secondary to service-connected disability. 2. Entitlement to service connection for tinnitus, including as secondary to service-connected disability. 3. Entitlement to service connection for sleep apnea. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from August 1952 to August 1955. These matters are before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision of the Philadelphia, Pennsylvania RO. In October 2013, a Travel Board hearing was held before the undersigned Veterans Law Judge; a transcript of the hearing is included in the claims file. At the hearing the Veteran requested, and was granted, a 30 day abeyance period to allow for the submission of additional evidence; new evidence was received with a waiver of RO initial consideration. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of service connection for tinnitus is being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action on his part is required. FINDINGS OF FACT 1. A variously diagnosed psychiatric disability was not manifested in service; a psychosis was not manifested in the first year following the Veteran's discharge from active duty; and the preponderance of the evidence is against a finding that the Veteran's current psychiatric disability is related to his service or was caused or aggravated by his service-connected hearing loss. 2. Sleep apnea was not manifested in service, and the preponderance of the evidence is against a finding that such disability is related to the Veteran's active service. CONCLUSIONS OF LAW 1. Service connection for a variously diagnosed psychiatric disability, to include as secondary to service-connected hearing loss, is not warranted. 38 U.S.C.A. 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 2. Service connection for sleep apnea is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). 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, 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to their initial adjudication. July 2009 and October 2011 letters explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence he was responsible for providing, and informed him of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record, and has not alleged that notice in these matters was less than adequate. At the hearing before the undersigned, the Veteran was advised of what was needed to substantiate his claims, and what elements remained to be satisfied. His representative and the undersigned presented questions to him eliciting testimony to address the unsubstantiated elements of his claims. The Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. The RO arranged for VA examinations and addendum opinions in June 2012 and March 2013. As will be discussed in greater detail below, the Board finds these examinations and opinions to be (cumulatively) adequate, as they included a thorough review of the Veteran's medical history, mental status examinations noting all pertinent findings, and medical opinions with adequate supporting rationale. See Barr v. Nicholson, 21 Vet. App. 303 (2007). In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration: (1) Whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain chronic diseases were manifested during an applicable postservice presumptive period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the U.S. Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, a VA examination for sleep disability is not necessary, as there is no evidence suggesting there may be a nexus between any current sleep apnea disability (first diagnosed many years after service) and the Veteran's active duty service. The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims file and in Virtual VA, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) evidence of incurrence or aggravation of a disease or injury in service; and (3) evidence of a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Disorders diagnosed after discharge may still be service connected if all the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Id. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Psychiatric disability Certain chronic disabilities (to include psychosis) may be service connected on a presumptive basis if manifested to a compensable degree within a specified period of time following discharge from active duty (one year for psychosis). 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (as in effect before and after October 10, 2006). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). The Veteran's theory of entitlement as to this claim is primarily one of secondary service connection. He contends that his variously diagnosed psychiatric disability developed secondary to his service-connected hearing loss disability. Service connection has been established for bilateral hearing loss, rated 0 percent. As the Veteran has also advanced a contention that the psychiatric disability may have begun during service and persisted, the Board will also address a direct (i.e., to service) causation theory. The Veteran's STRs are largely silent for any psychiatric complaints, findings, treatment, or diagnosis. On July 1952 service enlistment examination, he reported a history of nervous trouble; on clinical evaluation, the examiner noted mild anxiety and nail biting. On August 1955 service separation examination, psychiatric clinical evaluation was normal. On December 1956 reserve transfer examination, psychiatric clinical evaluation was normal; the Veteran denied any history of frequent or terrifying nightmares, depression or excessive worry, loss of memory or amnesia, or nervous trouble of any sort. A May 1975 VA hospital discharge summary indicates that the Veteran was admitted with complaints of depression, lack of ambition, and confusion. The hospitalization seemed to be precipitated by being laid off from his job, divorce, and pressure from his wife due to non-support of their children. He reported that he had been drinking heavily since his divorce in June 1974. It was noted that he did not have previous psychiatric illness. The assessments included depressive neurosis and alcohol addiction. He was discharged after one month of treatment with clinical improvement having reached a plateau. On May 1999 treatment, the Veteran complained of anxiety and insomnia. In June 1999, he was noted to be taking Vistaril for anxiety treatment. In June 2000, the Veteran complained of anxiety and agitation due to family difficulties with his son and his ex-wife with whom he maintained an active relationship; he was noted to show some symptoms of depression. On August 2002 treatment, the Veteran reported occasional depression that was described as situational; his son was noted to be in a halfway house for drugs. He reported marked irritability at home. On February 2009 treatment, the assessments included depression and generalized anxiety disorder. In March 2009, the Veteran complained of low mood and decreased energy, and he felt guilty about his ex-wife who lived in a nursing home, for whom he was the primary caregiver; she had a long history of bipolar disorder. The assessments included a history of alcohol dependence in remission and major depression, complicated by family stressors. A trial of sertraline was prescribed. In April 2009, the Veteran complained of headaches and gastrointestinal distress as side effects of sertraline; he was instructed to stop taking sertraline and try citalopram instead. In May 2009, the citalopram was stopped and a trial of Lamictal was begun; the diagnoses included depression, not otherwise specified, and rule-out bipolar II disorder. In June 2009, the diagnosis was bipolar II disorder. Subsequent VA treatment records through 2012 note ongoing treatment for varying diagnoses of anxiety, major depressive disorder, and bipolar disorder. On June 2012 VA examination, the Veteran reported that he drank a lot after service and entered an alcohol treatment unit in 1974. He reported having a lot of depression and relationship problems as a result of some of his health problems. He reported difficulty falling and staying asleep early every night, and irritability. He reported symptoms including depressed mood, chronic sleep impairment, flattened affect at times, disturbances of motivation and mood at times, and difficulty in establishing and maintaining effective work and social relationships at times. He reported being fired from a couple of jobs and having occasional problems with co-workers, before he retired due to vision problems. He believed his depression is related to his hearing and vision problems. The diagnosis was adjustment disorder with depressed mood, which the examiner opined is at least as likely as not secondary to his hearing loss and exacerbated by his vision problems. The examiner opined that the disability is related directly to the Veteran's hearing problems. In a March 2013 VA addendum opinion, a reviewing VA psychiatrist opined that the Veteran's diagnosed adjustment disorder with depressed mood is more likely than not associated with his worsening vision loss, as directly stated by the Veteran in his treatment records. In other treatment records, the Veteran consistently described the primary cause of his depressed mood as guilt and anguish related to being a caretaker for his ex-wife, who died in May 2009; on multiple occasions in 2009 and 2010, he reported sadness, grief, loss, and guilt related to her death. The psychiatrist also noted that the Veteran's sleep disturbances and nightmares were entirely related to her death and the guilt surrounding it. The psychiatrist noted the Veteran's reports of other factors leading to his depressed mood and difficulty with adjustment disorder, including financial difficulties and difficulties in transitioning to a nursing home. He reported social isolation and significant impairments compounded by his blindness. The psychiatrist noted the Veteran's June 2012 report that his tinnitus directly impacted on his adjustment disorder, as well as his initial claim that his adjustment disorder is related to his hearing loss; the reviewing psychiatrist questioned the face value of the Veteran's claims, as they cannot be separated from the context in which the Veteran is seeking financial disability compensation. The reviewing psychiatrist opined that a more reliable account of his disability and perceived emotional problems related to tinnitus is best accounted for in the treatment records, where the Veteran makes no mention directly of tinnitus impacting his adjustment disorder. Therefore, based on the evidence of record, the reviewing psychiatrist opined that the Veteran's adjustment disorder with depression is less likely than not related to his hearing loss. The reviewing psychiatrist opined that the treatment records, specifically from 2009 through 2010, offer more probative value than the single statement of the Veteran in June 2012 relating the causes of his adjustment disorder. The reviewing psychiatrist opined that the Veteran's adjustment disorder with depressed mood is more likely than not caused by his financial difficulties, social isolation, transition to a nursing home, and most importantly to his blindness and deteriorating eyesight, as well as guilt and loss related to his ex-wife's death. At the October 2013 hearing, the Veteran testified that he had been seeing a geriatric psychiatrist, but he stopped going the previous year. He testified that he believed he was not treated right in service because he should have advanced more than he did; for one year, he did not advance until after he was appointed to be an artillery instructor and demonstrated that he merited advancement. The Veteran has also submitted VA treatment records through 2012 showing findings similar to those on the VA examinations outlined above. It is not shown that a psychiatric disability became manifest in service and persisted, or that a psychosis was manifested in the first postservice year. The Veteran's STRs do not contain any evidence of mental health complaints, findings, treatment or diagnosis during service. There is also no evidence of postservice continuity of mental health complaints; by the Veteran's own accounts on treatment, such complaints began many years after his separation from service. Postservice evaluation/treatment records provide no indication that any psychiatric disability may somehow be directly related to the Veteran's service. Accordingly, service connection for a psychiatric disability on the basis that such was incurred or aggravated in service, or on a presumptive basis (for psychosis as a chronic disease under 38 U.S.C.A. §§ 1112, 1137), is not warranted. Inasmuch as any reports of longer-existing psychiatric complaints or symptoms are inconsistent with, and contradicted by, the Veteran's own accounts on examination regarding the onset of such problems, such reports are deemed obviously self-serving, and the Board finds them not credible. The preponderance of the evidence is also against the Veteran's alleged secondary service connection theory of entitlement to the benefit s sought. The Board notes the June 2012 VA examiner's opinion that the diagnosed adjustment disorder with depressed mood is at least as likely as not secondary to his hearing loss and exacerbated by his vision problems. However, the examiner provided no supporting rationale or explanation for this opinion. By contrast, the March 2013 VA reviewing psychiatrist cited to several treatment records throughout the claims file in which the Veteran variously related his psychiatric symptoms to his financial difficulties, social isolation, his transition to a nursing home, and most importantly to his blindness and deteriorating eyesight, as well as guilt and loss related to his ex-wife's death. The reviewing psychiatrist opined based on the Veteran's own reports upon treatment that his adjustment disorder with depressed mood is more likely than not caused by these other stressors in his life, rather than his service-connected hearing loss. The reviewing psychiatrist opined that the treatment records, specifically from 2009 through 2010, offer more probative value than the Veteran's single statement on June 2012 examination regarding the causes of his adjustment disorder. This provider noted the history of the claimed disability and thoroughly explained the rationale for the opinions stated. The examiner provided further rationale for the opinions by identifying other etiological factors, considered more likely. The Board finds this evidence highly probative in the matters at hand. Because there is no competent (medical opinion/treatise) evidence to the contrary with opinion supported by adequate explanation, the Board finds the March 2013 VA reviewing psychiatrist's opinion to be persuasive. Regarding the Veteran's own opinion that his claimed psychiatric disability is due to his service-connected hearing loss disability, he is a layperson (with no demonstrated or alleged expertise in determining whether there is a nexus between a psychiatric disability and hearing loss); does not offer supporting medical opinion or medical treatise evidence; does not cite to any supporting factual data; and does not offer any explanation of rationale for his opinion. Therefore, his opinion on this question of causality lacks probative value. See Jandreau, supra, at 1372, 1377. The Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for a various diagnosed psychiatric disability. Accordingly, his appeal in this matter must be denied. Sleep apnea The Veteran contends that he has sleep apnea that was incurred in or caused by service. The Veteran's STRs are silent for any complaints, findings, treatment, or diagnosis regarding sleep apnea. On August 1955 service separation examination, the mouth and throat, and the lungs and chest, were normal on clinical evaluation. On December 1956 reserve transfer examination, the mouth and throat and the lungs and chest were normal on clinical evaluation; at that time, the Veteran denied any history of frequent trouble sleeping. The Veteran's VA treatment records through 2012 reflect that he is being treated for sleep apnea. The records indicate that obstructive sleep apnea was diagnosed following a sleep clinic study in August 2006. At that time, CPAP treatment was prescribed. The treatment records contain no opinions regarding the etiology of the sleep apnea. At the October 2013 hearing, the Veteran testified that he was issued a VA-prescribed CPAP machine approximately four years earlier. He contended that the constant noise while he was sleeping in service may have caused his current sleep apnea. In November 2013, the Veteran submitted (with a waiver of RO consideration) a lay statement from his son, who stated that he remembered sleeping next to his parents when he was a child and noticing that his father had trouble sleeping due to breathing problems. He stated that the Veteran would often snore very loudly which would cause him much discomfort. Sleep apnea was not diagnosed in service or postservice until approximately 2006, or 51 years after the Veteran's separation from active duty service. While he has reported that he has had continuous sleep problems since service, his accounts have been inconsistent and are self-serving. Furthermore, where contemporaneous records would be expected to provide support for the accounts, they do not. Consequently, the Board finds his reports of sleep apnea symptoms existing ever since service to not be credible. The Veteran has not reported seeking sleep apnea treatment postservice prior to 2006. Regarding the lay statement from the Veteran's son attesting that the Veteran had sleep difficulties when the son was a young child, the Board accepts it as credible corroboration that the Veteran has snored for many years. However, whether or not the snoring was a symptom of then-existing obstructive sleep apnea is a medical question. The diagnosis of sleep apnea is not one that can be made by lay observation; it requires medical expertise/diagnostic studies. No medical provider has opined that complaints of snoring of themselves support a diagnosis of sleep apnea for the Veteran when he was on active duty. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009. The Board finds that there is no competent evidence that relates the Veteran's sleep apnea to his service. Regarding the Veteran's own opinion that his current sleep apnea disability is due to his service, he is a layperson (with no demonstrated or alleged expertise in determining a medical nexus); does not offer any supporting medical opinion or medical treatise evidence; does not cite to any supporting factual data; and does not offer any explanation of rationale for his opinion. His unsupported theory of entitlement is mere lay speculation, and has no probative value. As there is no competent evidence to the effect that the Veteran's sleep apnea may be related to his service (or circumstances therein, as alleged), the preponderance of the evidence is against his claim of service connection for sleep apnea, and the appeal in the matter must be denied. ORDER Service connection for a variously diagnosed psychiatric disability, including as secondary to service-connected disability, is denied. Service connection for sleep apnea is denied. REMAND The Board finds that the matter of service connection for tinnitus must be remanded for evidentiary development. The Veteran contends that he was exposed to excessive loud noise in service due to working as a rifle instructor, in an attack squadron, and in ordnance; he stated that he often worked near propeller aircrafts loading ammunition. His MOS in service was aircraft armament mechanic; his likely exposure to excessive noise is conceded. In March 2009, the Veteran was prescribed a trial of sertraline for depression. In April 2009, he complained of a "hissing" in both ears for about one month; he reported that he believed the tinnitus was related to taking sertraline. In May 2009, he reported constant left-sided tinnitus with unknown date of onset that had worsened over the previous 2 years. In June 2009, he denied any resolution of the tinnitus that began after starting an antidepressant in April 2009, although he had since changed medications. On September 2009 VA examination, the examiner noted the Veteran's April 2009 complaints of new onset bilateral tinnitus and longstanding bilateral hearing loss. The examiner noted the complaints reported on May 2009 and June 2009 treatment. The Veteran reported that he was unsure of the onset of his tinnitus but stated that he had had it for a long time. The examiner opined that, given the evidence, the date of the tinnitus onset is unclear; the examiner noted the stated possibility in the treatment records that it is a recent occurrence. The examiner opined that the tinnitus is less likely a result of military service. The examiner further opined that it is less likely that the Veteran's diagnosed hearing loss is a result of his military service, based on the available evidence. In a November 2009 opinion, a VA treating physician opined that it is clear that the etiology of the Veteran's hearing loss is related to his time in the service and, although he had coped quite well with the deficit for many years, it had not become a problem until recently. The physician noted that, during the Veteran's time in service, he was a weapons instructor and also worked on the flight lines; the physician opined that he therefore had adequate noise exposure in service to explain his current hearing loss. In a June 2012 VA addendum opinion, the September 2009 VA examiner reviewed the claims file and noted the above findings. The examiner opined regarding the audiometric data from the September 2009 examination that the right ear data are fairly consistent with the Institute of Medicine's data on age-related hearing loss for men, while the left ear configuration is slightly worse on examination which would suggest more hearing loss than expected from the aging process based on the Institute of Medicine data. The examiner noted that there is a high probability of noise exposure based on the Veteran's MOS of aviation ordinance. The examiner opined that the Veteran's left ear hearing loss is at least as likely as not related to his military service; however, he reiterated his previous opinion regarding tinnitus. The examiner noted that the Veteran reportedly believed the onset of tinnitus was related to an antidepressant medication he was taking, as documented in the treatment records. The examiner further noted that at several evaluations in 2009, the Veteran was unsure of how long he had experienced tinnitus. The examiner noted, per the website drugs.com, that a noted side effect of sertraline is tinnitus, persistent or severe ringing in the ears; therefore, the examiner opined that the tinnitus is less likely related to the Veteran's military service. The examiner opined based on the treatment records and evidence that the etiology may be related to the previously dispensed medication. In a March 2013 VA addendum opinion, a reviewing VA psychiatrist supported the June 2012 opinion that sertraline is known to cause reversible tinnitus and that it is possible that when the Veteran was prescribed sertraline in 2009, it may have exacerbated existing tinnitus or caused new onset of tinnitus. In another March 2013 VA addendum opinion, a reviewing examiner noted that audiologic evaluation indicated bilateral hearing loss. The reviewing examiner opined that the Veteran's current tinnitus is at least as likely as not related to his previously dispensed psychiatric medication; the examiner noted the April 2009 ear, nose, and throat report that the Veteran stated he was recently given the antidepressants in March 2009 and he believed that his tinnitus was related to that. The Board notes that an April 2013 rating decision granted the Veteran service connection for hearing loss based on the opinions cited. The Board further notes that the opinions of record (September 2009, November 2009, June 2012, and March 2013) identify other possible etiology for the Veteran's tinnitus, but do not adequately address whether the etiology of the tinnitus may be disassociated from that of the now service-connected hearing loss (i.e., establish that cause for the tinnitus would not at least contribute to cause tinnitus). . Accordingly, the case is REMANDED for the following: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. The RO should return the claims file to the VA audiologist who conducted the September 2009 examination of the Veteran, and submitted the June 2012 addendum opinion, to provide another addendum opinion that addresses the medical question remaining. The Veteran's claims file (to include this remand) must be reviewed by the examiner in conjunction with the examination. Based on a review of the record and examination/interview of the Veteran, the examiner must offer an opinion that responds to the following: Is there a factual or medical basis for disassociating the etiology of the Veteran's tinnitus from the etiological factors responsible for his now service-connected hearing loss? If so, please identify the basis for doing so (with citation to medical literature that supports the conclusion). 2. The RO should then review the record and readjudicate the claim of service connection for tinnitus. If it remains denied, the RO should issue an appropriate supplemental statement of the case, and afford the Veteran and his representative opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs