Citation Nr: 1300602 Decision Date: 01/08/13 Archive Date: 01/16/13 DOCKET NO. 10-04 364 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for a bilateral wrist disability, to include carpal tunnel syndrome. 3. Entitlement to service connection for a low back disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD C. J. Houbeck, Associate Counsel INTRODUCTION The Veteran had active service from May 1968 to June 1976, with additional service in the Air Force Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah, which denied the claims on appeal. The Veteran had a hearing before the undersigned Veterans Law Judge in May 2012. A transcript of that proceeding has been associated with the claims file. The record reflects that after the final Supplemental Statement of the Case (SSOC) the Veteran submitted additional relevant evidence to the Board in May 2012 at his Board hearing. No subsequent SSOC was issued, but this is not necessary because the evidence was accompanied by a waiver of initial review by the agency of original jurisdiction in accordance with 38 C.F.R. § 20.1304 (2012). The Board has not only reviewed the Veteran's physical claims file, but also his Virtual VA electronic claims file to ensure a total review of the evidence. The issues of entitlement to service connection for bilateral hearing loss and a bilateral wrist disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran has a low back disability that is etiologically related to a disease, injury, or event in service. CONCLUSION OF LAW A low back disability was not incurred in or aggravated by active service, nor may it be presumed to have occurred therein. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's low back claim, VA has met all statutory and regulatory notice and duty to assist provisions. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his or her possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. A VCAA letter dated in October 2006 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claim. The letter informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The letter also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As noted above, the Veteran also was afforded a hearing before the undersigned Veterans Law Judge (VLJ) during which he presented oral argument in support of his service connection claim. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2011) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ fully explained the issue on appeal during the hearing and specifically discussed the basis of the prior determination, the element(s) of the claim that were lacking to substantiate the claim for benefits, and suggested the submission of evidence that would be beneficial to the Veteran's claim. Specifically, the VLJ discussed that while the Veteran had a current low back disability the critical question was whether such current disability was related to his military service. Significantly, the Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Furthermore, even if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced Veterans Service Organization and has submitted argument in support of his claim. These arguments have referenced the applicable law and regulations necessary for a grant of service connection. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claim and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's VA treatment records are in the file. The Veteran's service treatment records from his period of active service could not be obtained by the RO, despite numerous attempts to multiple federal agencies. Any further attempts to obtain these records would be futile. The Veteran's service treatment records from his Reserve service, however, have been located and are of record. As such, to the extent such service treatment records are missing from the claims file, the Board does not find that a remand is warranted to attempt to obtain such records. Private treatment records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time otherwise referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claims, as defined by law. See 38 C.F.R. § 3.159(c)(4). In this case, the Veteran was provided a VA orthopedic examination for his low back in May 2011. The examiner considered the Veteran's claims of multiple injuries to his back in service; however, the examiner opined that the Veteran's low back disability was less likely than not caused by or related to his military service. As will be discussed in greater detail below, the examiner's opinions were based on review of the claims file and available medical records, the Veteran's reported history, his current symptoms, and a physical examination. The Board, therefore, finds the VA examination report to be thorough, complete, and sufficient upon which to base a decision with respect to the Veteran's claim for service connection. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in line of duty. 38 U.S.C.A. § 101(21) and (24) (West 2002 & Supp. 2012); 38 C.F.R. § 3.6(a) (2012). Active military, naval, or air service also includes any period of inactive duty training (INACDUTRA) duty in which the individual concerned was disabled from injury incurred in the line of duty. Id. Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ACDUTRA or from injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1131 (West 2002 & Supp. 2012). ACDUTRA includes full time duty performed by members of the National Guard of any state or the reservists. 38 C.F.R. § 3.6(c). INACDUTRA includes duty other than full time duty performed by a member of the Reserves or the National Guard of any state. 38 C.F.R. § 3.6(d). In this case, the Board notes that the Veteran had many years of Air Force Reserve service, but there is no medical evidence to indicate that he was diagnosed with a low back disability during this service. The Board notes that the Veteran's primary contention is that his back problems were caused by numerous hard landings that occurred on active duty, while parasailing (or swing landing training) during the training of new pilots in his position of Physiological Training Supervisor. Also, while serving in Vietnam the Veteran contends that he was required to push, pull, and carry 150 pound boxes of propaganda leaflets that he would push out of planes while in flight. That said, the Veteran also argues that his low back problems were aggravated by his Reserve service, in that he was required to lift and carry heavy panels of sheet metal. As will be discussed in greater detail below, the Board finds that a remand is required to ascertain the Veteran's specific periods of ACDUTRA and INACDUTRA with respect to his bilateral hearing loss and bilateral wrist claims. The Board finds that such remand is not necessary with respect to the low back claim because there is not a medical diagnosis of a low back disability during the Veteran's Reserve service and the Board finds the Veteran's representations of a continuity of low back pain from active service and through his Reserve service to be less than credible. As such, any determination as to specific periods of ACDUTRA and INACDUTRA are not necessary for adjudication of this claim. 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) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established for a current disability on the basis of a presumption under the law that certain chronic diseases, to include arthritis, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C.A. §§ 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a) (2012). In this case, the Veteran was not diagnosed with arthritis of the low back in service or within one year of separation from service. As such, entitlement to service connection on a presumptive basis is not warranted. To establish a right to compensation for a present disability on a direct basis, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Regrettably, the Veteran's service treatment records from his active military service from could not be obtained for his period of active service from May 1968 to June 1976. Attempts to rebuild the file from other sources were unsuccessful. Where "service medical records are presumed destroyed . . . the BVA's [Board's] obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt is heightened." O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The case law does not, however, lower the legal standard for proving a claim for service connection, but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the claimant. See Russo v. Brown, 9 Vet. App. 46 (1996). The Veteran's service treatment records from his Reserve service are of record. In a June 1982 Report of Medical History, the Veteran specifically denied a history of recurrent back pain. Contemporaneous physical examination of the spine was normal. In July 1983, October 1984, and December 1984, the Veteran stated that he was unaware of any medical disability that would preclude him from full military duty. In an October 1985 Report of Medical History, the Veteran specifically denied a history of recurrent back pain. Contemporaneous physical examination of the spine was normal. In January 1986, January 1987, and February 1989, the Veteran stated that he was unaware of any medical disability that would preclude him from full military duty. In July 1989 and June 1993 Reports of Medical History, the Veteran specifically denied a history of recurrent back pain. Contemporaneous physical examinations of the spine were normal. In August 1993, July 1994, November 1995, September 1996, and November 1996, the Veteran specifically denied any current medical problems or any medical problems since the last periodic physical examination. Physical examination of the spine in August 1999 was normal. The first report of back problems in the claims file is a June 2000 service treatment record, at which time the Veteran reported that he had awoken that morning with knee and back pains, as well as bloating, nausea, and diarrhea. The Veteran denied a past history of medical illnesses. The assessment was acute gastroenteritis with nausea, diarrhea, and myalgias. The Veteran was afforded a VA examination for his low back problems in May 2011. The examiner noted review of the claims file and commented on the absence of the service treatment records from the Veteran's period of active service. The Veteran reported his hard landings during swing landing training and episodes of back pain when pushing 100 plus pound boxes out of a C130 during service in Vietnam, as discussed above. Currently, the Veteran did not have constant back pain, but rather chronic recurrent sharp pains. The Veteran's initial diagnosis was recurrent mild lumbar strain, but following x-rays the diagnosis was changed to degenerative disc disease, most pronounced at L3-L4 and L5-S1. As to etiology, the examiner noted that from 1982 to 1999 the service treatment records either did not include complaints of recurrent low back pain or specifically denied recurrent low back pain, including explicit denials of recurrent low back pain in 1993 and 1999. As such, the examiner concluded that it was less likely as not that his chronic recurrent subjective back pain and strain was related to an active duty injury or other events, given the results of the in-service records that included multiple denials of recurrent back pain during numerous physical examinations. The examiner acknowledged that the Veteran's activities as a swing landing instructor could possibly cause low back pain; however, "one would see this at an earlier stage and onset as well as complaints on an earlier level rather than 20 plus years later, and in the case of his low back, this becomes much later than 1999." The examiner found the Veteran credible in his belief that he injured his back during the above activities, but again noted that his reported history during service "does not corroborate or confirm his subjective recollection of such." In support of his claim, the Veteran submitted a May 2012 private treatment record. The record discussed the Veteran's in-service work history and that he complained to military doctors for back problems. The Veteran reported that in subsequent decades he experienced exacerbations, flare-ups, and back pangs. The provider diagnosed low back pain, facet arthropathy, and degeneration of the lumbar spine. As to etiology, the treatment provider stated that there had been a pathological aggravation of the lumbar spine. However, as the reported injury was over the course of several decades, it was difficult to determine the causative trauma. Thus, the Veteran has current diagnosed degenerative disc disease of the lumbar spine. The crucial inquiry, therefore, is whether that low back disability is related to any incident of service. For the reasons and bases set forth below, the Board concludes it is not. The Board finds there is no credible and competent evidence of record demonstrating continuity of low back symptomatology since service. In reaching this decision, the Board has considered the Veteran's statements and descriptions of the in-service injuries and his assertions of a continuity of symptomatology thereafter. The Board also considered the Veteran's assertion that he failed to report ongoing back pain during his Reserve service because of the culture of the military. Credibility, however, is an adjudicative and not a medical determination. The Board has "the authority to discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In this case, the "inherent characteristics" of the Veteran's current statements as to the circumstances of any continuity of back problems are inconsistent with the objective medical record and the Veteran's own contemporaneous statements. In that regard, the Board again notes that the Veteran's service treatment records for his period of active duty service are not of record. Even assuming that the Veteran injured his back during parasailing or manipulating 100 plus pound boxes, the Board finds the Veteran's reports of continuity of back problems less than credible. As noted, the service treatment records for the Veteran's Reserve service include no treatment for back problems. Of even greater significance, on multiple occasions the Veteran explicitly denied a history of recurrent back pain. The Veteran has stated that he sought treatment for low back problems during his period of active service; however, he claims that he did not seek treatment for back problems during his Reserve service because that was not the culture and that he was expected to "tough out" such problems. The Veteran has not explained and the Board finds it extremely problematic that the "culture" described by the Veteran permitted him to complain about and seek treatment for back pain following incidents while parasailing or carrying and otherwise moving 100-150 pound boxes of leaflets, but that same culture would not permit the Veteran to complain about or seek treatment for back pain following the carrying and otherwise moving panels of sheet metal or other associated duties during Reserve service. Not only did the Veteran fail to report back problems, but he explicitly denied recurrent back pain on numerous occasions. The Board finds it much more reasonable to conclude that had the Veteran been experiencing low back problems after carrying panels of sheet metal or other Reserve duties he would have sought treatment or otherwise reported such problems - in the same way he concedes he did seek treatment for and/or otherwise reported low back problems after parasailing and moving 150 pound boxes of leaflets. Moreover, while the Veteran did report backache on one occasion, in June 2000, he reported that the pain had started that morning and was associated with acute gastroenteritis. The Board also finds it significant that at that time the Veteran denied any associated past medical illnesses, such as recurrent low back pain, that he associated with his current symptoms. The Board also notes the Veteran's contention that he stopped seeking treatment for his back problems because the treatment provided did not offer him complete relief and there was no further help that treatment providers could afford. Again, this contention might explain why the Veteran failed to seek further treatment for back problems, but would not address his multiple explicit denials of a history of recurrent back pain. The Board also has considered the case of Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), wherein the Court held that the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. However, this is not a case in which the record is merely silent regarding whether he experienced a continuity of back problems from parasailing, manipulating 100 plus pound boxes of propaganda literature in Vietnam, or his Reserve duties involving sheet metal repair. Rather, the Veteran specifically denied a history of recurrent back pain problems on multiple occasions during military service. In short, the Board gives greater credence and weight to the contemporaneous medical records filed in this matter than to the recent assertions of a continuity of symptomatology following in-service injury, which were made in support of his claim. Regardless of whether the Veteran is purposely mischaracterizing the events in service and thereafter or unintentionally doing so, the ultimate conclusion is that his current statements regarding a continuity of symptomatology since service are simply not credible evidence. As discussed above, there are objective documents and the Veteran's own statements that refute his claim of experiencing ongoing low back problems beginning during his period of active service. Because of the inconsistency, the Board finds that the Veteran's allegations have no probative value. In addition, the Board finds the opinions expressed in the May 2011 VA examiner's report of significant probative value. The report was based on an interview of the Veteran, his reported medical history, appropriate diagnostic testing, physical examination, and complete review of the claims file, including service treatment records. Further, a complete and through rationale is provided for the opinions rendered. As noted, the examining physician discussed the absence of any complaints or treatment for back problems during the Veteran's Reserve service and his explicit denial of a history of recurrent back pain as recently as 1999. While the examiner's opinion ostensibly limited the opinion to the Veteran's active service, given the consideration and discussion of the Veteran's Reserve service, including his denial of recurrent back pain in 1999, and the overall nature of the examiner's opinion (and unlike the opinion from the same examiner with respect to the Veteran's bilateral wrists, as discussed below) the Board concludes that the examiner's opinion fully contemplated and encompassed the Veteran's periods of ACDUTRA and INACDUTRA service. The examiner's conclusion is fully explained and consistent with the evidence of record. Moreover, the Veteran's private treatment provider, as discussed above in the May 2012 treatment record, has noted that the precise etiology of the Veteran's current low back disability was difficult to determine and has not affirmatively linked such current disability to the Veteran's military service. The Board also has considered the statements of record from the Veteran's wife during the May 2012 Board hearing. To the extent that any of her statements represented an attempt to link any current back problems to the Veteran's military service, the Board acknowledges that as a layperson she can attest to factual matters of which she has first-hand knowledge, such as the Veteran experiencing back pain and related problems, and her assertions in that regard are entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Laypersons, however, are not generally competent to render an opinion as to the cause or etiology of any current disability because they do not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). In this case, the Board concludes that her conclusions as to etiology are significantly outweighed by the opinion of the May 2012 medical professional and the Veteran's numerous and consistent denials of recurrent back pain during his Reserve service following active duty. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). In conclusion, no medical professional has linked the Veteran's current low back disability to his military service and, indeed, multiple medical professionals have concluded that such a link cannot be made. The Veteran's representations of a continuity of back problems beginning during his period of active service are refuted by the record and deemed less than credible. Finally, the Board finds any statements by the Veteran's wife that could be viewed as an attempt to link current low back problems to his military service to be significantly outweighed by the Veteran's numerous denials of a history of recurrent back pain as late as 1999 and the medical evidence of record. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim for service connection for a low back disability must be denied. See 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2012); See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). ORDER Entitlement to service connection for a low back disability is denied. REMAND The Veteran also is seeking entitlement to service connection for bilateral hearing loss and bilateral wrist disabilities. Despite the extensive development already undertaken, the Board has determined that additional development is necessary prior to the adjudication of these claims. As noted above, the Veteran had extensive service in the Air Force Reserve, which has not been verified. Unlike the above low back claim, prior to adjudication of the hearing loss and wrist claims it is necessary to verify the specific dates of the Veteran's ACDUTRA and INACDUTRA service. In that regard, while the Veteran consistently denied a history of recurrent back pain during his Reserve service (whether ACDUTRA or INACDUTRA) and he was not otherwise diagnosed with a low back disability, multiple audiograms taken during Reserve service showed a right and/or left ear hearing loss disability as defined by VA pursuant to 38 C.F.R. § 3.385 (2012). In addition, in an August 1999 Report of Medical History a medical professional indicated that the Veteran had bilateral mild carpal tunnel syndrome. The timing of the diagnoses is important, as service connection may be established for diseases and/or injuries incurred during ACDUTRA, but injuries only during INACDUTRA. Given that the Veteran reports acoustic trauma during his Reserve service that could represent an injury and he also contends that his bilateral wrist disease could be associated with the repetitive task duties of sheet metal repairman during his Reserve service, the Board concludes that verification of the Veteran's ACDUTRA and INACDUTRA service is necessary. In addition, the Veteran was afforded VA examinations for his bilateral hearing loss and bilateral wrist claims in May 2011. Both examiners explicitly limited their opinions to whether the Veteran's wrist or hearing loss disabilities were the result of his active duty service. Neither examiner discussed whether the hearing loss or wrist disabilities were the result of injury or disease related to any period of ACDUTRA or INACDUTRA. While the May 2011 examination report with respect to the bilateral wrist claims discussed the 1999 diagnosis of bilateral mild carpal tunnel syndrome and that there was no noted basis for such diagnosis, the overall rationale clearly indicated that the examiner was considering whether the Veteran's bilateral wrist problems were incurred in or otherwise related to his active duty service and did not consider the applicability of any periods of ACDUTRA or INACDUTRA. Specifically, the examiner indicated that the Veteran was not diagnosed with carpal tunnel syndrome until almost 20 years after service, which could not include all his periods of INACDUTRA and ACDUTRA. With respect to the May 2011 VA audio examination report, the examiner noted that the Veteran had a diagnosed left ear hearing loss disability by 1989 and a right ear hearing loss disability by 1998; however, the report stated that hearing loss typically occurred at the time of exposure and since the Veteran was not diagnosed with left or right ear hearing loss until the above times, his hearing loss was not caused by or a result of his military noise exposure. Again, this rationale did not take into account the Veteran's periods of INACDUTRA and ACDUTRA. As such, after verified periods of INACDUTRA and ACDUTRA have been obtained, a supplemental opinion for both examination reports should be obtained to consider whether the Veteran's hearing loss or wrist disabilities are the result of an injury or disease incurred or aggravated as a result of any period of INACDUTRA or ACDUTRA. While the further delay of this case is regrettable, due process considerations require such action. Accordingly, the case is REMANDED for the following action: 1. Contact all appropriate sources in order to verify the specific dates of the Veteran's ACDUTRA and INACDUTRA service. 2. After the above is completed, obtain a supplemental opinion from the examiner who conducted the May 2011 VA audio examination. If the examiner is not available, obtain an opinion from another appropriate medical professional. If the reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The claims file must be made available to and reviewed by the reviewer/examiner. The reviewer/examiner is asked to provide an opinion regarding whether it is as least as likely as not (50 percent probability or more) that the Veteran's current bilateral hearing loss disability is the result of an injury incurred or aggravated during any period of INACDUTRA or an injury or disease incurred or aggravated during any period of ACDUTRA. For the purpose of this opinion, the examiner/reviewer may presume that any hearing loss as a result of acoustic trauma may be considered an injury. It would be helpful if the examiner/reviewer would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner/reviewer should explain the reasons behind any opinion provided. 3. After paragraph 1. above is completed, obtain a supplemental opinion from the examiner who conducted the May 2011 VA orthopedic examination. If the examiner is not available, obtain an opinion from another appropriate medical professional. If the reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The claims file must be made available to and reviewed by the reviewer/examiner. The reviewer/examiner is asked to provide an opinion regarding whether it is as least as likely as not (50 percent probability or more) that the Veteran's current bilateral wrist disability is the result of an injury incurred or aggravated during any period of INACDUTRA or an injury or disease incurred or aggravated during any period of ACDUTRA. It would be helpful if the examiner/reviewer would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner/reviewer should explain the reasons behind any opinion provided. 4. After the above is complete, readjudicate the Veteran's claims. If one or more claims remains denied, issue a supplemental statement of the case (SSOC) to the Veteran and his representative, and they should be given an opportunity to respond, before the case is returned to the Board. 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. 2012). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs