Citation Nr: 1316705 Decision Date: 05/22/13 Archive Date: 05/31/13 DOCKET NO. 09-37 187 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to service connection for left ear hearing loss. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Shauna M. Watkins, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1968 to April 1971. The Veteran's claims come before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the U.S. Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied the benefits sought on appeal. The Veteran then perfected a timely appeal of these issues. The Veteran's Virtual VA paperless claims file was also reviewed and considered in preparing this decision and remand, along with the Veteran's paper claims file. The issue of entitlement to service connection for left ear 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. FINDING OF FACT The Veteran's current sensorineural right ear hearing loss was not manifested during his active military service, is not shown to be causally or etiologically related to his active military service, and is not shown to have manifested to a degree of 10 percent or more within one year from the date of separation from the military. CONCLUSION OF LAW Service connection for sensorineural hearing loss of the right ear is not established. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.385 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. VA's Duties to Notify and Assist Under applicable law, VA has a 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); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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. This notice must be provided prior to an initial unfavorable decision on a claim by the Agency of Original Jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board finds that the content requirements of a duty to assist notice letter have been fully satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). A letter from the RO dated in August 2008 provided the Veteran with an explanation of the type of evidence necessary to substantiate his claim, as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. The letter also provided the Veteran with information concerning the evaluation and effective date that could be assigned should service connection be granted, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). The letter was provided prior to the initial RO adjudication of his claim. Accordingly, VA has no outstanding duty to inform the Veteran that any additional information or evidence is needed. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records (STRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. His STRs and post-service treatment records have been obtained. The claims file does not present evidence that the Veteran is currently receiving disability benefits from the Social Security Administration (SSA) for the disorder currently on appeal. Therefore, the Board does not need to make an attempt to obtain these records. The Board does not have notice of any additional relevant evidence that is available but has not been obtained. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on a claim, as defined by law. The record indicates that the Veteran participated in VA examinations in January 2009 and February 2009, the results of which have been included in the claims file for review. A medical opinion was provided at the January 2009 examination, but the examiner did not review the Veteran's claims file prior to providing his medical opinion. Accordingly, another VA examination and medical opinion were obtained in February 2009. The February 2009 examination involved a review of the claims file, a thorough examination of the Veteran, and an opinion that was supported by sufficient rationale. Therefore, the Board finds that the February 2009 VA examination is adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claim. For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claim. Therefore, no further assistance to the Veteran with the development of evidence is required. II. Service Connection The Veteran seeks service connection for right ear hearing loss. To establish direct service connection, the record must contain: (1) medical evidence of a current disorder; (2) medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease; and, (3) evidence of a nexus between the current disorder and the in-service disease or injury. In other words, entitlement to service connection for a particular disorder requires evidence of the existence of a current disorder and evidence that the disorder resulted from a disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including organic diseases of the nervous system, such as sensorineural hearing loss, will be presumed if they manifest to a compensable degree within one year following the active military service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). For the showing of a chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a) (West 2002); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); see 38 C.F.R. §§ 3.102. If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. As noted above, the first element of direct service connection requires medical evidence of a current disorder. Impaired hearing will be considered a disability for VA purposes when the auditory thresholds in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) are 40 decibels or more; or, when the thresholds for at least three of these 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. Here, a current diagnosis has been established. At a September 2008 VA outpatient treatment visit, the Veteran was diagnosed with sensorineural hearing loss in his right ear. Additionally, at the February 2009 VA examination, the measure of pure tone threshold levels, in decibels, at the noted frequencies were: HERTZ 500 1000 2000 3000 4000 RIGHT 60 50 70 65 65 Thus, the Veteran has satisfied the first element of service connection (i.e., a current diagnosis). As stated above, the second element of service connection requires medical evidence, or in certain circumstances, lay testimony, of in-service incurrence or aggravation of an injury or disease. Here, the Veteran's STRs are silent for documentation of the disorder. The records reveal no complaints or treatment related to the Veteran's right ear hearing loss. At his April 1971 military separation examination, his hearing in his right ear was normal. At his January 2009 VA examination, the Veteran reported that he was exposed to noise in the military while working in a welding shop and using pneumatic tools without hearing protection. The Veteran's DD-214 Form documents that the Veteran's Military Occupational Specialty (MOS) was Pipefitter. Therefore, in giving the Veteran the benefit of the doubt, the Board finds that the Veteran is presumed to have been exposed to excessive noise during his active military service. 38 C.F.R. § 3.102. In Hensley v. Brown, 5 Vet. App. 155 (1993), the United States Court of Appeals for Veterans Claims (Court) held that, even though disabling hearing loss may not have been demonstrated at the military separation, a Veteran may still establish service connection for a current hearing loss disability by showing he now satisfies the threshold minimum requirements of § 3.385 and by submitting evidence that his current disability is related to his active military service. See also Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The first post-service relevant complaint of right ear hearing loss was in a September 2008 VA Medical Center (VAMC) treatment record, which documented a diagnosis of sensorineural hearing loss of the right ear. Again, the Veteran's active duty ended in 1971. This lengthy period without treatment for the disorder weighs heavily against the claim. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (holding that service incurrence may be rebutted by the absence of medical treatment of the claimed disorder for many years after the military discharge). As previously mentioned, the third element of service connection requires medical evidence of a nexus between the current disorder and the in-service disease or injury. Here, the claims file currently contains positive and negative medical nexus opinions. As for the positive medical nexus evidence, the Veteran was afforded a VA QTC examination by a private audiologist in January 2009. The examiner did not review the Veteran's claims file. The Veteran described his in-service noise exposure and his post-service twenty-two year history of noise exposure to the examiner. Following a physical examination of the Veteran, the examiner determined that the Veteran had a current diagnosis of sensorineural hearing loss of the right ear. The examiner then found that the Veteran's current right ear hearing loss is as least as likely as not related to his military service. The examiner reasoned that the degree of hearing loss is a common side effect of noise-induced hearing loss. As for the negative medical nexus evidence, the Veteran was afforded a VA audiological examination in February 2009. Following a physical examination of the Veteran, the examiner determined that the Veteran had a current diagnosis of sensorineural hearing loss of the right ear. The examiner then found that the Veteran's current right ear hearing loss is less likely as not (less than 50/50 probability) caused by or a result of military acoustic trauma. The examiner noted that a 15 dB pure tone shift was documented at 1000 Hz and 10 dB pure tone shift was noted at 4000 Hz, when comparing the results of the military entrance examination with the military separation examination. However, the examiner found that the hearing acuity in the Veteran's right ear was clinically within normal limits at the military separation examination. The examiner concluded that the Veteran's current mixed hearing loss in his right ear occurred sometime post-service. In forming his opinion, the examiner reviewed the Veteran's claims file, to include the prior January 2009 examination. The examiner also considered the Veteran's lay statements, in which the Veteran described noise exposure during his three years of military service and described a twenty-three year history of post-service noise exposure. There are no other medical opinions of record. The Veteran has not submitted any medical opinions to support his claim. The treatment records do not provide contrary evidence. The Board finds the negative evidence outweighs the positive on the issue of direct service connection. It is to be noted that the Board is not free to substitute its own judgment for as such a medical expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). However, the Board is required to assess the credibility and weight to be given to the evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). As the February 2009 VA examiner provided an informed explanation as to why the Veteran's right ear hearing loss is not related his active military service, the Board finds the probative value of the February 2009 VA examination report is greater than the cursory conclusions of the January 2009 examination. The January 2009 VA examiner did not review the Veteran's claims file, and thus did not consider the complete medical history prior to providing his opinion. The January 2009 examiner also did not address or account for the Veteran's extensive post-service noise exposure, despite the fact that the Veteran described this noise exposure at the examination. This lack of discussion of the post-service noise exposure is noteworthy as it shows that the doctor failed to consider a significant intervening trauma in his assessment of the cause of the Veteran's right ear hearing loss. Specifically, the January 2009 examiner found that the Veteran's levels of hearing loss were a common side effect of noise-induced hearing loss. However, the examiner did not consider whether the "noise-induced hearing loss" could be from the Veteran's extensive civilian noise exposure as opposed to his military noise exposure. As such, the Board finds the January 2009 opinion to be of low probative value. In contrast, the VA examiner who conducted the February 2009 VA examination and authored the accompanying report accurately and thoroughly characterized the evidence of record and conducted a comprehensive examination of the Veteran's right ear hearing loss. His report of the Veteran's medical history and his clinical findings are consistent with the entire body of medical evidence of record. There is no basis on which to find that the report is incomplete or insufficient in any way. The Veteran reports continuous symptomatology since his active military service. However, the Veteran's contentions are not supported by the medical evidence of record. As stated above, the earliest pertinent post-service medical evidence associated with the claims file is dated from 2008, over thirty-five years after the Veteran's military separation in 1971. Furthermore, the record contains evidence of post-service noise exposure. At his January 2009 VA examination, the Veteran reported a twenty-two year civilian history of noise exposure at his place of employment. This post-service noise exposure demonstrates that the Veteran has not had continuous right ear hearing loss since his in-service injuries; instead, there are superseding causes. Further, the STRs do not show that the Veteran developed chronic right ear sensorineural hearing loss during his active military service. The STRs do not contain any complaints of or diagnoses of right ear hearing loss. His hearing in his right ear was normal at his April 1971 military separation examination. The evidence of record does not document continuity of symptomatology during and since the Veteran's active military service. Thus, the Board finds that the medical evidence does not establish a "chronic disorder." 38 C.F.R. § 3.303; see Walker, 708 F.3d at 1331. The Veteran's service connection claim cannot be granted on this theory of entitlement. Additionally, the Board finds that the Veteran is not entitled to presumptive service connection for sensorineural hearing loss of the right ear. As stated above, the earliest post-service medical treatment records are dated from September 2008, and the Veteran was separated from the active duty in 1971. No diagnosis of sensorineural hearing loss of the right ear was made within one year of the Veteran's military discharge. Thus, the presumption for service connection for chronic diseases does not apply. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). In reaching this decision, the Board has considered the Veteran's arguments in support of his claim. The Board acknowledges that the Veteran is competent, even as a layperson, to attest to factual matters of which he has first-hand knowledge, e.g., an injury during his active military service. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that lay evidence is one type of evidence that must be considered, and that competent lay evidence can be sufficient in and of itself. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). In Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009), and in Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit determined that lay evidence can be competent and sufficient to establish a diagnosis of a disorder when: (1) a layperson is competent to identify the medical disorder (noting that sometimes the layperson will be competent to identify the disorder where the disorder is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (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. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient in a particular case is a fact issue. Id. Although the Veteran is competent to report that he experienced hearing loss in his right ear during his active military service, which resulted in his current right ear hearing loss, the Board must still weigh his lay statements against the medical evidence of record. See Layno v. Brown, 6 Vet. App. 465 (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")). In making this credibility determination, the Board does not find the Veteran's statements concerning the etiology of his right ear hearing loss to be credible, since his STRs make no reference to a right ear injury or right ear hearing loss. Further, the record documents that the Veteran did not complain of right ear hearing loss until 2008, over thirty-five years after his separation from the active duty. See Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd per curiam, 78 F.3d. 604 (Fed. Cir. 1996); see also Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). It is important to point out that the Board does not find that the Veteran's lay statements lack credibility merely because they are unaccompanied by contemporaneous medical evidence. See Davidson, 581 F.3d at 1313, quoting Buchanan, 451 F.3d at 1337 ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). Rather, the Veteran's statements are found to be incredible because they are inconsistent with the evidence of record, which fails to show right ear hearing loss or a right ear injury during his active military service, and which fails to show right ear hearing loss until 2008, many years after his separation from the active duty in 1971. For the reasons set forth above, the Board finds that the Veteran's lay statements that his symptoms have been present since his active military service are not credible. Therefore, these statements do not warrant a grant of service connection or a determination that further development of the medical evidence is required. All other evidence of record, aside from the Veteran's statements in support of this current claim, is unfavorable to the claim for service connection for right ear hearing loss. The Board notes that under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran's claim, and thus that doctrine is not applicable. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER The claim for service connection for right ear hearing loss is denied. REMAND Inasmuch as the Board regrets the additional delay of this appeal, a remand is required before the left ear hearing loss claim can be properly adjudicated. Initially, the evidence of record suggests that the Veteran's left ear hearing loss pre-existed his active military service and was aggravated during service. In this regard, the Veteran has not been provided with a proper duty-to-assist notice letter. Specifically, the Veteran has not been informed of the requirements for establishing service connection based on aggravation of a pre-existing disorder. The Veteran must be provided with this requisite notice. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159. Additionally, the most recent outpatient treatment records from the VAMC in Fayetteville, Arkansas, are dated from February 2009. On remand, all pertinent records since this date should be obtained and added to the claims file. See 38 U.S.C.A. § 5103A(a)(1), (b)(1), (c)(1); Loving v. Nicholson, 19 Vet. App. 96, 101-03 (2005). Finally, the Veteran was afforded a VA audiological examinations in January 2009 and February 2009 to address the nature and etiology of his left ear hearing loss. However, for the foregoing reasons, the Board finds these examinations to be inadequate. The Veteran was afforded a VA examination in January 2009. The examiner did not review the claims file. The VA examiner provided a medical opinion, but the opinion addressed direct service connection (38 U.S.C.A. § 1110), which is the incorrect standard, since the Veteran's left ear hearing loss was noted on his military entrance examination. See 38 U.S.C.A. § 1111 ("Every Veteran shall be taken to have been in sound condition when examined, accepted and enrolled for active military service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment."). Additionally, the Veteran's STRs contain notations of left ear hearing loss. In this regard, the examiner did not address whether this pre-existing left ear hearing loss was aggravated beyond its natural progression by the Veteran's active military service. 38 U.S.C.A. §§ 1111, 1153 (West 2002); 38 C.F.R. § 3.306 (2012). In deciding an aggravation claim, after having determined the presence of a pre-existing disorder, the Board must determine whether there has been any measurable worsening of the disorder during the active military service and whether this worsening constitutes an increase in the disorder. Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). Following a physical examination of the Veteran and a review of the claims file, the February 2009 VA examiner provided a medical opinion regarding the Veteran's current left ear hearing loss. Specifically, in response to the question of whether the Veteran's pre-existing left ear hearing loss worsened beyond progression during his active military service, the VA examiner found that he could not resolve the issue "without resort to mere speculation." The examiner reasoned that he was uncertain about whether the reported hearing responses in the left ear from 1968-71 were consistently masked revealing true thresholds and not cross-over responses due to interaural attenuation. The examiner stated that the type of pre-existing hearing loss in the left ear was unknown without bone conduction results. The examiner then indicated that the Veteran reported a family history of hearing loss and a history of childhood ear infections. Concerning a medical opinion in which the VA medical professional cannot render an opinion as to etiology without resorting to mere speculation, the Court determined that a VA examiner cannot use speculation "as a substitute for the full consideration of all pertinent and available medical facts to which a claimant is entitled." Jones v. Shinseki, 23 Vet. App. 382 (2010). Here, it is unclear whether the VA examiner closely considered the Veteran's lay statements regarding his in-service noise exposure, his STRs, his VA treatment records, the Veteran's post-service noise exposure, and the medical literature reviewed in forming his medical opinion. The Board finds the aforementioned VA examinations to be inadequate. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr, 21 Vet. App. at 303. Thus, the Board finds that another VA examination is necessary before a decision on the merits may be reached. Accordingly, the case is REMANDED for the following actions: 1. The RO/AMC should send the Veteran another VCAA letter pertaining to his left ear hearing loss claim, to include information regarding establishing aggravation of a pre-existing disorder under 38 U.S.C.A. §§ 1111, 1153 and 38 C.F.R. § 3.306. 2. Obtain all pertinent VA outpatient treatment records from the Fayetteville, Arkansas, VAMC since February 2009 that have not been secured for inclusion in the record. Ensure that the Veteran has not been recently treated by any other local VAMCs. If no additional medical records are located, a written statement to that effect should be requested for incorporation into the record. 3. The RO/AMC shall ask the original February 2009 VA examiner to provide an addendum opinion, or if this examiner is not available, schedule the Veteran for a VA audiological examination to determine the etiology of his current left ear hearing loss. The VA examiner should thoroughly review the Veteran's VA claims file, particularly the STRs and lay statements. The VA examiner should note that this action has been accomplished in the VA examination report. The VA examiner is requested to specifically address the following: Was the pre-existing left ear hearing loss clearly and unmistakably (i.e., highest degree of medical certainty) not aggravated beyond the natural progress of the disease by his active military service, to include his presumed in-service noise exposure? All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file itself, must be made available to the examiner. If the examiner determines that a decision cannot be made without resort to mere speculation, then it should be clear in the examiner's remarks whether it cannot be determined from current medical knowledge that a specific in-service injury or disease can possibly cause the claimed disorder, or whether the actual cause is due to multiple potential causes. In other words, simply stating that an opinion cannot be provided without resort to mere speculation is not acceptable without a detailed reason as to why this is so. The Veteran is hereby notified that it is his responsibility to report for the examination scheduled in connection with this REMAND and to cooperate in the development of his case. The consequences of failure to report for a VA examination without good cause may include denial of his claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 4. After the above actions have been completed, readjudicate the Veteran's left ear hearing loss claim. If the claim remains denied, issue to the Veteran and his representative a Supplemental Statement of the Case (SSOC). Afford them the appropriate period of time within which to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims 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). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs