Citation Nr: 1311348 Decision Date: 04/05/13 Archive Date: 04/19/13 DOCKET NO. 11-32 942 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim of service connection for bilateral hearing loss. 2. Entitlement to service connection for bilateral hearing loss. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Saira Spicknall, Counsel INTRODUCTION The Veteran served on active duty from October 1968 to August 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision of the Boise, Idaho Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction remains with the Albuquerque, New Mexico RO. Notwithstanding the RO's actions, the Board has a legal duty under 38 U.S.C.A. §§ 5108 and 7105 (West 2002) to address the question of whether new and material evidence has been received to reopen the claim for service connection for bilateral hearing loss. That matter goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim on a de novo basis. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). As the Board must first decide whether new and material evidence to reopen the claim for service connection for bilateral hearing loss has been received before it can address this matter on the merits-and in light of the Board's favorable action on the petition to reopen-the Board has characterized the appeal as to the bilateral hearing loss as encompassing the two issues listed on the title page. A review of the Virtual VA paperless claims processing system reflects that additional records have been added to the present appeal. These records include VA medical records. A supplemental statement of the case (SSOC) was issued in December 2012 which addressed this additional evidence. The issue of service connection for bilateral hearing loss is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In an unappealed decision of March 1998, the Board denied service connection for bilateral hearing loss, finding no new and material evidence had been received; this decision is final. 2. The evidence added to the record since the March 1998 Board decision was not previously submitted to agency decisionmakers, is not cumulative or redundant and, by itself or when considered with the previous evidence of record, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for service connection for bilateral hearing loss. CONCLUSION OF LAW Subsequent to the final March 1998 Board decision, new and material evidence has been presented to reopen the claim of service connection for bilateral hearing loss. 38 U.S.C.A. § 1110, 5108, 7105 (West 2002); 38 C.F.R. §§ 3.104(a), 3.156(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act (VCAA) The VCAA, codified, in part, at 38 U.S.C.A. § 5103, was signed into law on November 9, 2000. Implementing regulations were created, codified at 38 C.F.R. § 3.159 (2012). The legislation has eliminated the well-grounded claim requirement, has expanded the duty of VA to notify the appellant and the representative, and has enhanced its duty to assist an appellant in developing the information and evidence necessary to substantiate a claim. See generally VCAA. In this case, the Board finds that the RO has substantially satisfied the duties to notify and assist, as required by the VCAA. To the extent that there may be any deficiency of notice or assistance, there is no prejudice to the Veteran in proceeding with this issue given the fully favorable nature of the Board's decision. Pertinent Laws and Regulations Because the Board previously denied the Veteran's claim seeking entitlement to service connection for bilateral hearing loss in a March 1998 decision, and the Veteran did not initiate an appeal, the doctrine of finality as enunciated in 38 U.S.C.A. §§ 7104(b), 7105(c) (West 2002) applies, and thus that decision became final based on the evidence then of record. 38 U.S.C.A. § 7104; 38 C.F.R. § 3.104. Generally, a claim, which has been denied in a Board decision or an unappealed RO decision, may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c) (West 2002). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C.A. § 5108 (West 2002). New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be 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 must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2012). VA must review all of the evidence received since the last final decision in order to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). For the limited purpose of determining whether new and material evidence has been received to reopen a finally adjudicated claim, the recently submitted evidence will be presumed credible. See Kutscherousky v. West, 12 Vet. App. 369, 371 (1999) (per curiam) (holding that the "presumption of credibility" doctrine continues to be binding precedent). Applicable law provides that service connection may be established for a disability resulting from personal injury suffered or disease contracted, or from aggravation of a preexisting injury suffered or disease contracted, in the line of duty in active military, naval or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Analysis The March 1998 Board decision denied reopening the Veteran's claim for service connection for bilateral hearing loss, finding that new and material evidence had not been received. Specifically, the Board found that there was a question as to whether the current hearing loss was related to acoustic trauma experienced in service and therefore there was no reasonable possibility that the additional evidence of record would change the outcome of the Veteran's claim. The evidence of record at the time of the March 1998 Board decision included service treatment reports, the Veteran's Record of Separation from Active Service (DD form 214), and VA examinations. The Veteran's DD form 214 reflects that his miliary occupational specialty (MOS) was that of an airplane repairman with a related civilian occupation of an aircraft mechanic and repairman. This record also reflects that the Veteran served in the Republic of Vietnam from August 1969 to August 1970. Service treatment reports reflect that the Veteran noted having a history of hearing loss in the October 1968 Report of Medical History at induction and the service medical officer at that time noted there was questionable hearing loss. In the October 1968 induction examination, the Veteran was diagnosed with hearing loss and provided an H-2 PULHES physical profile. Audiometric testing at this time revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 20 - 20 LEFT 0 15 25 - 20 A January 1969 hearing consultation reflects that the Veteran reported having a ringing in both ears for the past one and a half months and an examination was negative. The examiner noted the Veteran needed an audiogram and provided a provisional diagnosis of probable high frequency hearing loss. January 1969 audiometric testing revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 35 45 50 45 LEFT 20 25 35 35 35 In January 1970, the Veteran was tested or hearing loss again. Audiometric testing revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 25 - 50 LEFT 15 15 25 - 25 In the August 1970 separation examination, a clinical evaluation of the ears and drums revealed normal findings. Audiometric testing at this time revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 15 25 20 LEFT 20 20 20 20 15 In a March 1978 VA examination, audiometric testing revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 30 45 55 LEFT 0 15 25 40 40 The examiner concluded there was a normal general medical examination and no diagnoses were provided. The Veteran submitted audiology reports from July 1987 and March 1994. The July 1987 audiology report has findings represented in graphical form and appears to indicate some increased hearing threshold levels, in decibels, at 2000, 3000 and 4000 Hertz in each ear. Audiometric testing from March 1994 revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 50 55 55 LEFT 15 20 45 50 40 In an October 1997 VA examination, the Veteran reported having difficulty with hearing in noise or with distance. He also noted that prior to entering service, there was a slight loss of hearing in both ears. He had no significant history of ear infections, problems with dizziness, and no familial hearing loss. He did report occupational noise exposure while in the military in the rifle range and working near aircraft. Audiometric testing revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 20 55 55 55 LEFT 10 30 45 55 40 The Veteran was assessed with moderate sensorineural hearing loss from 2000 Hertz to 6000 Hertz in the right ear and mild to moderate high frequency hearing loss from 2000 Hertz to 6000 Hertz in the left. The examiner concluded that the hearing loss could not be directly attributed to the Veteran's noise exposure while in service. He explained that audiograms at enlistment and discharge indicated normal hearing in both ears and hearing tests performed during his enlistment showed large abnormal fluctuations in thresholds, making their validity highly questionable. The new evidence of record submitted after the March 1998 Board decision includes VA outpatient treatment reports and a VA examination. VA outpatient treatment reports from April 2010 to December 2012 reflect that the Veteran was treated for and diagnosed with bilateral hearing loss. In a July 2010 audiology evaluation, the Veteran reported he had slight hearing loss when drafted in 1968 which had gotten worse since. The Veteran reported having worked as an airplane mechanic in Vietnam. He denied occupational noise and wore earplugs with lawn mowers and power tools. Audiometric testing revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 40 55 60 65 LEFT 15 40 55 45 50 The Veteran was assessed with mild to moderately severe sensorineural hearing loss in the right ear above 500 Hertz and mild to moderate sensorineural hearing loss at 1000 to 4000 Hertz in the left ear. He was diagnosed with high frequency hearing loss sufficient to limit speech understanding and warrant binaural amplification. His history of military noise exposure was also documented in the diagnosis. At an October 2012 VA examination, audiometric testing revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 25 45 55 65 LEFT 15 30 45 50 50 The Veteran was assessed with sensorineural hearing loss from 500 to 6000 Hertz or higher frequencies in both ears. The examiner opined that the Veteran's bilateral hearing loss was less likely than not proximately due to or the result of the Veteran's service-connected tinnitus. She explained that, based on a review of the previous hearing examinations, the hearing loss had remained stable and was not aggravated beyond its natural progression by the Veteran's service-connected tinnitus. In Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998), the United States Court of Appeals for the Federal Circuit (Federal Circuit) noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a Veteran's injury or disability, even where it would not be enough to convince the Board to grant a claim. Id. at 1363. The Board finds that the newly received evidence, when considered in conjunction with the previous evidence of record, presents a more complete picture of the origin of the Veteran's bilateral hearing loss and relates to unestablished facts that are necessary to substantiate his claim for service connection for bilateral hearing loss. The new and material evidence relevant to reopening the Veteran's claim for service connection includes VA outpatient treatment reports and the October 2012 VA examination. Significantly, the Veteran's reports in the July 2010 VA audiology evaluation that he had slight hearing loss when drafted in 1968 which had gotten worse since, that he worked as an airplane mechanic in Vietnam and he denied occupational noise and wore earplugs with lawn mowers and power tools constitute new and material lay evidence. The Board finds the Veteran's statements are presumed credible for the purposes of reopening the claim. See Kutscherousky v. West, 12 Vet. App. 369, 371 (1999) (per curiam) (holding that the "presumption of credibility" doctrine continues to be binding precedent). The newly received evidence is not considered cumulative or redundant of the evidence of record at the time of the final March 1998 RO decision, and furnishes a reasonable possibility of substantiating the Veteran's claim for service connection for bilateral hearing loss. Therefore, the Veteran's claim for service connection for bilateral hearing loss is reopened. See 38 C.F.R. § 3.156(a). ORDER New and material evidence having been received, the claim for service connection for bilateral hearing loss is reopened; and the appeal is granted to this extent only. REMAND Although the Board regrets any further delay in adjudicating the Veteran's claim, pursuant to the duty to assist, the issue of service connection for bilateral hearing loss must be remanded for further development. In order to establish service connection for a claimed disability, the facts must demonstrate that a disease or injury resulting in current disability was incurred in active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may 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) (2012). In addition, certain chronic diseases, including sensorineural hearing loss, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). A veteran is considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, except where clear and unmistakable evidence demonstrates that an injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002). Thus, veterans are presumed to have entered service in sound condition as to their health. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulation provides expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b), and that "[h]istory of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions." Id. at (b)(1). A preexisting injury or disease will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2012). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306(b) (2012); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). In this case the Board observes that the Veteran's MOS and Vietnam service are consistent with the places, types, and circumstances of his active service and are sufficient to support the Veteran's contentions that he was exposed to loud noises from airplanes and various military weaponry during his active service. See 38 U.S.C.A. § 1154(a) (West 2002). As noted above, his DD form 214 reflects that his MOS was that of an airplane repairman with a related civilian occupation of an aircraft mechanic and repairman. This record also reflects that the Veteran served in the Republic of Vietnam from August 1969 to August 1970. In addition, the Board finds that hearing loss was noted in the October 1968 service induction examination. In the October 1968 induction examination, the Veteran was diagnosed with hearing loss and provided an H-2 PULHES physical profile. Audiometric testing at this time revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 20 - 20 LEFT 0 15 25 - 20 As a preexisting hearing loss was noted at the Veteran's induction examination, he cannot be presumed to have entered service in sound condition as to his hearing and therefore, the presumption of soundness does not apply to the Veteran in this case. 38 U.S.C.A. § 1111 (West 2002). The Veteran also noted a history of hearing loss in the October 1968 Report of Medical History at induction and the service medical officer at that time noted there was questionable hearing loss. A January 1969 hearing consultation reflects that the Veteran reported having a ringing in both ears for the past one and a half months and an examination was negative. The examiner noted the Veteran needed an audiogram and provided a provisional diagnosis of probable high frequency hearing loss. January 1969 audiometric testing revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 35 45 50 45 LEFT 20 25 35 35 35 In January 1970, the Veteran was tested or hearing loss again. Audiometric testing revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 25 - 50 LEFT 15 15 25 - 25 In the August 1970 separation examination, a clinical evaluation of the ears and drums revealed normal findings. Audiometric testing at this time revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 15 25 20 LEFT 20 20 20 20 15 In a March 1978 VA examination, audiometric testing revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 30 45 55 LEFT 0 15 25 40 40 The examiner concluded there was a normal general medical examination and no diagnoses were provided. The Veteran submitted audiology reports from July 1987 and March 1994. The July 1987 audiology report has findings represented in graphical form and appears to indicate some increased hearing threshold levels, in decibels, at 2000, 3000 and 4000 Hertz in each ear. Audiometric testing from March 1994 revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 50 55 55 LEFT 15 20 45 50 40 In an October 1997 VA examination, the Veteran reported having difficulty with hearing in noise or with distance. He also noted that prior to entering service, there was a slight loss of hearing in both ears. He had no significant history of ear infections, problems with dizziness, and no familial hearing loss. He did report occupational noise exposure while in the military in the rifle range and working near aircraft. Audiometric testing revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 20 55 55 55 LEFT 10 30 45 55 40 The Veteran was assessed with moderate sensorineural hearing loss from 2000 Hertz to 6000 Hertz in the right ear and mild to moderate high frequency hearing loss from 2000 Hertz to 6000 Hertz in the left. The examiner concluded that the hearing loss could not be directly attributed to the Veteran's noise exposure while in service. He explained that audiograms at enlistment and discharge indicated normal hearing in both ears and hearing tests performed during his enlistment showed large abnormal fluctuations in thresholds, making their validity highly questionable. VA outpatient treatment reports from April 2010 to December 2012 reflect that the Veteran was treated for and diagnosed with bilateral hearing loss. In a July 2010 audiology evaluation, the Veteran reported he had slight hearing loss when drafted in 1968 which had gotten worse since. The Veteran reported having worked as an airplane mechanic in Vietnam. He denied occupational noise and wore earplugs with lawn mowers and power tools. Audiometric testing revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 40 55 60 65 LEFT 15 40 55 45 50 The Veteran was assessed with mild to moderately severe sensorineural hearing loss in the right ear above 500 Hertz and mild to moderate sensorineural hearing loss at 1000 to 4000 Hertz in the left ear. He was diagnosed with high frequency hearing loss sufficient to limit speech understanding and warrant binaural amplification. His history of military noise exposure was also documented in the diagnosis. At an October 2012 VA examination, audiometric testing revealed that the hearing threshold levels in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 25 45 55 65 LEFT 15 30 45 50 50 The Veteran was assessed with sensorineural hearing loss from 500 to 6000 Hertz or higher frequencies in both ears. The examiner opined that the Veteran's bilateral hearing loss was less likely than not proximately due to or the result of the Veteran's service-connected tinnitus. She explained that, based on a review of the previous hearing examinations, the hearing loss had remained stable and was not aggravated beyond its natural progression by the Veteran's service-connected tinnitus. The duty to assist requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. In claims for disability compensation, it requires that VA provide medical examinations or obtain medical opinions when necessary for an adequate decision. 38 C.F.R. § 3.159. A medical examination or medical opinion is deemed to be necessary if the record does not contain sufficient competent medical evidence to decide the claim, but includes competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of disability, establishes that a veteran suffered an event, injury, or disease in service, or has a disease or symptoms of a disease manifest during an applicable presumptive period, and indicates the claimed disability or symptoms may be associated with the established event, injury, or disease. 38 C.F.R. § 3.159(c)(4) (2012). The U.S. Court of Appeals for Veterans Claims (Court) has held the types of evidence that "indicate" that a current disability "may be associated" with military service include credible evidence of continuity and symptomatology such as pain or other symptoms capable of lay observation. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Board finds the medical evidence of record indicates that the Veteran's bilateral hearing loss may have preexisted his military service, as hearing loss was noted in the October 1968 service induction examination, and the presumption of soundness does not apply. 38 U.S.C.A. § 1111 (West 2002). In addition, the Board observes that his MOS and Vietnam support his contentions that he was exposed to loud noises from airplanes and various military weaponry during his active service and that the service treatment reports reflect a measured worsening in hearing threshold levels from the time of the Veteran's induction examination in October 1968 to the January 1969 and January 1970 audiometric testing. In addition, the August 1970 separation examination also reflects an increase in hearing threshold levels at 500 and 1000 Hertz in the left ear compared to the October 1968 induction examination. Finally, the August 1970 separation examination demonstrates that hearing threshold levels recorded at 3000 Hertz were at 25 on the right and 30 on the left at 3000 Hertz and the Board observes that speech reception thresholds were not recorded at 3000 Hertz in the Veteran's induction examination. Thus, the service treatment records indicate a worsening of the Veteran's hearing threshold levels in service, which continued to deteriorate after service as demonstrated in the March 1978 VA examination, March 1994 audiology evaluation, October 1997 VA examination, July 2010 VA audiology report and October 2012 VA examination. Therefore, the Board finds that a VA examination is necessary to obtain an opinion as to whether the Veteran's current bilateral hearing loss, which preexisted his active service, was aggravated (permanently worsened beyond the normal progress of the disorder) by his active service. 38 C.F.R. § 3.159(c)(4); McLendon, 20 Vet. App. at 83; Locklear v. Nicholson, 20 Vet. App. 410 (2006); see also Waters v. Shinseki, 601 F.3d 1274, 1276 (2010). Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should schedule the Veteran for a VA audiology examination by an appropriate specialist to determine the current nature and etiology of any bilateral hearing disorder found to be present; and, if so, whether such disability clearly and unmistakably existed prior to the Veteran's active service and was not aggravated by the Veteran's military service, i.e. considering the in-service audiometric findings from October 1968, January 1969, January 1970 and August 1970, the post service medical evidence including audiometric testing in March 1978, July 1987, March 1994, October 1997, July 2010 and October 2012 and the lay statements by the Veteran. The examination report is to contain a notation that the examiner reviewed the claims file. The examination is to include a review of the Veteran's history and current complaints, as well as a comprehensive audiology evaluation and any tests deemed as necessary. Please note: The Veteran is competent to report lay observable events and symptoms; i.e. he is competent to report his continued symptoms of hearing loss since active service. The examiner is asked to offer an opinion addressing the following: Please indicate whether the preexisting bilateral hearing loss noted in the October 1968 induction examination obviously or manifestly (clearly and unmistakably) increased in severity in service, and if so, whether there is obvious or manifest evidence that such increase was due to the natural progression of the disorder (i.e., not aggravated). In so finding, please note that the Veteran's service information also supports his reports of exposure to acoustic trauma in service. In providing the medical opinion above, the examiner is asked to discuss the Veteran's lay statements as well as the medical evidence of record, including (1) the in-service audiometric findings from October 1968, January 1969, January 1970 and August 1970 and (2) the post service medical evidence including audiometric testing in the March 1978 VA examination, March 1994 audiology evaluation, October 1997 VA examination, July 2010 VA audiology report and October 2012 VA examination. Note: The term "aggravation" of a preexisting disability refers to an identifiable, incremental, permanent worsening of the underlying condition, as contrasted with temporary or intermittent flare-ups of symptomatology. If an opinion cannot be expressed without resort to speculation, discuss why such is the case. In this regard, indicate whether the inability to provide a definitive opinion is due to a need for further information or because the limits of medical knowledge have been exhausted regarding the etiology of the disability at issue or because of some other reason. 2. The Veteran must be advised of the importance of reporting to the scheduled VA examination and of the possible adverse consequences, to include the denial of his claim, of failing, without good cause, to so report. See 38 C.F.R. § 3.655 (2012). A copy of the notification letter sent to the Veteran advising him of the time, date, and location of the scheduled examination must be included in the claims folder, and must reflect that it was sent to his last known address of record. If he fails to report to the examination, the claims folder must indicate whether the notification letter was returned as undeliverable. 3. Following completion of the foregoing, the AMC/RO must review the claims folder and ensure that all of the foregoing development has been conducted and completed in full. In particular, the AMC/RO should determine whether the examiner has responded to all questions posed. If not, the report must be returned for corrective action. 38 C.F.R. § 4.2 (2012). 4. After the requested development has been completed, the AMC/RO should readjudicate the merits of the Veteran's claim based on all the evidence of record, including any additional information obtained as a result of this remand. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran need take no action unless otherwise notified. 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). (CONTINUED ON NEXT PAGE) 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). ______________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs