Citation Nr: 1120557 Decision Date: 05/26/11 Archive Date: 06/06/11 DOCKET NO. 09-15 467A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of service connection for bilateral hearing loss. 2. Whether new and material evidence has been received to reopen a claim of service connection for tinnitus. 3. Entitlement to service connection for posttraumatic stress disorder (PTSD). 4. Entitlement to service connection for a cardiovascular disorder (claimed as a blocked cardiac artery), to include as secondary to service-connected hypertension. 5. Entitlement to service connection for a traumatic brain injury (TBI). ATTORNEY FOR THE BOARD C. C. Dale, Associate Counsel INTRODUCTION The Veteran had active duty service from July 1988 to October 1988 and from February 1995 to May 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Board notes that the Veteran did request a hearing before the Board at the local RO in his May 2009 substantive appeal. He was scheduled for such a hearing in January 2011. However, he did not appear for the hearing, and he has not requested that it be rescheduled. Therefore, the Board will consider the hearing request to have been withdrawn. 38 C.F.R. § 20.702(d). The Board further observes that additional evidence has been received, which was not previously considered by the RO. However, the Veteran submitted a waiver of the RO's initial consideration of the evidence in March 2011. Therefore, the Board will consider this newly obtained evidence and proceed with a decision. The merits of the claims for service connection for bilateral hearing loss, tinnitus, and a cardiovascular disorder will be addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. An unappealed November 2006 rating decision previously considered and denied service connection for bilateral hearing loss. 2. The evidence received since the November 2006 rating decision, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the claim for service connection for bilateral hearing loss. 3. An unappealed November 2006 rating decision previously considered and denied service connection for tinnitus. 4. The evidence received since the November 2006 rating decision, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the claim for service connection for tinnitus. 5. The Veteran's service records show that he served in Iraq and that his military occupational specialty was a combat engineer. 6. The Veteran has been diagnosed as having PTSD by a VA psychologist based upon reports of stressful experiences involving fear of hostile military activity consistent with the circumstances of his service in Iraq. 7. The Veteran injured his head during service, and VA medical records show that he experiences current cognitive disorders associated with that injury. CONCLUSIONS OF LAW 1. The November 2006 rating decision, which denied service connection for bilateral hearing loss, is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. § 3.104(a) (2010). 2. The evidence received subsequent to the November 2006 rating decision is new and material, and the claim for service connection for bilateral hearing loss is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2010). 3. The November 2006 rating decision, which denied service connection for tinnitus, is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. § 3.104(a) (2010). 4. The evidence received subsequent to the November 2006 rating decision is new and material, and the claim for service connection for tinnitus is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2010). 5. Resolving reasonable doubt in favor of the Veteran, PTSD was incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1111, 1153, 1154 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2010). 6. Resolving reasonable doubt in favor of the Veteran, a traumatic brain injury (TBI) was incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1111, 1153, 1154 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303(2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). Upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). With respect to the issues of whether new and material evidence has been submitted to reopen the claims for service connection for hearing loss and tinnitus, the RO had a duty to notify the Veteran what information or evidence was needed in order reopen his claim. The law specifically provided that nothing in amended section 5103A, pertaining to the duty to assist claimants, shall be construed to require VA to reopen a claim that has been disallowed except when new and material evidence is presented or secured. 38 U.S.C.A. § 5103A(f). In the decision below, the Board has reopened the Veteran's claims for service connection for bilateral hearing loss and tinnitus, and therefore, regardless of whether the requirements have been met in this case, no harm or prejudice to the appellant has resulted. Therefore, the Board concludes that the current laws and regulations have been complied with, and a defect, if any, in providing notice and assistance to the Veteran was at worst harmless error in that it did not affect the essential fairness of the adjudication. Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004); Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004); Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92. Moreover, in the decision below, the Board has granted the Veteran's claim for service connection for PTSD and TBI, and therefore, the benefits sought on appeal has been granted in full. Accordingly, regardless of whether the notice and assistance requirements have been met in this case, no harm or prejudice to the appellant has resulted. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92. Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain diseases, including organic diseases of the nervous system such as sensorineural hearing loss, may be also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 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. I. Hearing Loss and Tinnitus The Board observes that the Veteran's claims for service connection for bilateral hearing loss and tinnitus were previously considered and denied by the RO in a rating decision dated in November 2006. The Veteran was notified of those decisions and of his appellate rights; however, he did not submit a notice of disagreement. In general, rating decisions that are not timely appealed are final. See 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. In March 2008, the Veteran requested that his claims for service connection for bilateral hearing loss and tinnitus be reopened. The July 2008 rating decision currently on appeal denied reopening those claims. In order to reopen a claim which has been denied by a final decision, the claimant must present new and material evidence. 38 U.S.C.A. § 5108. For applications to reopen filed after August 29, 2001, as was the application to reopen the claim in this case, new and material evidence means evidence not previously submitted to agency decisionmakers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and which raises a reasonable possibility of substantiating the claim.38 C.F.R. § 3.156(a). To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, "credibility" of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The language of 38 C.F.R. § 3.156(a) creates a low threshold for finding new and material evidence, and the phrase "raises a reasonable possibility of substantiating the claim" is "enabling rather than precluding reopening." Evidence "raises a reasonable possibility of substantiating the claim," if it would trigger VA's duty to provide an examination in adjudicating a non-final claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). As noted above, the November 2006 rating decision previously considered and denied the Veteran's claims for bilateral hearing loss and tinnitus. The RO had considered the Veteran's service treatment records and a September 2006 VA audiology examination report. These records did not show hearing loss in either ear meeting the VA criteria for hearing loss as set forth in 38 C.F.R. § 3.385, nor did they document him as having tinnitus. In fact, the Veteran denied having a history of tinnitus during the September 2006 VA examination. Since the November 2006 rating decision, the record does not include any medical evidence suggesting the Veteran currently meets the VA criteria for hearing loss. See id. However, the Veteran submitted a lay statement regarding his hearing impairment and current tinnitus symptoms. See June 2008 Veteran statement. He reported that his wife complains about him maintaining a loud volume while watching TV and listening to the radio. He also stated that he has tinnitus symptoms. The Board notes that the Veteran is competent to describe his current symptoms, such as difficulty hearing and ringing in his ears. See Charles v. Principi, 16 Vet. App. 370, 274 (2002) (finding veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). The Board must presume the credibility of this evidence for the purpose of determining whether it constitutes new and material evidence needed to reopen the claims and may not assess its probative weight in relation or comparison to other evidence for reopening purposes. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, "credibility" of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). After careful consideration, the Board finds that new and material evidence has been submitted for both claims. 38 C.F.R. §§ 3.385, 3.156; Shade, supra. The evidence received following the November 2006 rating decision includes a statement indicating that he is currently experiencing hearing impairment and tinnitus. The lack of current disabilities was the basis for the final prior denial, and the lay statement would trigger VA's duty to provide an examination for both claims. Id. However, as will be explained below, the Board is of the opinion that further development is necessary before the merits of the Veteran's claim can be addressed. II. PTSD In addition to the laws and regulations cited above, additional regulations apply specifically to service connection claims for PTSD. 38 C.F.R. § 3.304(f). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f); see Cohen v. Brown, 10 Vet. App. 128 (1997); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Effective July 13, 2010, VA amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. See 75 Fed. Reg. 39843 (July 13, 2010). Specifically, the final rule amends 38 C.F.R. § 3.304(f) by redesignating current paragraphs (f)(3) and (f)(4) as paragraphs (f)(4) and (f)(5), respectively, and by adding a new paragraph (f)(3) that reads as follows: (f)(3) If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. at 39852. The Veteran's service treatment records do not document any complaints, treatment, or diagnosis of a psychiatric disorder. Rather, the Veteran asserts his current PTSD resulted from in-service stressors. The Veteran began a series of VA mental health treatments starting in March 2008. Initially, he was not diagnosed with PTSD, but was instead assessed as having depression as a result of multiple life stressors. VA treatment records dated in August 2008 reflect that the Veteran had reported two in-service stressors. The first one involved a landmine explosion in Bosnia that resulted in burn injuries, and the other one involved witnessing an improvised explosive device (IED) explosion in Iraq. The Board observes that the Veteran's service treatment records show extensive treatment for second degree burns to the face and left hand secondary to lighting a stove in December 1995, as opposed to a landmine explosion. Nevertheless, based upon these stressors, a VA psychologist diagnosed him as having PTSD. Subsequent VA mental health clinic records also list his diagnosis as PTSD. As such, the VA health care providers have diagnosed the Veteran with PTSD and related it his reported in-service stressors. The remaining issue is whether the Veteran's reported stressors are consistent with the places, types, and circumstances, of his service. His service personnel records show that he was stationed in Germany from March 1995 to February 1997 and from August 2001 to March 2004. They also confirm multiple assignments with combat and engineering battalions. The Veteran's DD 214 lists his military occupational specialty as a combat engineer and confirms service in Iraq. Based upon the record, the Board finds the Veteran's reports to be consistent with the types, places, and circumstances of his active service, and therefore, there appears to be satisfactory lay evidence of an in-service stressor. 75 Fed. Reg. 39843 (July 13, 2010). Based on the foregoing, there is at least an approximate balance of positive and negative evidence regarding the issue at hand, and the Board finds that the evidence raises at least a reasonable doubt as to whether the Veteran currently has PTSD that is related to an in-service stressor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board also observes that the Court has cautioned against seeking an additional medical opinion where favorable evidence in the record is unrefuted. The Court specifically indicated that it would not be permissible to undertake further development if the purpose was to obtain evidence against an appellant's claim. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003). Thus, for the reasons described above, the Board concludes that there is a reasonable doubt as to whether the Veteran has PTSD related to his period of service. To the extent that there is any reasonable doubt, that doubt will be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the Board concludes that service connection for PTSD is warranted. III. Traumatic Brain Injury (TBI) The Veteran's service treatment records show that he injured his head during an incident in December 1995 when a stove exploded upon lighting. He received extensive treatment for burn residuals to his face and left hand following the accident. In February 2008, the Veteran was referred to the VA neuropsychiatric clinic after reporting memory and cognitive problems in addition to a history of a head injury. The Veteran indicated that he had started noticing memory problems about one year earlier. He also reported having chronic fatigue, sleep disorders, and poor concentration. The examiner described the December 1995 injury as a loss of consciousness incident, and there were many other incidences of altered consciousness reported as being due to work as a combat engineer. Clinical testing revealed several cognitive defects. The examiner believed that the Veteran had mild cognitive defects due to the prior head injuries, but indicated that was able to cope prior to the onset of depressive and anxiety type psychiatric symptoms. He diagnosed the Veteran with an unspecified cognitive disorder. The Veteran underwent another VA neuropsychiatric evaluation in July 2009. He reported similar symptoms to those he described during the prior examination. The examiner noted the Veteran's military history involving the injury in December 1995 and his exposure to explosive devices. Cognitive testing revealed several mild deficits. The examiner concluded that the December 1995 incident was a mild TBI and diagnosed the Veteran with a mild unspecified cognitive disorder with minimal changes during the past year. The examiner commented that the present cognitive symptoms seemed to be secondary to TBI residuals. However, he indicated that individuals with mild TBI may recover in a few years and noted that the Veteran's history was significant for a reaction to anthrax vaccination. The examiner also recommended further evaluation to determine the medical cause of excessive fatigue before further cognitive remediation resumes. The Board finds the current evidence sufficient to warrant a grant of service connection for TBI. The Veteran's service treatment records document a head injury, and the Board has no reason to doubt the credibility of the Veteran's reports of working near explosive devices, as his military occupational specialty was listed as a combat engineer while serving in Iraq. In addition, the February 2008 and July 2009 VA neuropsychiatric reports both indicate that the Veteran currently experiences some cognitive impairment related to those incidents in service. Based on the foregoing, there is at least an approximate balance of positive and negative evidence regarding the issue at hand, and the Board finds that the evidence raises at least a reasonable doubt as to whether the Veteran currently has a TBI or residuals thereof that are related to his military service. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board also observes that the Court has cautioned against seeking an additional medical opinion where favorable evidence in the record is unrefuted. The Court specifically indicated that it would not be permissible to undertake further development if the purpose was to obtain evidence against an appellant's claim. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003). Thus, for the reasons described above, the Board concludes that there is a reasonable doubt as to whether the Veteran has a TBI related to his period of service. To the extent that there is any reasonable doubt, that doubt will be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the Board concludes that service connection for a TBI is warranted. ORDER New and material evidence having been submitted, the claim of entitlement to service connection for bilateral hearing loss is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for tinnitus is reopened. Subject to the provision governing the award of monetary benefits, service connection for PTSD is granted. Subject to the provision governing the award of monetary benefits, service connection for a traumatic brain injury is granted. REMAND The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2010). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2010). In this case, the Veteran filed a claim in March 2008 seeking service connection for a "cardiac blocked artery secondary to hypertension." He was later afforded a VA examination in June 2008 in connection with that claim. Following a review of the claims file and a physical examination, the examiner stated that there was not enough evidence to diagnose an acute or chronic cardiac blocked artery and indicated that she could not provide an opinion because there was no current diagnosis. However, the Board notes that the Veteran has had chest pain and a positive stress test resulting in a cardiac catheterization. Nevertheless, the June 2008 VA examiner did not discuss whether the Veteran may have had a cardiovascular disorder other than a blocked artery that would account for his symptoms. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Therefore, the Board finds that an additional VA examination and medical opinion are necessary for determining the nature and etiology of any cardiovascular disorder that may be present. In addition, the Board notes that the Veteran was afforded a VA examination in September 2006 in connection with a prior claim for service connection for bilateral hearing loss and tinnitus. However, he was not found to have current hearing loss or tinnitus during that examination. In fact, the Veteran had denied having tinnitus at that time. Since then, he has submitted statements indicating that he has tinnitus and difficulty hearing. The Board notes that the Veteran is competent to describe his current symptoms, such as difficulty hearing and ringing in his ears. See Charles v. Principi, 16 Vet. App. 370, 274 (2002) (finding veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). 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, (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). However, the record on appeal does not indicate that the appellant has the expertise or competence to provide a probative opinion on a medical matter that requires specialized knowledge, skill, experience, training or education, such as a diagnosis of a specific disability and a determination of the origins of a specific disorder. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The Veteran has not been afforded a VA examination in connection with his present claims for hearing loss and tinnitus. VA is obliged to provide an examination or to obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. The Veteran's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon, 20 Vet. App. at 83. Therefore, the Board finds that a VA examination and medical opinion are necessary for the purpose of determining the nature and etiology of any hearing loss and tinnitus that may be present. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded a VA examination to determine the nature and etiology of any cardiovascular disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. It should be noted that the Veteran was seen in service with complaints of chest pain and that he is service-connected for hypertension. He also had a cardiac catheterization in March 2008. The examiner should identify all current cardiovascular disorders that have been present at any time since the Veteran filed his claim in March 2008. For each diagnosis identified, the examiner should state whether it is at least as likely as not the disorder is causally or etiologically related to the Veteran's military service. If not, he or she should opine as to whether it is at least as likely as not that the disorder is either caused by or permanently aggravated by his service-connected hypertension. In so doing, the examiner should discuss the Veteran's chest pain and positive stress test in 2008 and indicate what may account for such symptoms and findings, particularly if there is no current diagnosis. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Since it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 (2010), copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 2. The Veteran should be afforded a VA examination to determine the nature and etiology of any hearing loss and tinnitus that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. It should be noted that the absence of in-service evidence of a hearing disability during service is not always fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). The Veteran has contended that he had noise exposure in service. It should be noted that he is competent to attest to factual matters of which he had first- hand knowledge. The examiner should state whether the Veteran has current bilateral hearing loss and tinnitus. If so, he or she should then state an opinion as to the likelihood (likely, unlikely, at least as likely as not) that the current disorder is causally or etiologically related to his military service, including noise exposure. He or she should also address whether the Veteran's tinnitus is caused or otherwise related to his hearing loss. In so doing, the examiner should discuss medically known or theoretical causes of hearing loss and tinnitus and describe how hearing loss and tinnitus which results from noise exposure generally present or develop in most cases, as distinguished from how hearing loss or tinnitus develops from other causes, in determining the likelihood that current hearing loss and tinnitus were caused by noise exposure in service as opposed to some other cause. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Since it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 (2010), copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The RO/AMC should review the examination reports to ensure that they contain the information and opinions requested in this remand and are otherwise complete. 4. After completing these actions, the RO should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. 5. When the development requested has been completed, the case should be reviewed by the RO on the basis of additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ JESSICA J. WILLS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs