Citation Nr: 1317744 Decision Date: 05/31/13 Archive Date: 06/06/13 DOCKET NO. 09-37 007A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder. 2. Entitlement to an initial disability rating in excess of 10 percent for tinnitus. 3. Entitlement to an initial compensable disability rating for left ear hearing loss. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD M. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from January 2004 to January 2006 with additional reserve service. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which granted service connection for left ear tinnitus, assigning a 10 percent evaluation effective October 17, 2007, and left ear hearing loss, assigning a noncompensable evaluation effective October 17, 2007; and denied service connection for posttraumatic stress disorder (PTSD). In April 2009, the Veteran submitted notices of disagreement (NODs) and subsequently perfected his appeal in October 2009. The issue of entitlement to an initial compensable evaluation 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. VA will notify the Veteran if further action on his part is required. FINDINGS OF FACT 1. The Veteran's claimed stressors are related to his in-service fear of hostile military or terrorist activity, consistent with the circumstances of his military service, and adequate to support a diagnosis of PTSD. 2. The Veteran's service-connected left ear tinnitus is manifested by recurrent tinnitus and does not present such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for PTSD are met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304(f)(3) (2012). 2. The criteria for an initial disability rating for in excess of 10 percent for tinnitus, including on an extraschedular basis, have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.87, Diagnostic Code 6260 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While 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). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim of entitlement to service connection for PTSD, this claim is being granted, as is discussed in detail below. As such, the Board finds that any error related to the VCAA with regard to this claim is moot. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With regard to the Veteran's claim for an increased initial rating for tinnitus, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that 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. Prior to initial adjudication of the Veteran's claim, a letter dated in December 2007 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio at 187. Additionally, the December 2007 letter informed the Veteran of how VA determines the appropriate disability rating or effective date to be assigned when a claim is granted, consistent with the holding in Dingess/Hartman v. Nicholson. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records, VA audiological examination reports, and VA treatment records are in the file. The Veteran has at no time referenced other available records that he wanted VA to obtain or that he felt were relevant to his claim. With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran with a VA examination for his service-connected audiological disabilities most recently in May 2009. The examination involved a review of the Veteran's claims file and a thorough examination, including appropriate diagnostic testing. Therefore, the Board finds that the examination is adequate for determining the disability rating for tinnitus. 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). Additionally, there is no evidence indicating that there has been a material change in the severity of the Veteran's service-connected tinnitus since he was last examined. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. The Board notes that a May 2009 VA treatment record indicated that the Veteran reported recently noticing tinnitus in his right ear as well as the left ear. However, as discussed in detail below, the maximum evaluation for tinnitus is 10 percent whether it is unilateral or bilateral. See 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (2) (2012); see also Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). As such, the onset of bilateral tinnitus does not establish a compensable worsening. Accordingly, the Board finds that a new VA examination is not required. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Merits of the Claim PTSD The Veteran alleges that he currently suffers from PTSD as a result of his active military service. Specifically, he reports that he was exposed to hostile military action in Southwest Asia, including hearing gunfire that he believed to be enemy gunfire. He contends that these experiences have resulted in PTSD. Therefore, he believes that service connection is warranted. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. See 38 U.S.C.A. § 1110 (West 2002). However, that an injury or disease occurred in service is not enough; there must also be a chronic disability resulting from that injury or disease. If there is no showing of the chronic disability during service, then a showing of continuous symptoms after service is required to support a finding of chronicity. See 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. See 38 C.F.R. § 3.303(d) (2012). In order to establish service connection for a disability, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection for PTSD specifically requires medical evidence establishing a diagnosis of the disability, credible supporting evidence that the claimed in-service stressor occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (2012). If the evidence establishes that a veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f)(2) (2012); see also 38 U.S.C.A. § 1154(b) (West 2002). Where a determination is made that a veteran did not "engage in combat with the enemy," or the claimed stressor is unrelated to combat, the veteran's lay testimony alone will not be enough to establish the occurrence of the alleged stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record must include service records or other credible evidence that supports and does not contradict the veteran's testimony. See Doran v. Brown, 6 Vet. App. 283, 289 (1994). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. See Moreau, 9 Vet. App. at 395-96; Cohen v. Brown, 10 Vet. App. 128, 42 (1997). If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See 38 C.F.R. § 3.304(f)(3) (2012). A review of the Veteran's VA psychiatric treatment records indicates that he has been diagnosed with and treated for PTSD. Although these records do not specifically state that the diagnosis of PTSD is being made in compliance with the DSM-IV, the Court has held that mental health professionals making diagnoses "are presumed to know the DSM requirements applicable to their practice and to have taken them into account." See Cohen v. Brown, 10 Vet. App. 128, 140 (1997). The Veteran's noted diagnoses of PTSD were made by a VA staff psychiatrist and VA clinical psychologist after interviewing and evaluating the Veteran and there is no indication that the diagnoses were made other than in line with DSM criteria. Significantly, a December 2007 diagnosis of PTSD made by the VA staff psychiatrist specifically states that the Veteran appeared to "meet the criteria for PTSD." Although it does not specifically state that he is referring to DSM criteria, it is reasonable to conclude that those are the referenced criteria. As such, the Board accepts the diagnosis of PTSD in the Veteran's VA treatment records. Essentially, the Veteran has claimed that he was exposed to hostile military experiences in service in Iraq that involved actual or threatened death or serious injury, or a threat to the physical integrity of himself or others. None of these specific stressors have been verified by the RO. See Formal Finding on Lack of Information Required to Corroborate Stressor(s), March 2008. During the pendency of the Veteran's appeal, VA regulations relating to stressor verification and service connection for PTSD changed. Specifically, 38 C.F.R. § 3.304(f)(3) went into effect on July 13, 2010. As referenced above, under 38 C.F.R. § 3.304(f)(3), if an in-service stressor involves fear of hostile military or terrorist activity, service connection for PTSD may be established if: a VA psychiatrist or psychologist, or contract equivalent, confirms that the claimed stressor is adequate to support a diagnosis of PTSD; the claimed stressor is consistent with the places and circumstances of the Veteran's service; and the Veteran's symptoms are related to the claimed stressor. See 38 C.F.R. § 3.304 (2012). In this case, the Veteran's personnel records show one year of foreign service in an "imminent danger pay area" in Iraq from April 2004 to April 2005. His DD-214 shows that he received an Iraq Campaign Medal and Global War on Terrorism Service Medal for his service in Iraq. Additionally, he has claimed to a VA staff psychiatrist and clinical psychologist that he feared for his life while in Iraq, as they were told to carry their weapons at all times and he felt that he could not trust the Iraqis that were being trained by Special Forces in his area. See VA treatment records, March 2007, July 2007. In light of his service records and decorations, the Board finds that the Veteran's claimed stressors are consistent with his service. Although none of the VA treatment records specifically state that the Veteran's current diagnosis of PTSD is related to his fear of hostile military action in Iraq, his psychiatric treatment is centered around discussing his in-service experiences and fears. Further, he has been diagnosed with PTSD by both a VA psychiatrist and a VA psychologist based on his reports of fear of hostile military action during his service in Iraq, as required by 38 C.F.R. § 3.304(f). The Board finds that it is reasonable to conclude that, as his in-service experiences are the basis of the Veteran's psychiatric treatment, his VA psychiatrist and psychologist's diagnoses of PTSD are related to these in-service experiences and fears. Therefore, under the new regulation, 38 C.F.R. § 3.304(f)(3) (2012) and affording the Veteran the full benefit of the doubt, the Board finds the VA treatment records showing a fear of hostile military action related to a current diagnosis of PTSD are sufficient to grant service connection for PTSD. In sum, the Board finds that the evidence of record places the evidence, at minimum, in equipoise regarding the question of whether the Veteran has PTSD which is related to his military service under the new PTSD regulation. As such, the benefit-of-the-doubt will be conferred in the Veteran's favor and his claim for service connection for PTSD is granted. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304(f)(3) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Tinnitus Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where the Veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the Veteran is entitled to "staged" ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. See 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Veteran's tinnitus is currently evaluated as 10 percent disabling under Diagnostic Code 6260. He seeks a higher initial rating. Under Diagnostic Code 6260, a 10 percent evaluation is assigned for recurrent tinnitus. See 38 C.F.R. § 4.87, Diagnostic Code 6260 (2012). A separate evaluation for tinnitus may be combined with an evaluation under diagnostic codes 6100, 6200, 6204, or other diagnostic code, except when tinnitus supports an evaluation under one of those diagnostic codes. See 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (1) (2012). Only a single evaluation may be assigned for recurrent tinnitus, whether the sound is perceived in one ear, both ears, or in the head. See 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (2) (2012). Objective tinnitus (in which the sound is audible to other people and has a definable cause that may or may not be pathologic) is not to be evaluated under this diagnostic code, but rather it is to be evaluated as part of any underlying condition causing it. See 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (3) (2012). The Veteran was examined for his service-connected audiological disabilities in April 2008 and twice in May 2009. Each of the examiners noted his complaints of ringing in the left ear. VA treatment records also reflect the Veteran's complaints of ringing in the left ear. Additionally, as noted in the VCAA section above, a May 2009 VA treatment record noted the Veteran's recent complaints of ringing in both ears. The medical evidence of record does not establish that the Veteran's service-connected tinnitus warrants more than a 10 percent disability rating under any diagnostic code. He is already in receipt of the maximum schedular rating under his currently assigned Diagnostic Code 6260. As noted above, this is the maximum schedular evaluation whether the Veteran's tinnitus is perceived unilaterally or bilaterally. See 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (2) (2012); see also Smith, supra. As such, a higher rating cannot be granted under this diagnostic code. The Board has also reviewed the remaining diagnostic codes relating to diseases of the ears. However, the claims folder contains no medical evidence indicating that the Veteran's tinnitus is manifested by otitis media or externa, mastoiditis, cholesteatoma, otosclerosis, loss of auricle, malignant or benign neoplasm, perforation of the tympanic membrane, or symptoms other than those discussed above. As such, an increased rating cannot be assigned under Diagnostic Codes 6200-6202 or 6207-6211. See 38 C.F.R. § 4.87, Diagnostic Codes 6200-6202, 6207-6211 (2012). To the extent that the Veteran has argued that his tinnitus is related to a peripheral vestibular disorder and/or Meniere's disease, he was already been denied service connection for this condition in an October 2008 rating decision. He did not appeal this denial and it became final. As there is no medical evidence to support that the Veteran has a peripheral vestibular disorder and/or Meniere's disease that are manifestations of his service-connected tinnitus and he has been denied service connection for these conditions, a rating cannot be assigned under the Diagnostic Codes 6204 or 6205. See 38 C.F.R. § 4.87, Diagnostic Codes 6204, 6205 (2012). Additionally, there is no evidence indicating that the severity of Veteran's tinnitus has fluctuated throughout the appeals period to warrant staged ratings. Thus, the assignment of staged ratings is not appropriate. See Fenderson, supra. In reaching the above-stated conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to an increased initial rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court set forth a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, a veteran's disability picture requires the assignment of an extraschedular rating. With regard to the Veteran's service-connected tinnitus, the evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for the Veteran's currently assigned 10 percent disability rating under Diagnostic Code 6260 contemplates any level of recurrent tinnitus. This specifically contemplates and compensates the Veteran for the symptoms of ringing in the ears that he experiences. As the Veteran's disability picture is contemplated by the rating schedule, the threshold issue under Thun is not met and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the evidence does not support the proposition that the Veteran's service-connected tinnitus presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). Thus, referral of this issue to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. ORDER Entitlement to service connection for PTSD is granted. Entitlement to an initial disability rating in excess of 10 percent for tinnitus is denied. REMAND After a thorough review of the Veteran's claims file, the Board has determined that additional evidentiary development is necessary prior to the readjudication of his claim of entitlement to a compensable initial rating for left ear hearing loss. The Veteran was last examined for his hearing loss disability in May 2009. As noted in the tinnitus discussion above, he was provided two VA audiological examinations during that month. However, neither of the examinations provided reliable results that were suitable for rating purposes. The last VA examination to provide audiometric data that is suitable for rating purposes was in April 2008. Since the time of the April 2008 VA examination, the Veteran and his representative have contended that his hearing loss has worsened and that he now has to use a hearing aid. See NOD, April 2009; Informal Hearing Presentation, May 2013. Additionally, VA treatment records from the Veteran's electronic claims file include a May 2011 audiology consult note. Although the results of the audiogram performed at that time are not available for the Board's review, as discussed further below, the note did indicate that the Veteran's left ear hearing acuity had significantly decreased since his most recent audiological examination in February 2009. As there is lay and medical evidence of a possible worsening of the Veteran's service-connected left ear hearing loss, the Board finds it is appropriate to afford the Veteran a new VA audiological examination to evaluate the current severity of his left ear hearing loss. See Green, supra; Schafrath, supra. As the Court explained in Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991), the Board may consider only independent medical evidence to support its medical findings. The Court went on to say that, if the medical evidence of record is insufficient, the Board is free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. See Colvin at 175. For the reasons described above, the Veteran's claim of entitlement to a compensable initial rating for left ear hearing loss must be remanded for a new VA examination. Additionally, the Board notes that three audiology consult notes, dated in November 2007, February 2009, and May 2011, indicate that audiograms were performed at those times. Although the results have not been associated with the claims file for the Board's review, the notes indicate that the audiograms can be viewed using the CPRS TOOLS menu. This tool is not available to the Board. Therefore, on remand, the AMC should obtain these audiogram results and include them in the claims file for the Board's review, in addition to any other outstanding audiological treatment records. Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the claims file any outstanding VA audiological treatment records, to include copies of the results of the VA audiograms performed in November 2007, February 2009, and May 2011 available through the CPRS TOOLS menu. 2. Obtain and associate with the claims file any outstanding VA audiological treatment records since May 2011, to include copies of the results of the VA audiograms available through the CPRS TOOLS menu. 3. Thereafter, the Veteran should be scheduled for a VA audiological examination in order to determine the current severity of his service-connected left ear hearing loss. The claims folder must be made available to the examiner for review in connection with the examination. The examination report must reflect that such a review was conducted. All indicated studies, to include appropriate audiometric testing, should be completed. 4. After completing the above actions and any other development that may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim of entitlement to a compensable initial rating for left ear hearing loss should be readjudicated. If the claim remains denied, a supplemental statement of the case should be provided to the Veteran and his representative. After they have had an adequate opportunity to respond, the case should be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claim. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. See 38 C.F.R. § 3.655 (2012). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs