Citation Nr: 1306281 Decision Date: 02/22/13 Archive Date: 02/27/13 DOCKET NO. 07-35 755 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for bilateral hearing loss. REPRESENTATION The Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD E. Woodward Deutsch, Counsel INTRODUCTION The Veteran served on active duty from November 1968 to April 1975. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision of the Waco, Texas, Department of Veterans Affairs (VA) Regional Office (RO). A Board hearing was held before the undersigned in September 2010. A transcript of the hearing is of record. At the hearing, the Veteran submitted additional evidence accompanied by a waiver of initial review by the Agency of Original Jurisdiction (AOJ). 38 C.F.R. §§ 20.800, 20.1304 (c) (2012). The Board subsequently remanded the case for additional development in August 2011 and July 2012. That development has been completed and the case is once again before the Board. FINDING OF FACT The Veteran's currently-diagnosed bilateral hearing loss was not shown in service or for many years thereafter, and is not related to his in-service acoustic trauma or to any other aspect of his active service. CONCLUSION OF LAW Service connection for bilateral hearing loss is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 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). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012). VCAA notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements apply to all five elements of a service-connection claim: Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006). In this case, VCAA notice was provided through two letters issued in March 2006. The first March 2006 letter specifically advised the Veteran of the evidence needed to substantiate his claim for service connection for bilateral hearing loss and outlined his responsibilities and those of VA in obtaining relevant evidence. The second March 2006 letter described in detail how VA assigns a disability rating and an effective date following the grant of service connection. Therefore, that second letter satisfied the heightened VCAA notice requirements set forth in Dingess, even though such criteria have now been rendered moot by the Board's decision to deny the Veteran's service-connection claim. In light of the above VCAA notice letter, which was sent prior to the May 2006 rating decision on appeal, the Board finds that no further development is required with respect to the duty to notify under 38 C.F.R. § 3.159(b). With respect to the duty to assist, the AOJ has obtained the Veteran's service personnel and treatment records. The AOJ also has obtained the Veteran's post-service VA and Social Security Administration records, even though the latter are not relevant to this appeal. Additionally, in accordance with the Board's initial Remand, the AOJ has attempted to obtain the report of a VA audiometry test that was reportedly performed at the Dallas, Texas, VA Medical Center in the mid-1990s. However, an August 2011 response from that VA facility has indicated that no such report is available. The Veteran has been duly apprised of that negative finding, but has declined to provide any additional information that would enable VA to obtain the results of his purported audiometry test. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (VA's duty to assist is not a one-way street.) As such, additional efforts to obtain those test results would be futile and are therefore unwarranted. See 38 U.S.C.A. § 5103A(a)(2) (West 2002) (stating that VA is not required to provide assistance to a claimant if no reasonable possibility exists that such assistance would aid in substantiating the claim); see also Hayre v. West, 188 F.3d 1327 (Fed. Cir. 1999) (finding that VA's efforts to obtain Federal records shall continue until the records are obtained or unless it is reasonably certain that such records do not exist or that further efforts to obtain those records would be futile). Significantly, the Veteran has not contended, and the record has not otherwise shown, that any other service or post-service records remain outstanding that are necessary to decide his hearing loss claim. In addition to undertaking the above records development, the AOJ has elicited other clinical and lay evidence pertinent to this appeal. Such evidence includes a July 2007 VA examination report; a December 2011 VA examination report and a January 2012 Addendum opinion; an August 2012 VA medical opinion obtained through the disability benefits questionnaire (DBQ) process; and the Veteran's own written statements and Board hearing testimony. As detailed below, the inadequacies inherent in the July 2007 VA examination report and the January 2012 Addendum have been effectively remedied by the August 2012 DBQ medical opinion. Despite expressing dissatisfaction with the conclusions reached by the audiologist who authored that DBQ medical opinion, the Veteran has not alleged, and the record does not otherwise suggest, that the opinion itself is inadequate to rate his hearing loss claim. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (finding that VA must provide an examination that is adequate for rating purposes). As such, the Board considers it unnecessary to obtain a new examination or opinion in support of that claim. The Board also considers it unnecessary to otherwise delay adjudication as its prior Remand has met with substantial compliance by the AOJ. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, the AOJ has honored the Board's request for a medical opinion from a different VA audiologist than the examiner who conducted the December 2011 VA examination and authored the January 2012 Addendum opinion. Moreover, in rendering the requested medical opinion, the August 2012 VA audiologist has expressly heeded the Board's Remand directives to conduct a thorough records review, provide a detailed rationale in support of all findings, and accept as true the Veteran's account of in-service acoustic trauma. In contrast, the August 2012 VA audiologist does not appear to have strictly followed the Board's instruction to accept as true the Veteran's account of insignificant post-service noise exposure. Nevertheless, that clinician has expressly acknowledged the Veteran's testimony in this regard and discussed it in the context of his earlier statements. As such, the Board is satisfied that the August 2012 VA audiologist has given adequate consideration to the Veteran's lay assertions and, thus, achieved substantial, if not total, compliance with the terms of its July 2012 Remand. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); D'Aries v. Peake, 22 Vet App. 97, 105 (2008) (discussing situations when it is acceptable, instead, to have 'substantial' compliance, even if not 'exact', 'total' or 'complete' compliance, per se). In further compliance with the Board's Remand, the Veteran's hearing loss claim has been readjudicated in a January 2013 Supplemental Statement of the Case (SSOC). In that readjudication, the AOJ has expressly addressed the August 2012 VA audiologist's opinion, which comprises the only substantive evidence introduced since the previous SSOC. As such, the AOJ has substantially complied with VA's governing regulatory provisions that the SSOC consider all evidence added to the record since the Statement of the Case or the most recent SSOC. See 38 C.F.R. § 19.31 (2012). Even if the January 2013 SSOC had not specifically mentioned the newly received VA audiologist's opinion, another Remand would not be warranted. On the contrary, "[t]here is a presumption of regularity that public officers perform their duties 'correctly, fairly, in good faith, and in accordance with law and governing regulations.'" Marsh v. Nicholson, 19 Vet. App. 381, 385 (2005) (quoting Alaska Airlines, Inc. v. Johnson, 8 F.3d 791, 795 (Fed. Cir. 1993)). Courts presume that, "'in the absence of clear evidence to the contrary,'" public officers have "'properly discharged their official duties.'" Ashley v. Derwinski, 2 Vet. App. 62, 64 (1992) (quoting United States v. Chem. Found., Inc., 272 U.S. 1, 14-15 (1926)). Therefore, absent any evidence to the contrary, the Board presumes that the AOJ has reviewed all of the pertinent evidence of record when readjudicating the Veteran's hearing loss claim in the January 2013 SSOC. Neither the Veteran nor his representative has presented any arguments alleging that this duty was not discharged; they also have not presented any evidence to the contrary. Thus, the presumption of regularity has not been rebutted. The Board therefore concludes that the January 2013 SSOC has substantially complied with the Board's Remand directive to readjudicate the Veteran's hearing loss claim and that there has been substantial compliance with the entirety of its Remand instructions related to that claim. See Stegall, 11 Vet. App. at 271. In light of the foregoing, the Board finds that VA's duties to notify and assist have been satisfied in this case and, thus, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). II. Service Connection for Bilateral Hearing Loss The Veteran, in written statements and testimony before the Board, contends that he developed bilateral hearing loss in the United States Air Force and that service connection is therefore warranted for that disability. Service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). A currently diagnosed disorder also may be service-connected if the evidence of record shows that the disorder was chronic in service or, if not chronic, that it was noted in service and that continuity of symptomatology was thereafter shown. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted on a presumptive basis for certain chronic disabilities, including sensorineural hearing loss and other organic diseases of the nervous system, which manifest to a compensable degree within the initial post-service year. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309(a) (2012). To establish service connection for the claimed disorder, generally, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). Alternatively, the second and third requirements set forth in Hickson may be satisfied with evidence of a chronic disease shown during service or a continuity of symptomatology. 38 C.F.R. § 3.303(b) (2012); see Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). In a claim of service connection for hearing loss, the requirements for establishing the first Hickson element are defined by regulation. Specifically, impaired hearing will be considered a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; when the auditory thresholds for at least three of the above frequencies 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 (2012). Here, the Veteran has demonstrated that he meets the VA criteria for disabling bilateral hearing loss. Indeed, all of the audiological tests administered throughout the appeals period have revealed hearing impairment in both ears that falls within the parameters set forth in 38 C.F.R. § 3.385. Accordingly, the threshold criterion for service connection - evidence of a current disability - has been met in this case and the Board will now address the other Hickson elements necessary to prove the Veteran's claim. Hickson, 12 Vet. App. at 253. With regard to the element of in-service incurrence/aggravation, the Board notes, at the outset, that the absence of documented hearing loss in service is not fatal to a claim for service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). To the contrary, when the regulatory requirements for such a disability are not shown at separation, service connection may still be established through probative evidence that the current disability is causally related to service. See Hensley v. Brown, 5 Vet. App. 155, 159-60 (1993); see also 38 C.F.R. § 3.303(d) (2012). In this case, the Veteran acknowledges that he did not display disabling bilateral hearing loss at any time throughout his active duty. Nevertheless, he contends that his hearing became permanently impaired through acoustic trauma incurred as an Air Force weather observer. The Veteran alleges that this military occupational specialty (MOS) required him to serve in the immediate vicinity of Air Force runways, where he provided meteorological reports to aerial crews during takeoffs and landings. He acknowledges wearing earplugs whenever he ventured into the path of aircraft. However, he denies using such hearing protection when positioned in a nearby weather station that was almost as noisy as the flight line itself. Board Hearing Tr. at 6. The Veteran is competent to report a history of in-service noise exposure, which falls within the scope of his personal experience. 38 C.F.R. § 3.159(a)(2) (2012); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Moreover, the Board considers his account of such exposure to be credible as it has remained internally consistent throughout the appeal and has been corroborated by other evidence of record. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006); Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony). The Veteran's Form DD 214 confirms that he held the MOS of weather observer and also completed basic training as an airman. In addition, the Veteran's reports of acoustic trauma incurred on the flight line are consistent with the overall circumstances of his service. 38 U.S.C.A. § 1154(a) (West 2002). Thus, despite the fact that the Veteran's service treatment records are silent for any complaint of ear problems, or any clinical finding of hearing loss that qualifies as disabling under 38 C.F.R. § 3.385, the Board accepts the Veteran's lay assertions as probative evidence that the claimed noise exposure occurred. Such evidence of active-duty acoustic trauma satisfies the second Hickson element. Hickson, 12 Vet. App. at 253. Moreover, the Board's reliance on that evidence, notwithstanding the lack of disabling hearing loss shown at separation, comports with the Court's holding in Ledford that a disability need not manifest in service in order to warrant service connection. Ledford, 3 Vet. App. at 89. Nevertheless, for the Veteran to prevail in the instant case, there still must be probative evidence of a link between his recognized in-service injury and his current disability. Hickson, 12 Vet. App. at 253; Hensley, 5 Vet. App. at 159-60. In an effort to demonstrate the required nexus, the Veteran underwent an initial VA audiological examination in July 2007. At that time, he recounted his history of in-service acoustic trauma incurred as a weather observer. The Veteran also acknowledged that he had been intermittently exposed to loud noise in his post-service pursuits as a construction worker, as an employee in the engineering department of VA Medical Center, and, in particular, as an inspector with the Texas Highway Department. He added that he had used hearing protection in these civilian occupations, but had not done so consistently. In describing the onset of his current symptoms, the Veteran reported experiencing gradual hearing loss over the last five to seven years. However, he also stated that his symptoms had manifested on an earlier occasion, specifically, during a VA audiometry test administered in the mid-1990s. Despite taking note of these lay assertions, the July 2007 VA examiner focused on the clinical findings in the Veteran's service treatment records, particularly his October and November 1968 entrance audiometry results, which revealed significant variations in his pure tone threshold shifts. The July 2007 VA examiner reasoned that these results reflected significant test/retest reliability issues and were therefore questionable. That VA examiner then noted that, while the pure tone thresholds on the Veteran's December 1974 periodic examination revealed slight threshold shifts from his entrance audiometry, the overall results remained consistent with normal hearing. Based on the above evidence, and the fact that the Veteran had waited until several decades after service to pursue a claim for service connection, the July 2007 VA examiner concluded that, while the Veteran currently exhibited moderate bilateral sensorineural hearing loss, this disability was less likely than not related to any acoustic trauma incurred in service. The VA examiner declined to specify whether his negative nexus opinion had been predicated on a review of the Veteran's entire claims file. After the above VA examiner completed his report, the Veteran testified at the September 2010 Board hearing that his post-service jobs had not entailed significant noise exposure. Board Hearing Tr. at 6-7. He also testified that he could not remember having occupational exposure to loud noise for a very long time. Id. at 7. In light of these clarifying remarks, the Board determined that the July 2007 VA examiner had unduly favored the clinical findings in the Veteran's service treatment records over his subsequent lay assertions. Accordingly, the Board concluded that an additional VA audiological examination was needed and consequently remanded the claim. The requested VA examination was conducted in December 2011 by a different audiologist than the one who had examined the Veteran in July 2007. Nevertheless, the second VA examiner's conclusions concerning the etiology of the Veteran's hearing loss were consistent with those of her predecessor. In a January 2012 Addendum opinion, the second VA examiner concluded that, while the Veteran continued to exhibit bilateral sensorineural hearing loss, this disability had been neither caused nor aggravated by an event in service. As a rationale for that conclusion, the second VA examiner noted that the Veteran's in-service entrance and exit audiometry results had all been within normal limits. Additionally, that VA examiner acknowledged the Veteran's lay assertions of in-service noise exposure and indicated that she had reviewed the claims file in its entirety. Nevertheless, the underlying rationale for that VA examiner's negative nexus opinion appeared to rest on the Veteran's normal hearing sensitivity findings noted at service entrance and exit. In its subsequent July 2012 remand, the Board noted that such reliance on in-service findings conflicted with 38 C.F.R. § 3.303(d), which directed that service connection could be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, established that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Accordingly, the Board concluded that the second VA examiner's opinion was also inadequate to make an informed decision on the Veteran's claim and that another Remand was therefore necessary. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (finding that an examination report is adequate where it describes the disability in sufficient detail so the Board can make a fully informed evaluation of the disability). Pursuant to this latest Remand, the AOJ elicited a follow-up VA opinion, which was obtained in August 2012 through the DBQ process. As directed by the Board, the August 2012 DBQ medical opinion was authored by a VA audiologist who had not previously examined the Veteran. Nevertheless, the new audiologist arrived at the same negative conclusion regarding nexus that had been reached by the prior VA examiners. However, whereas those prior examiners had relied on the Veteran's service treatment records as support for their negative findings, the August 2012 VA audiologist offered a more robust rationale that took into account the Veteran's lay statements. Specifically, the August 2012 VA audiologist accepted as true the Veteran's account of active-duty acoustic trauma incurred while serving in close proximity to jet engine noise. The VA audiologist also acknowledged the Veteran's hearing testimony in which he denied any significant post-service noise exposure. However, the VA audiologist accurately pointed out that this testimony conflicted with the Veteran's earlier statements, rendered during the July 2007 VA examination, in which he had attested to civilian occupational noise exposure, particularly at the Texas Highway Department. In addition to highlighting this discrepancy between the Veteran's statements and testimony, the VA audiologist noted that, while the Veteran had reported that his hearing problems arose five to seven years before his July 2007 examination, he had left service more than three decades earlier. The audiologist further noted that, at separation, the Veteran's hearing thresholds had been within normal limits and had reflected no significant change since enlistment, thereby indicating that he had not been adversely impacted by in-service noise exposure. The audiologist then opined that the Veteran's lengthy post-service period without evidence of symptoms was consistent with a pattern of hearing loss attributable to aging (presbycusis), as well as hereditary factors and possible negative effects of occupational noise exposure and/or unreported recreational noise exposure. Consequently, that clinician determined that it was less likely than not that the Veteran's current bilateral hearing loss had been caused by or otherwise resulted from his military noise exposure. Significantly, the Veteran has not submitted any additional medical opinions contradicting the August 2012 DBQ medical opinion. Nor has he submitted other evidence in support of his hearing loss claim or provided information that would enable VA to elicit such evidence on his behalf. Consequently, the Board finds that, to the extent such favorable evidence exists but has not been obtained, the responsibility lies with the Veteran. See Wood, 1 Vet. App. at 193 (1991). In the absence of any additional medical opinion evidence, the Board will now evaluate which of the existing opinions of record is most probative in this appeal. See Wensch v. Principi, 15 Vet. App. 362, 367 (2001) (In its assessment of medical opinion evidence, the Board can favor some evidence over other evidence so long as the Board adequately explains its reasons for doing so.) In making this determination, the Board must consider whether the respective VA examiners were 1) fully informed of the pertinent factual premises (i.e., history) of the case; 2) provided fully articulated opinions; and 3) supported those opinions with analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008) (noting that while the Federal Rules of Evidence are not binding on the Court, nor on the Board, the rules on expert witness testimony provide useful guidance in assessing the probative weight of medical opinions). With regard to the first prong of this three-part inquiry, the Board observes that the examiner who authored the initial July 2007 VA examination report did not indicate whether he had reviewed the claims file. The Board recognizes that claims file review is not a strict prerequisite for medical opinions, even those authored by VA examiners. See Nieves-Rodriguez, 22 Vet. App. at 301. Nevertheless, the evidentiary weight assigned to such an opinion may be reduced if the clinician fails to acknowledge relevant evidence, particularly that which is contrary to the opinion. Such is the case here. Indeed, as the Board observed in its prior Remand, the initial VA examiner did not adequately account for the Veteran's lay assertions of in-service acoustic trauma. Nor did that VA examiner give due consideration to the Veteran's description of VA audiometric testing in the mid-1990s. Moreover, that initial examiner's report preceded and, thus, did not address the Veteran's September 2010 Board hearing testimony in which he denied any significant post-service occupational noise exposure. The Veteran's hearing testimony was of record at the time of the December 2011 VA examination and the January 2012 Addendum opinion. However, despite ostensibly reviewing the claims file, the VA examiner responsible for that examination and Addendum also failed to adequately account for the Veteran's lay assertions. Instead, that second VA examiner relied on the clinical findings in the service treatment records as the basis for her negative nexus opinion. As discussed above, the Veteran's account of in-service noise exposure, while not expressly documented in his service records, is nonetheless consistent with the circumstances of his active duty and, thus, is accepted as true. Moreover, the Veteran is capable of observing and therefore competent to report a history of significant noise exposure in service as well as a lack of such exposure thereafter. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran also is competent to report the perceived date of onset of his hearing problems. Id. Further, while the Veteran's credibility in these matters has been called into question, for the reasons set forth below, this does not exempt his statements from consideration by the prior VA examiners. To the contrary, determinations of credibility fall within the province of the Board as a finder of fact. See Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). As such, it is the responsibility of VA examiners to duly consider competent lay evidence of record, and to reserve the Board's right to determine credibility after all the evidence has been admitted. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ('a legal concept determining whether testimony may be heard and considered') and credibility ('a factual determination going to the probative value of the evidence to be made after the evidence has been admitted')); see, also, Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006) (indicating the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence). Having thus determined that the prior VA examiners discounted lay evidence crucial to the Veteran's hearing loss claim, the Board considers those examiners' opinions to be inadequate for the purpose of deciding that claim. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In contrast with the above examiners, the VA audiologist who authored the August 2012 DBQ medical opinion expressly acknowledged, and did not dispute, the Veteran's account of in-service acoustic trauma. Nor did that VA audiologist question the Veteran's self-reported onset of hearing problems. Conversely, that audiologist did convey doubt about the Veteran's alleged lack of significant post-service noise exposure. As noted above, such determinations of credibility are more appropriately left to the Board as fact-finder. See Barr, 21 Vet. App. at 308. Nevertheless, the Board considers it significant that, unlike the prior VA examiners, the August 2012 audiologist noted the inherent inconsistencies in the Veteran's prior statements and testimony, rather than simply dismissing them outright. As such, while the Board reserves the right to make its own credibility determinations, as set forth below, it nonetheless considers the report of the August 2012 VA audiologist to be probative since, unlike the prior VA examiners, that clinician duly considered the competent lay evidence of record. The August 2012 VA audiologist also demonstrated a familiarity with the other pertinent facts of the case by extensively referencing the evidence in the service treatment records and the prior examination reports. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (holding that among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). Moreover, that VA audiologist's August 2012 DBQ medical opinion constitutes the most recent evidence of record. Accordingly, the Board presumes that VA audiologist took into account all of the relevant contents in the claims file, which had been forwarded to him in its entirety. See Marsh v. Nicholson, 19 Vet. App. at 385 (2005); see also Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed. Cir. 2009) (applying the presumption of regularity to the competence of VA examiners). Such a thorough review of the evidence adds to the probative value of that audiologist's August 2012 DBQ medical opinion, relative to the other medical opinions of record. The Board now turns to the second and third criteria for weighing medical opinion evidence set forth in Nieves-Rodriguez, supra. In applying these criteria, the Board recognizes that the July 2007 and December 2011 VA examiners each provided clear opinions as to a lack of nexus between the Veteran's service and his current bilateral hearing loss. Nevertheless, those VA examiners declined to adequately weigh the Veteran's lay assertions. As such, the rationales underlying their findings cannot be considered factually accurate, fully articulated, and sound. See Nieves-Rodriguez, 22 Vet App at 305. This undercuts the overall evidentiary weight of those VA examiners' opinions. Conversely, the August 2012 VA audiologist fully accounted for the pertinent medical and lay evidence, thereby solidifying his report's status as the most probative medical opinion of record. Id. In this regard, the Board acknowledges that the August 2012 VA audiologist used speculative language in opining that the Veteran's current hearing loss was likely attributable to nonservice-related factors, including "possible" occupational and recreational noise exposure. The Court has held on numerous occasions that medical evidence which is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Nevertheless, the Board observes that the discussion of nonservice-related hearing loss causal factors was the only speculative aspect of the August 2012 VA audiologist's opinion. That clinician was definitive in opining that no nexus existed between the Veteran's service-related noise exposure and his current bilateral hearing loss. Given that clear determination and the robust rationale supporting it, the Board finds that the August 2012 VA audiologist provided a fully articulated and well-reasoned opinion with respect to the matter central to this appeal. See Nieves- Rodriguez, 22 Vet. App. at 304. Accordingly, in light of the August 2012 DBQ medical opinion, which the Board deems highly probative, the preponderance of the evidence does not support a nexus between the Veteran's active service and his currently diagnosed bilateral hearing loss. Moreover, the Board considers it significant that the opinions expressed by the prior VA examiners, while less probative than that of the August 2012 audiologist, do not contradict this clinician's findings. In fact, there are no medical opinions of record that denote a positive relationship between the Veteran's conceded in-service acoustic trauma and his currently diagnosed bilateral hearing loss. The Board recognizes that the Veteran himself is of the opinion that such a positive nexus exists. However, while competent to attest to a history of in-service and post-service noise exposure and hearing problems, which are capable of lay observation, he has not shown that he has the expertise to comment on complex medical issues, such as the nature and etiology of his current bilateral sensorineural hearing loss. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms, but not to speak as to etiology except in limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg.). As such, whether the acoustic trauma that the Veteran experienced in service is in any way related to his current hearing loss is a question that requires medical expertise to resolve. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the Veteran is competent to testify to the pain he has experienced since his [active service], he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Moreover, the Board observes that the need for an expert medical opinion is particularly great where there is evidence of an intercurrent injury. See Hensley, 5 Vet. App. at 159. Such is the case here. Indeed, the record suggests that the Veteran was exposed to acoustic trauma both during and after his Air Force service. The Board recognizes that he denied any significant post-service noise exposure at his September 2010 Board hearing. However, while the Veteran's testimony in this regard is deemed competent, it conflicts with his prior statements to the July 2007 VA examiner. This reduces the overall credibility of the Veteran's hearing testimony. See Caluza, 7 Vet. App. at 511. Furthermore, the Board considers the statements the Veteran made during his initial July 2007 clinical examination, when his hearing loss was first diagnosed, to hold greater evidentiary weight than his subsequent testimony, which was elicited solely in the pursuit of VA benefits following the perfection of his appeal. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy); Cf. Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (a pecuniary interest may affect the credibility of a claimant's testimony); see also Coburn v. Nicholson, 19 Vet. App. 427, 432 (2006) (Board may reject such statements of the Veteran if rebutted by the overall weight of the evidence). In making this assessment, the Board emphasizes that it is acting as an independent fact-finder and not relying on the views expressed by the VA examiners, whose province does not extend to credibility determinations. See Barr, 21 Vet. App. at 308. Accordingly, given the inherent complexity of the Veteran's sensorineural hearing loss, which is further complicated by the fact that he appears to have incurred both in-service and post-service acoustic trauma, the Board finds that the etiology of this disability can only be resolved by a clinical expert, such as the author of the August 2012 DBQ medical opinion. This clinician's specialized training as an audiologist adds to the probative weight of his opinion, relative to the unvarnished views of the Veteran. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997) (in determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data). Moreover, the Board considers it significant that, despite disagreeing with the August 2012 VA audiologist, the Veteran has not alleged that this specialist was unqualified to render etiological findings in connection with this appeal. Nor has the Veteran submitted any evidence refuting those findings or showing, in the alternative, that he himself is qualified to ascribe his currently diagnosed bilateral sensorineural hearing loss to acoustic trauma incurred as a weather observer in the Air Force. Accordingly, the Board finds that the Veteran's own views in this regard are outweighed by the negative nexus opinion of the August 2012 VA audiologist. Next, the Board recognizes that, under current law, the nexus requirement may be satisfied through a showing of continuity of symptomatology, which may be established under certain circumstances through lay evidence. See 38 C.F.R. § 3.303(b) (2012); see Savage, 10 Vet. App. at 495-96. However, in this case, the Veteran has not professed to have experienced continuous hearing problems since service. On the contrary, he has informed the VA audiologists who have examined him that his hearing loss only became noticeable in the late 1990s or early 2000s. The Board acknowledges that the Veteran has also attested that his hearing loss manifested on an earlier occasion, specifically during an audiometry test conducted in the mid-1990s. However, the Board is unable to verify the Veteran's lay assertions as a copy of that purported audiometry test has not been obtained, despite reasonable efforts on the part of the AOJ pursuant to the July 2011 Remand. Even affording the Veteran the benefit of the doubt and assuming that his hearing loss did become symptomatic in the mid-1990s, that is still more than 20 years after he left active duty. Thus, by the Veteran's own admission, there exists a lengthy gap between his separation from service and the initial manifestation of his disability. Such a time lapse, while not a sufficient stand-alone basis for denying his claim for service connection, nevertheless weighs against that claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (noting that a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred during the active military service and resulted in a chronic or persistent disorder). In light of the foregoing, the Board finds that, while the Veteran's reports of active-duty acoustic trauma are consistent with the circumstances of his service and are therefore deemed credible, the probative evidence of record weighs against the finding of a nexus between that in-service injury and his current bilateral hearing loss. Thus, even though the Veteran has met the first two core requirements for direct service connection - existence of a current disability and in-service incurrence/aggravation - he has not satisfied the final element (nexus). See Hickson, 12 Vet. App. at 253. As such, while cognizant that his hearing loss need not have manifested in service in order to establish service connection under current law, the Board finds that, given the particular evidence presented in this case, service connection is not warranted on a direct basis. Further, as there is no competent evidence indicating that the Veteran suffered from compensably disabling sensorineural hearing loss within one year following discharge from service, service connection on a presumptive basis is also not warranted. 38 C.F.R. §§ 3.307, 3.309 (2012). In summary, the preponderance of the evidence is against the claim of service connection for bilateral hearing loss under any of the theories presented by the Veteran or otherwise suggested by the record. Thus, while the Board has considered the benefit of the doubt rule, that rule is not for application. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 4.3 (2012). The benefit sought on appeal is accordingly denied. (CONTINUED ON NEXT PAGE) ORDER Service connection for bilateral hearing loss is denied. ______________________________________________ DONNIE R. HACHEY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs