Citation Nr: 0533751 Decision Date: 12/14/05 Archive Date: 12/30/05 DOCKET NO. 97-30 864 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for a cervical spine disorder. 2. Entitlement to service connection for a hearing loss disability. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The veteran and his son ATTORNEY FOR THE BOARD Michael Holincheck, Counsel INTRODUCTION The veteran served on active duty from February 1951 to February 1953, and from June 1990 to July 1992. He had additional service in the U. S. Naval Reserve from 1953 to 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 1994 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. The veteran's case was remanded for additional development in September 2003. It is again before the Board for appellate review. The Board notes that the veteran submitted a written claim for an increased rating for his service-connected thoracolumbar pain with degenerative disc disease, T12-L2, then rated as 10 percent disabling, in September 1999. He included a letter from a private physician that reported that the veteran had had surgery on his back in August 1999. The RO issued a rating decision in January 2000 that deferred making a decision on the veteran's increased rating claim. The veteran was granted a 100 percent rating under 38 C.F.R. § 4.30 by way of a rating decision dated in March 2000. The rating decision specifically deferred the issue of an increase for the 10 percent disability rating. The veteran was apprised of this by correspondence from the RO dated in April 2000. Efforts were made to schedule the veteran for a VA examination; however, they were unsuccessful. Thus no examination was done to assess the veteran's status following his August 1999 surgery. The veteran provided testimony regarding his back disability at a hearing in May 2001. He submitted a written claim for an increased rating for his service-connected back disability in May 2002. There is no evidence of an adjudication of the veteran's 1999 claim for an increased rating. The Board is aware of the RO's attempt to have the veteran examined. However, there is no indication that the issue of the increased rating has been addressed following the last attempt to have the veteran examined in October 2000. The issue of an increased rating for the veteran's service-connected thoracolumbar pain with degenerative disc disease, T12-L2, was referred to the RO for appropriate consideration by the Board in September 2003. There is nothing in the records assembled for appellate review to indicate that the RO took any action as to this claim. In a document dated in April 2005, the claim for an increased rating was again raised and it was requested that the veteran be scheduled for an examination for disability evaluation purposes. This matter is again referred to the RO for appropriate action. FINDINGS OF FACT 1. The veteran does not have a cervical spine disorder attributable to his military service. 2. The veteran's bilateral hearing loss is not related to his military service. CONCLUSIONS OF LAW 1. The veteran does not have a cervical spine disorder that is the result of disease or injury incurred in or aggravated during service. 38 U.S.C.A. §§ 101, 1101. 1110, 1111, 1112, 1113, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.303, 3.304, 3.307, 3.309 (2005). 2. The veteran does not have a hearing loss that is the result of disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 101, 1101, 1110, 1111, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.6, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Background The veteran originally served on active duty from February 1951 to February 1953. The veteran served as a commissioned officer in the dental corps as a dentist. His December 1950 entrance physical examination was negative for any evidence of hearing loss or a cervical spine disorder. The veteran's hearing was reported as 15/15 for the whispered and spoken voice tests. The remainder of the veteran's service medical records (SMRs) for that period of service do not reflect any treatment for complaints related to hearing loss or problems involving the cervical spine. The veteran was released from active duty in February 1953. The Board notes that military personnel records for the veteran show that he served onboard the USS WASP (CV 18) from August 1951 to October 1952. The veteran was discharged from the Naval Reserves in June 1954. However, he applied for reappointment in the Naval Reserves that same month. The veteran underwent a physical examination in August 1954. The veteran did not express any problems with his hearing and there was no finding of any abnormalities associated with the cervical spine. His hearing level was listed as 15/15 for the whispered and spoken voice tests. The veteran was found to be physically qualified for reappointment. The veteran was afforded numerous physical examinations during his period of service in the Naval Reserves. Physical examinations in 1955, 1957, 1960, 1965, 1966, 1970, 1973, 1974, and 1976 were all negative for any evidence of hearing loss or any problems with the cervical spine. The veteran's hearing was tested with either the whispered or spoken voice, or both. The veteran did undergo audiometric testing as part of a physical examination in February 1978. The examination was done as an annual evaluation and for record replacement. The veteran was not serving on active duty, active duty for training, or inactive duty for training. The testing revealed puretone thresholds of 15, 5, 5, 60, and 55 decibels in the right ear, at 500, 1,000, 2,000, 3,000, and 4,000 Hertz, respectively. Testing revealed puretone thresholds of 15, 5, 20, 60 and 65 decibels in the in the left ear for the same frequencies. The average decibel losses were 28 in the right ear and 33 in the left ear. There was no comment as to the etiology of the hearing loss. The veteran had additional physical examinations in 1979, 1980, and 1981. However, his hearing was again tested by the whispered or spoken voice method. There were no findings of hearing loss and no complaints or findings regarding a problem with the cervical spine. The SMRs also contain numerous entries wherein the veteran was certified as qualified for release from periods of active duty for training. The records do not contain any reference to hearing loss, or complaints regarding the cervical spine. In addition, the SMRs contain a statement of service that denotes the veteran's period of active duty from 1951 to 1953, his periods of service in the Naval Reserve, and his periods of active duty for training from the period from 1954 to 1990. The veteran entered a period of active duty on June 1, 1990. He reported to the Naval Hospital in San Diego, California, for duty in July 1990. Service medical records from July 1990 to September 1992 are associated with the claims file. There is no indication that the veteran had a physical examination prior to reporting for active duty. The records reflect that the veteran was given an audiogram on August 7, 1990. The results of the audiogram were not interpreted, however the audiologist said that the veteran had a slightly asymmetric sensorineural hearing loss, greater in the left than the right. The audiologist also noted that the results showed a progressive decline in the veteran's hearing since a 1976 evaluation. A clinical record, dated the same date, noted that impressions were taken for hearing aids. No opinion as to the etiology of the hearing loss was provided. As a result of the August 1990 audiogram, the veteran was issued hearing aids in April 1991. Additional entries show that the veteran was first seen for a complaint of headaches in the right occipital area on September 20, 1990. The veteran gave a four day history of headaches. The veteran was seen on a neurology consult that same day. The veteran again gave a four day history of headaches. The veteran denied similar headaches in the past. The assessment was exacerbation of chronic headaches. The veteran was seen by the neurologist again in November 1990 with the same assessment. The veteran had a physical examination in January 1991. He completed an Officer Physical Examination Questionnaire, NAVMED Form 6120/2. He did not indicate any musculoskeletal problems. He did report idiosyncratic headaches. No physical abnormalities were noted on the actual physical examination. The results of an audiogram were reported on the physical examination form. The testing revealed puretone thresholds of 15, 15, 45, 50, and 55 decibels in the right ear, at 500, 1,000, 2,000, 3,000, and 4,000 Hertz, respectively. Testing revealed puretone thresholds of 20, 20, 65, 65, and 60 decibels in the in the left ear for the same frequencies. The average decibel losses were 36 in the right ear and 46 in the left ear. The veteran had an annual physical examination in January 1992. He reported muscle pain or cramps and painful joints on his NAVMED Form 6120/2. Comments from the examiner did not make any mention of a cervical spine complaint. No orthopedic abnormalities were noted on the physical examination. The veteran was given an audiogram as part of the examination. The testing revealed puretone thresholds of 10, 10, 45, 60, and 65 decibels in the right ear, at 500, 1,000, 2,000, 3,000, and 4,000 Hertz, respectively. Testing revealed puretone thresholds of 10, 10, 65, 60, and 60 decibels in the in the left ear for the same frequencies. The average decibel losses were 38 in the right ear and 41 in the left ear. A notation on the audiogram said that the veteran's hearing sensitivity was essentially within the "test retest" of the evaluation done on August 7, 1990. The veteran was issued new hearing aids in February 1992. The veteran also had a release from active duty physical examination in June 1992. He reported muscle pain or cramps and backaches, as well as headaches, on his NAVMED Form 6120/2. The examiner noted that the cramps were associated with diverticuli. The examiner further noted that the veteran was followed by a neurologist for the headaches that were longstanding. The headaches were said to be of unknown etiology. There was no mention of any problems involving the cervical spine on the physical examination. The veteran was given an audiogram as part of the examination. The testing revealed puretone thresholds of 15, 10, 45, 55, and 60 decibels in the right ear, at 500, 1,000, 2,000, 3,000, and 4,000 Hertz, respectively. Testing revealed puretone thresholds of 15, 15, 60, 65, and 55 decibels in the left ear for the same frequencies. The average decibel losses were 37 in the right ear and 42 in the left ear. The veteran received additional treatment at the Naval Hospital following his release from active duty from July 1992 to September 1992. He was treated for complaints of back pain beginning in July 1992. There were no complaints regarding the veteran's cervical spine. The veteran submitted his claim for service connection for hearing loss in September 1992. He also sought entitlement to service connection for headaches. The veteran was afforded a VA neurology examination in November 1992. The veteran made no complaints of problems involving the cervical spine. The veteran was diagnosed with muscular contraction/vascular headaches. The veteran had a VA audiology examination in November 1992. The veteran reported a hearing loss since the early 1980's. The examiner noted that the veteran had a four year history of noise exposure working as a dentist while in the military from working with high speed drills. The veteran also gave a history of 40 years of service in the reserves with very little practical dentistry. He was mostly involved in administration and research. Audiometric testing revealed puretone thresholds of 10, 5, 55, 55, and 55 decibels in the right ear, at 500, 1,000, 2,000, 3,000, and 4,000 Hertz, respectively. Testing revealed puretone thresholds of 5, 10, 65, 55, and 60 decibels in the left ear for the same frequencies. The average decibel losses were 36 in the right ear and 39 in the left ear. (The Board notes that the examiner listed average losses of 43, and 48 decibels, respectively; however, those averages were based on the 1,000-4,000 frequencies). The veteran had a speech recognition score of 98 percent for the right ear and 96 percent for the left ear. The examiner did not express any opinion as to the etiology of the veteran's hearing loss. The veteran was also afforded a VA orthopedic examination in December 1992. The veteran did not express any complaints related to the cervical spine. His complaints were focused on the lower spine. The examiner provided a diagnosis of spinal stenosis. The veteran was granted service connection for muscle contraction/vascular headaches by way of a rating decision dated in May 1993. The veteran was also granted service connection for thoracolumbar pain with degenerative disc disease (DDD), T12-L4. The issue of hearing loss was deferred. The RO wrote to the veteran in July 1993. He was asked to provide a copy of his entrance examination for his last period of active service and a copy of any audiometric testing results he may have had prior to his last period of active duty. The veteran submitted his claim for service connection for a cervical spine disorder in August 1993. He noted that he was currently service connected for DDD of the low back. He said that he had involvement of the neck. His said that his neck condition caused him to grind his teeth and was causing a dental disability. The veteran submitted private records in response to the RO's letter in February 1994. The veteran provided copies of his SMRs from his last period of active duty regarding his several audiograms and his being fitted with hearing aids. He included an outpatient entry from February 1993 that noted that he was referred for hearing amplification following his evaluation in August 1990. No opinion was expressed as to the etiology of the veteran's hearing loss although the Navy audiologist noted that the veteran had been encouraged to contact VA to establish service connection for hearing loss. The veteran also submitted a copy of an audiogram from the University of Iowa Hospital dated in November 1976. The audiogram did not contain an interpretation of the charted findings; however, it appears to show a level of hearing loss, particularly at the 4,000 Hertz level. The veteran was afforded a VA audiology examination in February 1994. The examiner noted that the veteran said that he first noticed a hearing loss during the 1970's. The examiner further noted that a 1976 audiogram indicated moderately severe high frequency hearing loss. The veteran said that he felt that his hearing loss had increased significantly during the past two to three years. Audiometric testing revealed puretone thresholds of decibels in the right ear, of 25, 10, 55, 50, and 55 at 500, 1,000, 2,000, 3,000, and 4,000 Hertz, respectively. Testing revealed puretone thresholds of 20, 20, 65, 60, and 55 decibels in the left ear for the same frequencies. The average decibel losses were 39 in the right ear and 44 in the left ear. The veteran had a speech recognition score of 94 for each ear. The examiner did not express any opinion as to the etiology of the veteran's hearing loss. The veteran was afforded a VA ear, nose, and throat (ENT) examination in February 1994. The examiner noted that the veteran reported an onset of hearing loss in 1990. The examiner reported that the veteran had a lifelong history of primarily being an educator and a dentist and had not had significant noise exposure. The examiner also said that the veteran had no history of ototoxic drugs, head injury, or ear injury. The examiner noted that the February 1994 audiogram showed a bilateral, predominantly high frequency hearing loss in both ears. The examiner said that the hearing loss was probably on a hereditary basis. The veteran was afforded a VA orthopedic examination in February 1994. The veteran said that his neck pain began with military activities in 1990. The veteran complained of headaches, temporomandibular joint (TMJ) pain bilaterally, pain at the neck and both trapezius muscles. There was also some shoulder joint discomfort. The veteran said that he had x-rays in the military and did not want newer x-rays. The examiner stated that the chronic pain in the neck and trapezius muscles since about 1990 was diagnosed as chronic muscular strain. He said that the degenerative status was per military radiology and that the cervical nerve roots were okay. The examiner provided a specific opinion regarding etiology. The examiner stated: Apparently the back is considered service connected. The veteran says that the neck pain started in the military so on a basis of history there would be a direct connection to the miliary. If I am asked to hypothetically assume that his neck was okay in the military and that his neck did not have any pain for at least three or four years after the military I would say that the neck problems probably does not have any relationship to military activities. However, based on the history given by the veteran, there is a connection of neck to military. Regarding the question of whether the neck pain is directly secondary to the back pain, I would say that this [sic] is no probable causal relationship between the neck pain versus the chronic low back pain. VA orthopedic examination of February 1994. The RO denied the veteran's claim for the issues on appeal in May 1994. The RO determined that there was no evidence of any type of injury of the cervical spine in service and no evidence of complaints or treatment for a cervical strain. In regard to hearing loss, the RO determined that the 1976 audiogram clearly showed evidence of hearing loss before the veteran's period of active duty in 1990. Further, the veteran was evaluated two months after entering active duty in 1990 and found to have a severe hearing loss. Audiometric tests in service, and by VA, were consistent with the initial August 1990 evaluation. It was determined that the veteran's hearing loss existed prior to service and that it was not aggravated beyond natural progression. The veteran submitted his notice of disagreement in March 1995. He said that his chronic pain syndrome was related in part to muscular contracture (tension) headaches that were documented in service. He acknowledged that his hearing loss began before his recall to active duty; however, he claimed that it worsened during his period of active duty. Initially the RO determined that the veteran's appeal regarding the issues on appeal was not timely. The Board issued a decision that found the appeal to be timely and remanded the case for additional development in January 1999. The RO wrote to the veteran in February 1999. The veteran was asked to submit any additional evidence that he felt was pertinent to his claim. He was informed that he could complete enclosed authorization forms if he wanted the RO to obtain the evidence on his behalf. Associated with the claims folder are VA treatment records for the period from April 1999 to May 2000. The records relate to treatment provided to the veteran for his hearing loss, to include issuance of hearing aids. The veteran and his son testified at a hearing at the RO in May 2001. The veteran testified that his hearing loss might be related to his service onboard the WASP. He said that he served in the reserves since his initial period of active duty and performed periods of summer training. When asked if he performed weekend drills, or inactive duty for training, he responded that he did summer training. The veteran's son said that he could not provide a specific date but he noticed that the veteran definitely had increased difficulty in hearing since his last period of active duty. The veteran noted that he had additional evidence to submit for the record that related, in part, to his claim for hearing loss. The veteran testified about his symptomatology involving his cervical spine. The veteran said that he received treatment for his claimed condition during his period of active duty from 1990 to 1992, to include physical therapy. He received additional therapy after service from the Loma Linda University Medical Center (Loma Linda) for his lower and upper back. The veteran said that his cervical complaints were present during his entire period of active duty from 1990 to 1992. In response to questions from the hearing officer, the veteran said that he first noticed some hearing loss when he was in graduate school in 1954-1955. He said that the first record of his hearing loss was in records from the University of Iowa in the 1960's. The veteran did not have any of the records from the earlier years to document his hearing loss. He said that Navy doctors told him that his hearing loss could be related to his service on the WASP. The veteran described how there was a lot of activity and noise involving the ship in order to get it recommissioned in 1951. He also testified about the ship being involved a collision at sea. In regard to his cervical spine, the veteran referred to a letter from a private physician, S. Tolchin, M.D., that he saw in 1992. He said he was referred to Dr. Tolchin by a Navy neurologist. The veteran submitted additional evidence and treatise material following his hearing. The submission related to several issues being pursued at the time, to include the current issues on appeal. The evidence included treatment records from Loma Linda for the period from October 1999 to April 2001. The records did not contain any evidence pertaining to complaints or treatment involving the cervical spine. The records documented treatment, to include physical therapy, for the veteran's lower back. In regard to his cervical spine the veteran submitted letters from Dr. Tolchin and a L. I. Becerra, M.D. Dr. Becerra was a Navy neurologist that evaluated the veteran for his headache complaints on a number of occasions during the 1990 - 1992 period. In a letter, dated in October 1993, Dr. Becerra related how he had seen the veteran in November 1990 for chronic headaches, both vascular (migraine) and muscle contracture (tension). Dr. Becerra also noted that the veteran had been treated for low back pain and bilateral lower extremity pain since the summer of 1992. Because of the combination of the back pain and headaches, the veteran was diagnosed with chronic pain syndrome. Dr. Tolchin evaluated the veteran in December 1992. He said that the veteran had undergone jet seat training in May or June of 1992 and developed buttock pain. The pain worsened. He noted that studies had confirmed a herniated disc at L3-L4 and lumbar stenosis at other levels. He noted that the veteran was seen for suboccipital and generalized headaches since 1990. There was a question of stress, cervical problems, or hypertension contributing to the headaches. The veteran had some limitation of motion of the cervical spine on physical examination. There were no x-rays, CT scans or magnetic resonance imaging (MRI) studies of the cervical spine. No specific diagnosis was provided in regard to the cervical spine. The veteran submitted treatise evidence in support his hearing loss claim. This included an article that appeared in Military Medicine in 1995. The article discussed the effectiveness of the Navy's hearing conservation program. The veteran submitted copies of audiograms done by the Navy in 1996. The audiograms reflected a continuity of the veteran's hearing loss. No opinion as to the etiology of the hearing loss was expressed. The veteran also submitted a copy of an audiogram from the University of Iowa Hospitals and Clinics that was dated in 1975. Although the charted audiogram did not contain a numeric interpretation, the charted values appear to show a hearing loss. Associated with the claims file are medical records from Loma Linda for the period from October 1955 to March 2002. Some of the treatment was provided concurrent with the veteran's last period of active duty from 1990 to 1992. The records show that the veteran was treated for complaints of low back pain beginning in 1956. The records do not reflect any treatment or evaluation of complaints involving the cervical spine. The veteran was hospitalized on several occasions. A discharge summary from February 1993 reported that the veteran had a full range of motion of his neck. The same was reported in a summary dated in September 1999 and again in December 2001. Moreover, the summaries make no mention of a cervical spine condition by way of a past medical history or current complaint. By contrast, the records contain an initial pain management evaluation report dated in May 2001. The examiner said that the veteran presented with a history of head and neck pain with an onset of greater than 10 years earlier. The examiner said that there was no particular event which was associated with the onset. The examiner further noted that the veteran had been followed by neurology and diagnosed with migraines. Physical examination noted a limitation of motion of the cervical spine secondary to pain. The diagnostic impression was chronic daily headaches, suggestive of analgesic rebound phenomenon. The examiner noted that the veteran's medical status was complicated in that medications used to treat his chronic low back pain, Oxycontin and Vicodin, were known to aggravate cephalgic complaints. Any attempt to eliminate the narcotic analgesic agents would leave the veteran with uncontrolled back pain. The records contained no information pertaining to the veteran's hearing loss, aside from several mentions of his having difficulty hearing. The veteran submitted additional argument and evidence to the RO, by way of a bound presentation, in August 2002. The evidence consisted primarily of treatise material and other articles. The veteran disputed a statement contained in his February 1994 ENT examination report wherein the examiner said that he did not report a history of noise exposure. The veteran again cited to his period of service onboard the WASP as a period of exposure to acoustic trauma. The submission included a letter from D. G. McGann, chief of audiology at Loma Linda, dated in July 2002. Mr. McGann said that the veteran was a patient of his since the mid-1990's for the fitting and orientation of hearing instruments. He said that previous audiological evaluations provided to him by the veteran demonstrated a significant high frequency hearing loss that was significantly more pronounced than what would be appropriate for his age. Mr. McGann added that, considering the veteran's history of noise exposure onboard his ship, there was a reasonable probability that most of his hearing loss was at least initiated by and subject to the noise he experienced. Mr. McGann further stated that "[o]bviously, a variety of other factors could and have caused a possible change in his hearing sensitivity; however, the initial onset at his early age and its continuation throughout the rest of his life is very suggestive of a hearing loss caused by noise exposure." Mr. McGann did not identify the audiological evaluations that he had reviewed, and did not indicate the dates that the hearing loss was first demonstrated. Further, Mr. McGann did not say that the veteran's level of hearing loss was aggravated by his period of active duty from June 1990 to July 1992. The veteran provided duplicate copies of personnel records to show his assignment aboard the WASP from August 1951 to October 1952. The treatise material and excerpted articles related to noise exposure, to include in the military. The audiograms included one done at the Naval Hospital in Rota, Spain, in April 1999. No interpretation of the audiogram chart was made, and no opinion was provided regarding any possible etiology of the hearing loss. In addition, two audiograms from the University of Iowa Hospitals and Clinics, both dated in November 1976, were submitted. The audiograms were in chart form with no interpretation. There was no comment as to the onset or etiology of the hearing loss. The veteran's case was returned to the Board in 2002. The veteran was notified that the Board would be conducting additional development of his claim in December 2002. The veteran was afforded a VA audiology examination in December 2002. Audiometric testing revealed puretone thresholds of 10, 25, 55, 50, and 55 decibels in the right ear, at 500, 1,000, 2,000, 3,000, and 4,000 Hertz, respectively. Testing revealed puretone thresholds of 35, 35, 55, 55, and 50 decibels in the left ear for the same frequencies. The average decibel losses were 39 in the right ear and 46 in the left ear. The veteran had a speech recognition score of 94 percent for the right ear and 92 percent for the left ear. The Board notes that the examiner listed an average decibel loss of 46 for the right ear and 49 for the left ear; however, these averages were based on losses for the 1,000-4,000 Hertz range and not all five tested levels. The examiner did not provide an opinion as to the etiology of the veteran's hearing loss. The veteran was afforded a VA orthopedic examination in January 2003. The examiner reported that he had reviewed the claims folder prior to the examination. The examiner also noted that the veteran had served on active duty from 1951 to 1953, and from 1990 to 1992, with service in the Naval Reserves in the intervening years. The examiner stated that the veteran had a history of a motor vehicle accident (MVA) when he was rear ended sometime in 1987-1988. He injured his neck and back and developed chronic problems with his back from that incident. Initially, the problem was with the upper back but migrated to the lower back and, starting in 1990, he began having sciatica. The examiner noted that the veteran had undergone lower back surgery in 1999 and 2002. The examiner said that the veteran had chronic neck and back pain. The examiner said that x-rays of the cervical and lumbar spine would be done; however, no results were included in the report. The examiner said that, clinically, the veteran had DDD and facet joint arthritis of the cervical and lumbar spine with some evidence of radiculopathy over L5 and S1 dermatome on the left side. The examiner stated that the veteran's problem with his neck started with the MVA and had gradually worsened over the years and that he had developed DDD and facet joint arthritis of the cervical spine. The Board wrote to the veteran in April 2003 and informed him that additional development was being done in his case, specifically the solicitation of medical opinions from the VA medical center (VAMC) in Loma Linda, California. The orthopedic examiner added an addendum to the previous report in June 2003. The examiner again repeated the statement that the veteran had a MVA accident sometime in 1987-1988 and that he sustained an extension acceleration injury of his cervical spine. The examiner added that the veteran's neck disability did not increase in severity beyond the natural progression of the disability during his period of active service from June 1990 to July 1992. The examiner said that the veteran did not have any brachialgia and had not had any objective evidence of nerve root lesion in the cervical spine. The Board remanded the veteran's case for additional development in September 2003. The RO wrote to the veteran in March 2004. He was advised of the evidence needed to substantiate a claim for service connection. He was given examples of evidence that would be helpful in substantiating his claim. He was asked to submit any evidence that he had and to identify evidence that could be obtained on his behalf. The veteran was informed of the evidence of record. He was further informed of what VA was responsible for in the development of the claim and what he was required to do. The veteran did not respond to the RO's letter. The RO wrote to the veteran in November 2004 and informed him that he would be scheduled for a VA examination. The veteran was afforded a VA audiology examination in December 2004. The veteran reported that he first noted hearing difficulties in 1953. The examiner noted that the veteran served on active duty from 1951 to 1953 and that he was exposed to loud noises with jet engines and ship collisions. The examiner said that the veteran was in combat in the Korean War. He noted that the veteran served in the reserves from 1952 to 1992 [sic]. The examiner said that the veteran was in combat during the Persian Gulf War from 1990 to 1992. The veteran was noted to be a university professor and denied noise exposure from vocational activities. The examiner provided a detailed review of the numerous physical examination reports in the veteran's SMRs. He noted that the veteran's hearing was tested as 15/15 between 1950 and 1980, although an examination in 1981 recorded the hearing test as 20/20. The examiner next listed the results of 8 audiograms from August 1990 to October 2002. The format showed the decibel loss from 250 Hertz to 8,000 Hertz for each of the audiograms. Audiometric testing revealed puretone thresholds of 30, 40, 65, 60, and 60 decibels in the right ear, at 500, 1,000, 2,000, 3,000, and 4,000 Hertz, respectively. Testing revealed puretone thresholds of 30, 50, 65, 65, and 65 decibels in the left ear for the same frequencies. The average decibel losses were 51 in the right ear and 56 in the left ear. The veteran had a speech recognition score of 94 percent for the right ear and 92 percent for the left ear. The Board notes that the examiner listed an average decibel loss of 56 for the right ear and 61 for the left ear; however, these averages were based on losses for the 1,000- 4,000 Hertz range and not all five tested levels. The examiner noted that the veteran claimed that his hearing loss was due to noise exposure during his period of service from 1951 to 1953. The examiner said that hearing evaluation results, although not shown with frequency specific data, were indicative of hearing that was within normal limits during the veteran's service. He said that there was no audiometric data that could support the veteran's claim of hearing loss due to noise exposure from 1951 to 1953. The examiner noted that hearing loss was documented, by way of an audiogram dated August 7, 1990. He said that the actual date of onset of the veteran's hearing loss was unknown. The examiner again said that the veteran reported that he was in combat in the Persian Gulf War from 1990 to 1992. The examiner said that there was no documentation to support either that the veteran's hearing loss was a preexisting condition prior to August 1990 or that it resulted from active duty during the Gulf War. Finally, the examiner said that even though the hearing loss was documented since 1990, no significant changes were noted since that time. He said that the aging process should be taken into consideration for the slight decrease. The veteran was issued a supplemental statement of the case (SSOC) in February 2005. The RO also wrote to the veteran in February 2005. The RO advised the veteran that it appeared that all the necessary evidence had been submitted or obtained. The RO specifically asked that the veteran submit any evidence he had in support of his claim in his possession. He was told that his case would be held for 60 days unless the veteran notified the RO sooner. The veteran's representative submitted a VA Form 9 signed by the veteran and received on April 7, 2005. The veteran noted that he had asked his representative to submit a statement in support of his claim. He also said that he would need additional time and this statement would be sent within 90 days. A copy of the VA Form 9 was received on April 8, 2005. There was a line drawn through the sentence regarding the additional time needed. The representative included a statement that was in response to the SSOC of February 2005. The representative said that the veteran was not trying to add service connection for an automobile accident in 1987/1988. He was trying to increase his currently rated intervertebral disc condition. The representative also referred to the statement from Mr. McGann as being sufficient to establish service connection for hearing loss. II. Analysis The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2005). In addition, certain chronic diseases, including sensorineural hearing loss, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active military service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2005). VA law provides that a veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where clear and unmistakable evidence establishes that an injury or disease existed prior to service and was not aggravated by service. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b) (2005). VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See VAOPGCPREC 3-2003. A claimant is not required to show that the disease or injury increased in severity during service before VA's duty under this rebuttal standard attaches. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); see also Cotant v. Principi, 17 Vet. App. 116 (2003). The term "active military, naval, or air service" includes active duty, and "any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty." 38 U.S.C.A. § 101(24) (West 2002); 38 C.F.R. § 3.6(a) (2005); see Biggins v. Derwinski, 1 Vet. App. 474, 477-478 (1991). Active duty for training is defined, in part, as "full-time duty in the Armed Forces performed by Reserves for training purposes." 38 U.S.C.A. § 101(22) (West 2002)38 C.F.R. § 3.6(c) (2005). The term inactive duty training is defined, in part, as duty, other than full-time duty, under sections 316, 502, 503, 504, or 505 of title 32 [U. S. Code] or the prior corresponding provisions of law. 38 U.S.C.A. § 101(23) (West 2002); 38 C.F.R. § 3.6(d) (2005). Generally, service connection requires (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. Pond v. West, 12 Vet. App. 341, 346 (1999); accord Caluza v. Brown, 7 Vet. App. 498 (1995). Alternatively, under 38 C.F.R. § 3.303(b), service connection may be awarded for a "chronic" condition when: (1) a chronic disease manifests itself and is identified as such in service (or within the presumption period under 38 C.F.R. § 3.307) and the veteran presently has the same condition; or (2) a disease manifests itself during service (or during the presumptive period), but is not identified until later, and there is a showing of continuity of related symptomatology after discharge, and medical evidence relates that symptomatology to the veteran's present condition. Savage v. Gober, 10 Vet. App. 488, 495-98 (1997). In light of the comments made by the VA examiner in December 2004, the Board notes that the veteran did not serve in combat during either the Korean War or the Persian Gulf War. The veteran served onboard the WASP during his initial period of service and the ship did not serve in support of the war during the veteran's period of service. The veteran served at the Naval Hospital in San Diego during his period of duty during the Persian Gulf War. Therefore, there is no basis to consider his claims under 38 U.S.C.A. § 1154(b) (West 2002). A. Cervical Spine Disability The veteran's SMRs are negative for any indication of a cervical spine injury. Further, the SMRs do not show treatment for any cervical spine disorder. The veteran has alleged that he received treatment for his complaints during his period of active duty from June 1990 to July 1992; however, a careful reading of the SMRs for that period do not support his contentions. The veteran was evaluated by Dr. Becerra, a Navy neurologist, on a number of occasions. All of the evaluations related to the veteran's complaints of headaches. There was no indication in any of the clinical records that Dr. Becerra attributed the veteran's headaches to any type of cervical spine disorder. Thus the SMRs, to include the approximately 42 years of active and reserve service, show no complaints or diagnoses related to a cervical spine disorder. The many years of treatment records from Loma Linda are likewise negative for any type of a cervical spine disorder. They document the veteran's long history of lower back complaints, to include his later complaints in the 1990's that required surgery. However, there is no reference to any type of a cervical spine disorder. The veteran was evaluated for many medical conditions, and a medical history was recorded on numerous occasions but there was no mention of a cervical spine disorder in the records. Several discharge summaries, dated subsequent to the veteran's last period of active duty, reported that the veteran had a full range of motion of the cervical spine. The May 2001 pain clinic evaluation was the first direct discussion of any pain relating to the cervical spine in the Loma Linda records, and attributed the veteran's complaints of head and neck pain to his headaches, a disability that is already service connected. The December 1992 evaluation by Dr. Tolchin noted that there was a question of whether stress, cervical problems, or hypertension contributed to the veteran's headaches. He did not identify any cervical spine disorder and did not relate the veteran's complaints to his military service. The veteran testified that he received treatment for his cervical spine complaints during his period of service from 1990 to 1992, to include physical therapy. However, there are no SMR entries to show such treatment. Further, the veteran received concurrent treatment at Loma Linda during his period of active duty and there are no records of treatment for the cervical spine, to include physical therapy, in those records. The February 1994 VA orthopedic examiner relied on a history as supplied by the veteran to conclude that the veteran had chronic muscular strain related to service. In that regard the veteran told the examiner that his neck pain began with military activities in 1990. The examiner did not cite to any evidence of record to show that the veteran had such muscular strain of the cervical spine in service. A physician's opinion is only as valid as its factual basis. See e.g., Swann v. Brown, 5 Vet. App. 229, 233 (1993); (medical opinion based solely or in large measure on a veteran's reported medical history will not be probative to disposition of claim if the objective evidence does not corroborate the reported medical history); see also LeShore v. Brown, 8 Vet. App. 406, 409 (1995). The Board is aware of the veteran's status as a medical professional, to include a Ph.D. in anatomy. However, the allegation of his receiving treatment in service for a cervical spine disorder is a factual issue that is resolved by a review of the medical records in evidence. The Board is not bound to accept a medical opinion which is based on history supplied by the veteran where that history is unsupported by the medical evidence; see Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); Guimond v. Brown, 6 Vet. App. 69 (1993), Boggs v. West, 11 Vet. App. 334 (1998). Despite the veteran's contention that his neck pain began with military activities in 1990, and that he has had a chronic pain in the cervical spine area since then, the evidence does not support a finding of continuity of symptomatology since service. The Court has held that chronicity was not demonstrated when the sole evidentiary basis for the asserted continuous symptomatology was the sworn testimony of the appellant himself and when "no" medical evidence indicated continuous symptomatology. McManaway v. West, 13 Vet. App. 60, 66 (1999). Prior to the examination in February 1994, there are no earlier service or post-service medical records reflecting pertinent complaints or findings. The sole evidentiary basis for the asserted in- service symptoms and post-service continuous symptomatology is lay testimony with no medical evidence indicating the presence of pertinent symptoms. See also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim). The January 2003 VA examiner elicited a history of a MVA that involved an injury to the veteran's cervical spine in 1987 or 1988. Although the claims folder does not contain documentation of this injury, the veteran has not disputed this fact, although it was cited in the February 2005 SSOC. The examiner stated that the veteran's currently clinically diagnosed DDD and facet joint arthritis of the cervical spine was due to the accident and that it was not aggravated beyond the natural progression of the injury during the veteran's period of service from 1990 to 1992. In assessing the evidence of record the Board finds that there is no evidence to demonstrate that the veteran suffered any type of a cervical spine injury during his two periods of active duty, from 1951 to 1953 and from 1990 to 1992. Moreover, there is no evidence to show that he suffered any type of a cervical spine injury during any period of reserve service. The veteran has not alleged an injury during any such period. He essentially alleges that he developed a cervical spine disorder during his second period of active duty. The medical evidence does not demonstrate the presence of any cervical spine disorder during his period of active duty or the year after July 1992. The report of the physician who examined the veteran in January 2003 reflects that the veteran was injured in a MVA in 1987 or 1988. The claims folder does not contain evidence of the referenced MVA. However, the examiner made an unequivocal statement that the MVA occurred and that the veteran suffered an extension injury of the cervical spine at the time. This occurred in either 1987 or 1988, approximately two years prior to the veteran's last period of active duty. Further, the statement of service contained in the claims file does not reflect any period of active duty for training between May 1981 and June 1990. So, assuming arguendo that the accident did occur, the injury did not happen when the veteran was on active duty or active duty for training. The VA examiner provided a definitive statement in June 2003 where he stated that the veteran had DDD and facet arthritis of the cervical spine. He said this started with the MVA and gradually worsened over the years. He also clearly stated that the veteran's DDD and facet arthritis did not increase in severity beyond their natural progression during the veteran's period of service from June 1990 to July 1992. There is nothing in this report that would tend to support the veteran's claim. In the opinion of the Board, the preponderance of the evidence is against the veteran's claim for service connection for a cervical spine disorder. The veteran's claim is denied. B. Hearing Loss Impaired hearing will be considered a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1,000, 2,000, 3,000, and 4,000 Hertz are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2005). The United States Court of Appeals for Veterans Claims (Court), has issued several opinions that are helpful in evaluating the veteran's claim. In Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992), the Court found that the absence of a documented hearing loss while in service is not fatal to a claim for service connection. Further, in Hensley v. Brown, 5 Vet. App. 155, 159-160 (1993), the Court noted that, when a veteran does not meet the regulatory requirements for a disability at separation, he can still establish service connection by submitting evidence that a current disability is causally related to service. Finally, in Peters v. Brown, 6 Vet. App. 540, 543 (1994), the Court said that a veteran may establish service connection for a disability not manifested during service, or within the statutory presumptive period, with evidence that demonstrates that the disability actually resulted from a disease or injury incurred in service. The first evidence of record that documents a hearing loss comes from the 1975 audiogram done at the University of Iowa Hospitals and Clinics. Audiograms done in November 1976 also demonstrated a hearing loss. A reading of the statement of service shows that the veteran did not perform any active duty for training during the period June 1974 to May 1981. Thus the first evidence of hearing loss was noted approximately 22 years after the veteran's last period of active service. The hearing loss was not manifest to a compensable level within one year after the veteran's initial period of active service. There is no objective evidence of the veteran suffering from a hearing loss during his period of service from 1951 to 1953. The Board realizes that audiometric testing was not employed at the time, however, eight military physical examinations, from 1954 to 1976, did not show any findings of hearing loss. Moreover, there was no complaint of a hearing loss by the veteran. The first military testing that showed evidence of a hearing loss was an audiogram from February 1978. The hearing loss was noted during a physical examination. The veteran was not on active duty for training at the time and he has testified that he did not attend weekend drills. The veteran was determined to have a sensorineural hearing loss at the time of his August 7, 1990, hearing evaluation. He was reevaluated on several occasions, to include physical examinations conducted in January 1991 and January 1992. The veteran's hearing loss was noted on those examinations. The SMRs associated with his period of active duty from June 1990 to July 1992 do not reflect an opinion as to the etiology of the veteran's hearing loss. The SMRs also do not include any statements from the veteran that he believed his hearing loss originated with noise exposure sustained during his service onboard the WASP. The February 1994 ENT examiner, a medical doctor, noted the veteran's history, and attributed the veteran's hearing loss to hereditary reasons. Mr. McGann, an audiologist, reviewed audiograms provided by the veteran, although they were never identified, and opined that there was a reasonable probability that the veteran's hearing loss was initiated by his noise exposure onboard ship. However he added that it was obvious that other factors "could and have" caused a possible change in the veteran's hearing sensitivity. He then said that the initial onset of the hearing loss at an early age and its continuation throughout the years was suggestive of hearing loss caused by noise. The opinion of Mr. McGann is speculative. First, it is not clear what audiograms were reviewed. Even if it assumed that they were the audiograms from 1976 they still show the veteran with a hearing loss, first evident more than 20 years after service. Second, he concedes that other factors "could and have" caused changes in the veteran's hearing sensitivity. He did not elaborate on these other factors but his concession that other factors caused and changed the veteran's hearing sensitivity further erodes the idea that the veteran's current hearing loss is related to service. Third, he says that the early onset of the veteran's hearing loss, and its continuance, was suggestive of a hearing loss caused by noise exposure. Mr. McGann's statement is vague and borders on speculation. See Bloom v. West, 12 Vet. App. 185, 186-87 (1999). Moreover, taken with the prior statement of a reasonable probability, does not rise to the level of at least as likely as not that the veteran's hearing loss is attributed to his period of service from 1951 to 1953. Finally, Mr. McGann has not alleged that the veteran's hearing loss was aggravated by any period of service, to include active duty, active duty for training, or inactive duty. The December 2004 VA examiner reviewed the claims file and noted the veteran's allegations. He also provided an extensive review of the veteran's multiple physical examinations from 1950 to 1981. He further reviewed audiograms for the veteran from August 1990 to October 2002. The examiner acknowledged the veteran's contention that his hearing loss originated with his noise exposure in service from 1951 to 1953. The examiner found that the evidence did not support that contention. The examiner, erroneously, stated that the actual of onset of the veteran's hearing loss was unknown (he did not discuss the 1975, 1976, or 1978 audiograms), thus he could not say if the hearing loss preexisted the veteran's last period of active duty. He did state that the hearing loss was not the result of the veteran's last period of active duty. Moreover, the examiner stated that the veteran's hearing loss had been documented since August 1990 but there were no significant changes since then. The examiner opined that the aging process should be taken into consideration for slight decrease. As other evidence of record demonstrates, the veteran had audiometric testing evidence of hearing loss, by way of audiograms from the University of Iowa dated in 1975 and 1976. Thus his hearing loss clearly was evident, by way of objective evidence, more than 20 years after his initial period of active duty, and prior to his last period of active duty. The veteran did not receive a physical examination in conjunction with his reporting for active duty in June 1990. His last military physical examination prior to that time was in 1981. No audiometric testing was conducted on the 1981 examination; however, the 1978 audiogram clearly showed evidence of a hearing loss prior to his reporting for his last period of active duty. In light of the evidence, the Board finds that the veteran's hearing loss clearly and unmistakably existed prior to his last period of active duty. The remaining question is whether the veteran's hearing loss was aggravated by his period of active duty from June 1990 to July 1992. The February 1994 VA ENT examiner did not address the issue of aggravation. Mr. McGann's opinion focused on the veteran's assertion that his hearing loss originated from his earlier period of active duty. He did not address the veteran's later period of active duty. Moreover, he stated that other factors, not enumerated, had caused a possible change in the veteran's hearing sensitivity. The December 2004 VA examiner reported that there were no significant changes in the veteran's hearing from his initial audiogram from August 1990 through his period of service. A fair reading of his opinion is that any change in the veteran's hearing could be attributable to aging. The Board finds that there is clear and unmistakable evidence that the veteran had a preexisting hearing loss that was not aggravated beyond any natural progression by his period of active duty from June 1990 to July 1992. Accordingly, there is no basis to establish entitlement to service connection for hearing loss. The claim is denied. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Therefore, the Board is unable to identify a reasonable basis for granting service connection for a cervical spine disorder or hearing loss. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b)(West 2002); 38 C.F.R. § 3.102 (2005). In deciding this case, the Board has considered the applicability of the VCAA, Pub. L. No. 106- 475, 114 Stat. 2096, (codified as amended at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2005)). VA has issued final regulations to implement these statutory changes, codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2005). Under the Act, VA has a duty to notify the veteran and his representative of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103 (West 2002); 38 C.F.R. § 3.159(b) (2005). There is no outstanding information or evidence needed to substantiate a claim in this case. He has provided the necessary information to complete his application for service connection. Under 38 U.S.C.A. § 5103, the Secretary is required to provide certain notices when in receipt of a complete or substantially complete application. The purpose of the first notice is to advise the claimant of any information, or any medical or lay evidence not previously provided to the Secretary that is necessary to substantiate the claim. The Secretary is to advise the claimant of the information and evidence that is to be provided by the claimant and that which is to be provided by the Secretary. 38 U.S.C.A. § 5103(a) (West 2002). In those cases where notice is provided to the claimant, a second notice is to be provided to advise that, if such information or evidence is not received within one year from the date of such notification, no benefit may be paid or furnished by reason of the claimant's application. 38 U.S.C.A. § 5103(b) (West 2002). In addition, 38 C.F.R. § 3.159(b), details the procedures by which VA will carry out its duty to assist by way of providing notice. The veteran submitted claims for service connection for hearing loss in September 1992 and a cervical spine disorder in August 1993. Both claims were submitted approximately seven years prior to the enactment of the VCAA. The RO issued a rating decision in May 1994 that denied service connection for both issues. Thus the initial unfavorable decision occurred before any VCAA notice in this case. The RO initially wrote to the veteran in September 1993. He was asked to provide a copy of his entrance examination and any audiometric testing that was done prior to his last period of active duty. The veteran's claim was initially before the Board in January 1999. The Board determined that his appeal of the original denial was timely and remanded the case for additional development. The RO wrote to the veteran in February 1999. The RO asked the veteran to either submit evidence in support of his pending claims or identify evidence that could be obtained on his behalf. The Board again remanded the veteran's case for additional development in September 2003. The remand specifically directed that the notice required by the VCAA be provided to the veteran. The RO wrote to the veteran in March 2004. He was informed of what VA would do to assist him in developing his claim. He was advised as to what evidence was required to substantiate his claim for service connection. The veteran was informed of what he was responsible for in supporting his claim. The veteran was also advised to submit any evidence that he had. He also was informed of the evidence of record at that time. The RO continued to deny the veteran's claim. He was issued a supplemental statement of the case (SSOC) in February 2005. He was provided notice as to why the evidence of record failed to establish entitlement to service connection. In reviewing the requirements regarding notice found at 38 U.S.C.A. § 5103 and 38 C.F.R. § 3.159(b), the Board cannot find any absence of notice in this case. As reviewed above, the veteran has been provided notice regarding the type of evidence needed to substantiate his claim. He has been provided with notice of what VA would do in developing his claim and what he needed to do. The veteran was asked to submit evidence that he had in support of his claim. In summary, the Board finds that no additional notice is required under the provisions of 38 U.S.C.A. § 5103 as enacted by the VCAA and 38 C.F.R. § 3.159(b). See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Board acknowledges the decision of the Court in Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004), which held in part, that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits. In this case, the veteran's claim was filed several years prior to the enactment of the VCAA, and the initial unfavorable decision of May 1994 was issued prior to any VCAA notice. Despite the timing of the VCAA notice in the case, the veteran has still been afforded proper VCAA notice. The March 2004 RO letter provided him with the notice necessary to substantiate his claim, and to identify outstanding evidence. The letter advised him of his duties and those of VA, and advised him to submit his evidence to VA. The RO issued a second letter in February 2005 to specifically advise the veteran to submit any evidence that he had or to identify any evidence he wanted the RO's help to obtain. The veteran has not alleged any adverse impact on his ability to support his claim as a result of the timing of the complete notice. As noted above, the veteran's case was remanded in January 1999 and again in September 2003 to allow for additional development. The veteran was then issued SSOCs that weighed the additional evidence in determining that it was not sufficient to establish entitlement to service connection. The Board finds that the RO's efforts, in total, afforded the veteran a "meaningful opportunity to participate effectively in the processing of [his] claim by VA" and thus "essentially cured the error in the timing of notice." See Mayfield v. Nicholson, 19 Vet. App. 103, 128-29 (2005). The duty to assist claimants under the VCAA is codified under 38 U.S.C.A. § 5103A (West 2002) and established by regulation at 38 C.F.R. § 3.159(c)-(e). This section of the VCAA and regulation sets forth several duties for the Secretary in those cases where there is outstanding evidence to be obtained and reviewed in association with a claim for benefits. However, in this case there is no outstanding evidence to be obtained, either by the VA or the veteran. The veteran was afforded multiple VA examinations. Extensive private records were obtained and associated with the claims file. The veteran submitted several presentations that contained treatise material, medical articles, and medical evidence. The veteran and his son testified at a hearing at the RO in May 2001. His case was remanded in January 1999 and September 2003 to afford him the opportunity to supplement the evidence of record. The Board finds that every effort has been made to seek out evidence helpful to the veteran. The veteran has not alleged that there is any outstanding evidence that would support his contentions. The Board is not aware of any outstanding evidence. Therefore, the Board finds that the VA has complied with the spirit and the intent of the duty-to-assist requirements found at 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c)-(e) (2005). ORDER Entitlement to service connection for a cervical spine disorder is denied. Entitlement to service connection for hearing loss is denied. ____________________________________________ Gary L. Gick Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs