Citation Nr: 1315082 Decision Date: 05/07/13 Archive Date: 05/15/13 DOCKET NO. 09-50 240 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas THE ISSUE 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran served on active duty from September 1959 to September 1985. This case comes to the Board of Veterans' Appeals (Board) on appeal from a March 2010 decision by the RO in Houston, Texas that in pertinent part, determined that new and material evidence had not been submitted to reopen previously denied claims for service connection for tinnitus and hypertension. A video conference hearing was held before the undersigned acting Veterans Law Judge in June 2012. In an October 2012 decision, the Board reopened the claims for service connection for heart disease, hypertension, bilateral hearing loss, tinnitus, and chronic lymphocytic leukemia, and remanded the claims for further development. On remand, in a February 2013 rating decision, the Appeals Management Center (AMC) granted entitlement to service connection for chronic lymphocytic leukemia, coronary artery disease, and bilateral hearing loss. The Veteran did not appeal the assigned initial ratings or effective dates, and these claims are no longer at issue. See 38 U.S.C.A. § 7105; Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement thereafter must be timely filed to initiate appellate review of the claim concerning "downstream" issues such as the compensation level assigned for the disability and effective date). Hence, the only issues remaining on appeal are as listed on the first page of this decision. Additional evidence and argument was received from the Veteran in April 2013. As the evidence is either duplicative or not relevant to the remaining issues on appeal, the Board finds that a remand for initial RO review of the evidence is not required prior to appellate review of these issues. See 38 C.F.R. § 20.1304 (2012). There are other issues that are not currently in appellate status. In a February 2013 memorandum, the AMC noted that an inferred issue of entitlement to service connection for a scar had been raised. Moreover, the issue of entitlement to an increased rating for service-connected prostatitis with erectile dysfunction has been raised by the record (see the Veteran's November 2012 letter). These issues have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over these issues, and they are referred to the AOJ for appropriate action. 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 issue of entitlement to service connection for tinnitus 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 There is no probative (meaning competent and credible) evidence of record confirming the Veteran has current hypertension, or that he has had this alleged condition at any point since filing this claim. CONCLUSION OF LAW Claimed hypertension was not incurred in or aggravated by military service, nor may it be presumed to have been so incurred, and it was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). These VCAA notice requirements apply to all five elements of a service-connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a downstream disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then going back and readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, a December 2009 notice letter was sent to the Veteran prior to the March 2010 rating decision on appeal, i.e., in the preferred sequence. This letter informed him of the type of information and evidence required to substantiate this claim for service connection, and apprised him of his and VA's respective responsibilities in obtaining this supporting evidence. He was advised, as well, of the downstream disability rating and effective date elements of this claim in this letter. See Dingess/Hartman, supra. So he has received all required VCAA notice concerning this claim. Moreover, he has not alleged any prejudicial error in the content or timing of the VCAA notice he received. As explained in Shinseki v. Sanders, 129 S. Ct. 1696 (2009), he, not VA, has this burden of proof of showing there is a VCAA notice error in timing or content and, moreover, above and beyond this, that it is unduly prejudicial - meaning outcome determinative of his claim. Thus, absent this pleading or showing, the duty to notify has been satisfied. VA also fulfilled its duty to assist the Veteran with this claim by obtaining all potentially relevant evidence, which is obtainable, and therefore appellate review may proceed without prejudicing him. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). To this end, the RO obtained his service treatment records (STRs) and private medical records, and the AMC arranged for VA compensation examinations in November 2012. The November 2012 VA examiner provided a medical opinion regarding the etiology of the claimed disability. The Board further finds that the AMC has substantially complied with its October 2012 remand orders. In this regard, the Board directed that the AMC should contact the Veteran in an attempt to obtain relevant private medical records, and this was done. The Veteran responded to the AMC's November 2012 letter with additional written argument, and additional private medical records were submitted. The AMC also obtained the Veteran's service pay records. And, as noted, VA examinations were conducted while this case was on remand. Therefore, the Board finds that no further development is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Board concludes that all the available records and medical evidence have been obtained in order to make a determination as to this claim. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Analysis The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by him or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran contends that he has hypertension that was incurred in service. Service connection is granted if it is shown the Veteran suffers from disability resulting from an injury sustained or a disease contracted in the line of duty during active military service, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.306. Hypertension will be presumed to have been incurred in service if manifested to a compensable degree of at least 10 percent within one year after service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For reference, the Board notes that under Diagnostic Code 7101 (for VA rating purposes), hypertension is defined as diastolic pressure of 90mm or greater and isolated systolic hypertension is defined as systolic blood pressure of predominantly 160mm or greater with a diastolic pressure of less than 90mm. See 38 C.F.R. § 4.104, Code 7101. To establish entitlement to service connection, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability or at least has since filing the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability. Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997)). So service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). When determining service connection, all theories of entitlement - direct, presumptive and secondary, must be considered. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). If chronicity (i.e., permanency) of disease or injury in service is not shown, or legitimately questionable, then a showing of continuity of symptomatology following service is required to support the claim. 38 C.F.R. § 3.303(b). Establishing continuity of symptomatology under 38 C.F.R. § 3.303(b) is an alternative method of satisfying the second and third Shedden requirements to establish chronicity (permanency) of disease or injury in service and, in turn, link the currently claimed disability to service. See also Clyburn v. West, 12 Vet. App. 296, 302 (1999). The Federal Circuit Court recently held that the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Hypertension is such a chronic condition under 38 C.F.R. § 3.309(a). To establish a showing of chronic disease in service, or within a presumptive period per § 3.307, a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic," is required. 38 C.F.R. § 3.303(b). Subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Id. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, the tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b) (2012). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Medical evidence also is generally, though not always, required to associate the claimed condition with a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993); Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); and Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is resolved in favor of the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The first and indeed perhaps most fundamental requirement for any service-connection claim is there must be competent and credible evidence first confirming the Veteran has the claimed disability or at least has since the filing of his claim. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (indicating service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it, and that, without this minimum level of proof, there can be no valid claim). See also Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997) (holding that VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability). See also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Turning now to the facts of this particular case. As discussed below, the weight of the competent evidence does not show that the Veteran currently has hypertension or that he had it during the pendency of his current appeal. The Veteran's service personnel records reflect that he served on active duty in the Air Force from September 1959 to September 1985, when he retired. His primary military occupational specialty was that of a dental officer and dental surgeon. The Veteran's service treatment records show that on medical examination in December 1959, his blood pressure was 128/74. On medical examination in September 1968, his blood pressure was 122/70, and on examinations in September 1970 and April 1980, his blood pressure was 120/84 and 118/74, respectively. In April 1980, the reviewing examiner noted that the Veteran complained of a periodic pain in his chest over the past few years, related to stress and anxiety, but a doctor was not consulted. The examiner indicated that a current cardiovascular examination was normal. On periodic medical examination in January 1985, the Veteran's vascular system was listed as normal, and his blood pressure was 132/86. A January 1985 electrocardiogram was normal. A May 1985 memorandum, signed by the Veteran, reflects that he chose not to have a retirement medical examination. His service treatment records are negative for diagnosis or treatment of hypertension. The Veteran's original claim for service connection was received in October 1985, and he claimed service connection for skin problems, declining vision, chest pains, hearing loss, and elevated triglycerides and cholesterol. He did not claim service connection for hypertension. Private medical records from Southwest Texas Methodist Hospital dated in October 2002 reflect treatment for heart disease. An October 2002 history and physical examination by Dr. L.R.H. reflects that the Veteran had a medical history of hypertension and dyslipidemia, but his hypertension was not treated with medication. On examination, his blood pressure was 110/80. The Veteran underwent cardiac surgery for critical aortic stenosis and severe coronary artery occlusive disease. In early November 2002, his blood pressure was 106/62. The discharge diagnoses were congestive heart failure, coronary artery disease, critical aortic stenosis, hypertension, hyperlipidemia, and leukocytosis. Private medical records from Dr. K. dated from 2002 to 2005 reflect treatment for heart disease and other conditions, including pulmonary hypertension. In October 2002 she noted that the Veteran had a past medical history of dyslipidemia and hypertension, not treated, and a family history of hypertension. In November 2005, the Veteran's blood pressure was 120/78, and hypertension was not diagnosed. An August 2003 private health assessment evaluation performed by San Antonio Metropolitan Health District reflects that the Veteran's blood pressure was 102/65, and shows that a normal range is below 140/90. In August and November 2003, the Veteran was examined by an oncologist, J.R.H., MD, and the diagnoses did not include hypertension. His blood pressure was 121/81 in November 2003. The Veteran's first claim for service connection for hypertension was received in September 2003. At that time, he claimed service connection for hypertension, but did not state when the condition began. He contended that he had heart disease due to stress from overwhelming work demands and long hours. In a July 2004 statement, the Veteran said that his blood pressure, cholesterol and triglycerides began increasing during service, and he had heart surgery in October 2002. By a letter dated in August 2007, a private physician, C.H., D.O., stated that she had reviewed the Veteran's service treatment records dated from 1980 to 1985, and he had risk factors for cardiovascular disease at that time. The instant claim was filed in November 2009. In a December 2009 statement, the Veteran asserted that his blood pressure was increasing during service. He reiterated his contentions in subsequent letters, including in a December 2011 statement, in which he said that his blood pressure was 132/86 in service, and that normal blood pressure is 120/80 or lower. At his June 2012 Board hearing, the Veteran testified that in service, his blood pressure was somewhat elevated, but "I never got to the point that I was taking medication, though." He testified that he did not have a complete retirement physical during service. In October 2012, this case was primarily remanded for a VA examination to determine the etiology of any current hypertension. In a November 2012 letter, the Veteran said his heart disease began in service and he had "blood pressure progression" during active duty. He said that during his final assignment in service from 1982 to September 1985, he had elevated triglycerides, and his blood pressure was approaching the need for medication, and was 132/86. He said he never had a complete retirement physical examination. He related that his Air Force service as a dentist was very stressful, and he worked very long days. He reported that he had open heart surgery several years later, in 2002. On VA examination in November 2012, the examiner stated that the Veteran did not currently have hypertension, and that the Veteran said he had never been diagnosed with hypertension and had never been on medication for hypertension. He was not taking medication for hypertension currently. On examination, his blood pressure was taken three times with the following readings: 138/78, 146/82, and 136/64. The examiner stated that there was no diagnosis of hypertension because at the moment there are no symptoms and no current clinical objective evidence of diagnosable disease or pathology. The examiner indicated that the claims file had been reviewed. The Board notes that service connection has since been established for coronary artery disease. In a March 2013 letter that was received by the Board in April 2013, the Veteran said he agreed that although his blood pressure was elevated in the last years of his active duty, his blood pressure had improved. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons and bases for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). There are no relevant post-service medical records regarding hypertension until 2002, so for approximately 17 years after the Veteran's separation from service in 1985. The evidence does not reflect, and the Veteran does not contend, that he had continuous hypertension symptoms from service until 2002. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (ruling 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 in service resulting in any chronic or persistent disability). And there is no competent medical evidence of record showing that he has current hypertension that is related to service. Moreover, the Veteran has never reported continuous symptoms of this condition ever since service. In fact, he has recently conceded that his blood pressure has improved over time. There is no evidence of treatment or diagnosis of this condition in service or for many years after service. And although he was diagnosed with hypertension and pulmonary hypertension in 2002, during his treatment for severe heart disease, the preponderance of the evidence does not show consistently elevated blood pressure readings during the many years during and after service, and hypertension was not found on private examination in November 2005, and on VA examination in November 2012. He has also denied receiving treatment or medication for claimed hypertension. Here, after reviewing all the relevant lay and medical evidence, the Board finds that the weight of this evidence (the most probative of it) indicates the Veteran has not experienced continuous symptoms of hypertension since service, so has not shown the required continuity of symptomatology under 38 C.F.R. § 3.303(b) to establish the required nexus between this claimed condition and his military service. Moreover, the November 2012 VA examiner opined that the Veteran does not have current hypertension. This medical report is of high probative value and is fully adequate for compensation purposes. See Nieves-Rodriquez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The examiner had the benefit of reviewing the Veteran's medical records and his current reported history and complaints in conjunction with medical findings on examination, and provided a supporting rationale. There is no contrary medical opinion of record. A review of the evidence of record shows there is no medical evidence of a current disability of hypertension during the pendency of this appeal. A current disability means a disability shown by competent and credible evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). The Board finds that the weight of the competent and credible evidence demonstrates that the Veteran does not have current hypertension. Additionally, the Board considers it significant that no VA examiner or other treating provider has indicated that the Veteran has current hypertension which arose during a period of active duty, during the first post-service year, or is otherwise related to service or a service-connected disability. Hypertension is a medically complex condition, not readily amenable to lay diagnosis, because it cannot be substantiated by mere lay observation or opinion. See Barr, 21 Vet. App. at 307. The Board recognizes that the Veteran himself has asserted that he has hypertension that is related to service. Although the Veteran is shown to have some medical training, as he is a dentist, the Board finds that his opinion in this matter is not competent, as he has not been shown to have the requisite clinical training to diagnose or etiologically relate his claimed hypertension condition to service or a service-connected disability. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability, including during service and since, even where not corroborated by contemporaneous medical evidence such as treatment records, but also indicating the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence). The Board also finds that his opinion is not credible, as the preponderance of the competent medical evidence of record does not demonstrate a current diagnosis of hypertension. As the preponderance of the evidence is against the claim for service connection for hypertension, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for hypertension is denied. REMAND Unfortunately, the issue of entitlement to service connection for tinnitus must be remanded again, as the December 2012 VA medical opinion is inadequate, since it does not consider the theory of secondary service connection. When determining service connection, all potential theories of entitlement, direct, presumptive, and secondary, must be considered. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004); see also Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). That is, a case encompasses "all potential claims raised by the evidence, applying all relevant laws and regulations, regardless of whether the claim is specifically labeled." Id. Moreover, "the Board is required to adjudicate all issues reasonably raised by a liberal reading of the appellant's substantive appeal, including all documents and oral testimony in the record prior to the Board's decision." Brannon v. West, 12 Vet. App. 32, 34 (1998); see also Solomon v. Brown, 6 Vet. App. 396 (1994). Private medical records from Dr. S. dated in December 1998 reflect that the Veteran had a history of tinnitus since September 1998. He gave a history of noise exposure in the military. An audiological examination showed sensorineural hearing loss, and the pertinent diagnostic impression was tinnitus. In September 2003, the Veteran contended that his hearing loss and tinnitus were due to noise exposure in service, specifically daily engine noise from B-52s in 1969. In a December 2009 statement, the Veteran asserted that he incurred hearing loss in service due to noise exposure in the Air Force both from airplanes and from repeated use of a dental drill. He contended that his tinnitus was "an eventual by-product" of his hearing loss. In a December 2011 statement, he said that he first noticed hearing loss when he was stationed at an Air Force Base in Thailand in 1969 and had significant noise exposure. He said his tinnitus did not occur until some years later, but he contended that it was a related symptom. In a November 2012 letter, the Veteran said his hearing loss began in January 1969, and his tinnitus began in December 1998. On VA audiological examination in December 2012, after an examination, the examiner opined that bilateral hearing loss was incurred in service, noting that he had normal hearing bilaterally on entrance physical examination in 1959, and left ear hearing loss at separation. The examiner noted that the Veteran reported current bilateral constant tinnitus which began in 1998. The examiner opined that it was less likely than not (less than 50 percent probability) that tinnitus was caused by or a result of military noise exposure. The rationale for the opinion was that the Veteran reported that the onset of his tinnitus was in 1998, which was thirteen years after retiring from military service. There is competent medical evidence showing that the Veteran has been diagnosed with tinnitus during the pendency of this appeal. See Degmetich, supra. Thus, the resolution of his appeal for service connection for tinnitus turns on whether the current tinnitus is attributable to his service or to a service-connected disability. In light of the recent grant of service connection for bilateral hearing loss, the Board finds that additional medical comment is needed as to the question of whether current tinnitus was caused or aggravated by now service-connected bilateral hearing loss. See 38 C.F.R. § 3.310. Although the December 2012 VA audiological examiner gave an opinion as to whether or not the current tinnitus is related to service, the examiner did not also comment on whether any current tinnitus alternatively was caused or permanently aggravated by the service-connected bilateral hearing loss. So medical comment is needed concerning this, as well, since medical evidence generally is needed to associate a claimed condition with service or a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); McQueen v. West, 13 Vet. App. 237 (1999); and Velez v. West, 11 Vet. App. 148, 158 (1998). Accordingly, the case is REMANDED for the following action: 1. Forward the claims file to the VA examiner who conducted the December 2012 VA audiological examination for an addendum medical opinion as to the etiology of the current tinnitus. (If that examiner is unavailable, an opinion should be obtained from an appropriate medical provider.) The examiner should specifically respond to the following question: What is the likelihood (very likely, as likely as not, or unlikely) that the current tinnitus was (a) caused, or (b) permanently aggravated by service-connected bilateral hearing loss? The term "as likely as not" means at least 50 percent probability. It does not, however, mean merely within the realm of medical possibility, rather, 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 causation as it is to find against it. Aggravation is defined for legal purposes as a chronic or permanent worsening of the underlying condition beyond its natural progression versus just a temporary or intermittent flare-up of symptoms. If the examiner determines there has been aggravation, he or she should try to quantify the amount of additional disability the Veteran now has, above and beyond that he had prior to the aggravation. The examiner must discuss the underlying rationale for all opinions expressed, whether favorable or unfavorable, if necessary citing to specific evidence in the file. 2. Then, in light of the additional evidence, readjudicate the claim for service connection for tinnitus on both direct and secondary bases. If this claim is not granted to the Veteran's satisfaction, send him and his representative a supplemental statement of the case (SSOC) concerning this claim and give them an opportunity to respond before returning the file to the Board. 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 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