Citation Nr: 1304890 Decision Date: 02/11/13 Archive Date: 02/21/13 DOCKET NO. 12-24 477 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for vertigo or a balance/dizziness disability, to include as secondary to service-connected anxiety reaction, bilateral hearing loss and/or tinnitus. REPRESENTATION Appellant represented by: Robert W. Gillikin II, Attorney ATTORNEY FOR THE BOARD Emily L. Tamlyn, Counsel INTRODUCTION The Veteran served on active military duty from September 1952 to September 1956 and from October 1956 to August 1962. This issue comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 RO rating decision of the Department of Veterans Affairs Regional Office (RO) in Pittsburgh, Pennsylvania. In that decision, the RO denied a claim for service connection for vertigo. In March 2012, a statement of the case (SOC) was issued listing service connection for vertigo. The same month, the RO also issued a deferral, stating that it interpreted filings from the Veteran's attorney as a claim for a separate evaluation for a balance problem and an increased rating for the service-connected anxiety reaction. In May 2012, a RO decision continued the current 10 percent rating for anxiety reaction and did not grant a separate evaluation for balance and dizziness. The Veteran's attorney filed an appeal in July 2012, asserting that an SOC should have been issued and stating that the sole issue in question was service connection for dizziness secondary to service-connected anxiety; the attorney also filed a notice of disagreement to the May 2012 decision in August 2012. In September 2012, the RO issued a supplemental statement of the case for "service connection for vertigo." Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The appeal is REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the appellant if further action is required. REMAND The Board finds that a remand is warranted for further clarification regarding a diagnosis of vertigo or a balance/dizziness disability. The Veteran is service-connected for bilateral hearing loss, as well as for anxiety reaction and tinnitus associated with bilateral hearing loss. He asserts that his current disability is either caused or aggravated by his service-connected anxiety reaction. Service treatment records show that in July 1960, the Veteran was diagnosed with anxiety reaction; one symptom noted was dizziness. In August 1962, the report of medical examination revealed hearing loss and the degeneration of acoustic nerves. He would require annual hearing tests. A February 1964 VA examination noted psychosomatic complaints while an April 1970 VA examination noted some disturbance of balance. VA records dated in 2009 show complaints of periodic vertigo and longstanding dizziness, including an association with cold and sinus issues. In November 2010, a VA primary care record stated a magnetic resonance imaging (MRI) report was negative with no acoustic neuroma found. Several examinations and opinions attempted to address the nature and etiology of a vertigo or a balance/dizziness disability, but none has comprehensively resolved this issue. A May 2009 VA examination report completed by an audiologist stated that the Veteran should discuss loss of balance and vertigo with his primary care and follow a multi-disciplinary plan to address etiology of the condition. This report stated that audiology and videonystagmography (VNG) testing should be included; therefore the report was inconclusive. In January 2010, Dr. A., a private audiologist, stated that the Veteran's dizziness was "suggestive of benign paroxysmal positional vertigo." At times the symptoms of this disability could be prolonged and recur with stress and fatigue. Fluid could also be a source of dizziness and should be evaluated and treated. The characterization of a disability as "suggestive" also renders this opinion inconclusive. In February 2012, the file was sent to a VA internal medicine doctor for an opinion. After reviewing the file, the examiner stated that, from the records, it did not appear to him that the Veteran's symptoms were benign paroxysmal positional vertigo. Rather, they were consistent with a nonspecific balance disorder. The recommendation was for formal balance or vestibular testing to be performed. Due to the inconclusive diagnosis, no opinion was offered. In April 2012, a VA psychologist examined the Veteran and completed a report. The examiner acknowledged the self-reported dizziness, but provided a negative opinion. Specifically, the examiner concluded that there was no relationship between anxiety symptoms and dizziness. However, from the phrasing used by the examiner, one cannot rule out the possibility that the Veteran's service-connected anxiety could have aggravated his disability manifested by dizziness. Moreover, the April 2012 opinion did not rule out a relationship between a vertigo disability and another service-connected disability or between the dizziness in service and a current vertigo disability. Two clinicians have recommended formal balance, vestibular testing and VNG testing. No clinician has given both a reasoned diagnosis and opinion considering service connection on both a direct basis and secondary basis. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any current vertigo or balance/dizziness disability. A copy of this remand and the claims file should be provided to the examiner in conjunction with the examination. All recommended testing should be included in the report. This includes: formal balance or vestibular testing (see February 2012 VA examination report) and audiology and VNG testing (see May 2009 VA examination report). If this testing is not completed, the examiner should state why it is not necessary. The examiner should first state whether the Veteran has a current diagnosis of a vertigo or vertigo-like disability. If so, the examiner should answer the following questions: * Is it as least as likely as not (a 50 percent or greater probability) that the disability was incurred in or related to service? Please note the July 1960 service treatment record showing dizziness. * Is it as least as likely as not that the disability was caused by or due service-connected bilateral hearing loss or tinnitus? Note Dr. A.'s January 2010 opinion and prior VA examinations described above. * Is it as least as likely as not that the disability was aggravated (made permanently worse beyond the natural progression of the disease) by service-connected bilateral hearing loss or tinnitus? o If the disability is aggravated by the service-connected bilateral hearing loss or tinnitus, identify the baseline level of severity of the disability and the permanent, measurable increase in the disability's severity that is attributable to the service-connected bilateral hearing loss or tinnitus. The examiner should give the reasons for the opinion given and support the reasons with accurate facts. 2. Readjudicate the claim. If the determination remains adverse to the Veteran, he and his representative should be furnished with a supplemental statement of the case and given an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) 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). _________________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board is appealable to the Court. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).