Citation Nr: 1318360 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 09-34 306 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for circulatory problems, claimed as secondary to service-connected diabetes mellitus, type II. 3. Entitlement to service connection for a right ear hearing loss disability. 4. Entitlement to service connection for a left ear hearing loss disability. 5. Entitlement to service connection for hypertension, claimed as secondary to service-connected diabetes mellitus, type II. ATTORNEY FOR THE BOARD E. I. Velez, Counsel INTRODUCTION The Veteran served on active duty from May 1964 to May 1966. Service in the Republic of Vietnam is indicated by the record. This matter comes before the Board of Veterans' Appeals (hereinafter Board) on appeal from a December 2009 rating decision, by the San Juan, Puerto Rico, Regional Office (RO), which denied the Veteran's claims. In September 2012, the Board remanded the claims for further development. Except with regards to the issue of entitlement to service connection for left ear hearing loss, the requested development has been substantially complied with and the claims is ready for appellate review. In a rating decision of February 2013 the RO granted service connection for erectile dysfunction. As the benefit sought on appeal has now been fully granted, the issue is no longer before the Board. The Board has reviewed the Veteran's Virtual VA file and has considered all relevant records contained therein in the decision below. The issue of entitlement to service connection for left ear hearing loss and tinnitus are addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran does not currently have a right ear hearing loss which is considered disabling for VA purposes. 2. The Veteran does not currently have a disability manifested by a circulatory problem. 3. Hypertension was not shown in service or within one year of service discharge, and the competent medical evidence does not support a finding that a relationship exists between the Veteran's currently diagnosed hypertension and military service or service connected type II diabetes mellitus. CONCLUSIONS OF LAW 1. The criteria for service connection for right ear hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.385 (2012). 2. Circulatory problems were not incurred in or aggravated by the Veteran's military service, may not be presumed to have been incurred therein, and is not proximately due to or the result of service-connected type II diabetes mellitus. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 3. Hypertension was not incurred in or aggravated by the Veteran's military service, may not be presumed to have been incurred therein, and is not proximately due to or the result of service-connected type II diabetes mellitus. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012) and 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 evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VA's notice requirements apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In cases that concern the assignment of a disability rating, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. Notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Regarding his claims a pre-rating July 2007 and September 2009 letters notified the Veteran of the information and evidence needed to substantiate his claims. Consistent with Dingess, the letter also notified the Veteran that a disability rating and an effective date are assigned where a disability is determined to be service-connected. After affording the Veteran reasonable opportunity to respond, his claims were adjudicated in the RO's December 2009 rating decision. Thus, because the VCAA notice that was provided before service connection was granted was legally sufficient, VA's duty to notify has been satisfied. In addition, VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claims. His service treatment records, service personnel records, claims submissions, hearing transcript, and VA treatment records have been associated with the record. The Veteran was also afforded a VA examination for circulatory problems in August 2009 and for hearing loss in Augusts 2009 and October 2012. These examinations, along with the other evidence of record to include an April 2013 VA medical opinion, are fully adequate for the purposes of determining the nature and etiology of the Veteran's disabilities. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Legal Criteria and Analysis In general, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). For the showing of chronic disease in service, there is required 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, a showing of continuity of symptoms after separation from service is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain listed chronic diseases such as hypertension may be awarded on presumptive basis and will presumed to have been incurred during active service, even though there is no evidence of the disability during service if such disability becomes manifest to a compensable degree within one year of separation from active duty. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. While hearing loss disability is not a disease listed in 38 C.F.R. § 3.309(a), organic diseases of the nervous system are listed as a disability subject to presumptive service connection. As the Veteran's hearing loss disability has been described as sensorineural in nature, the Board will consider whether service connection under the presumptive provisions contained in 38 C.F.R. §§ 3.307, 3.309 is warranted. An alternative method of establishing the second and third elements of service connection for those disabilities identified as a "chronic condition" under 38 C.F.R. § 3.309(a) is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, any disability which is proximately due to, or results from, another disease or injury for which service connection has already been granted shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the non-service-connected disease, will be service connected. Evidence that relates the current disorder to service must be medical unless it relates to a disorder that may be competently demonstrated by lay observation. For the showing of chronic disease in service, there is required 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." 38 C.F.R. § 3.303(b). Notwithstanding the lack of evidence of disease or injury during service, service connection may still be granted if all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. See 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). A service connection claim must be accompanied by evidence which establishes that the claimant currently has the claimed disability. See Brammer v. Derwinski, 3 Vet. App. 223. 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). The Board notes that a lay person is competent to describe what they observe. See Layno v. Brown, 6 Vet. App. 465 (1994). The Federal Circuit has held that lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). This would include weighing the absence of contemporary medical evidence against lay statements. In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court indicated that varicose veins was a condition involving "veins that are unnaturally distended or abnormally swollen and tortuous." Such symptomatology, the Court concluded, was observable and identifiable by lay people. Because varicose veins "may be diagnosed by their unique and readily identifiable features, the presence of varicose veins was not a determination 'medical in nature' and was capable of lay observation." Thus, the veteran's lay testimony regarding varicose vein symptomatology in service represented competent evidence. In Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007), the Federal Circuit determined that 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 (noting that sometimes the layperson will be competent to identify the condition where the condition 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. Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). See Barr, supra. In determining whether service connection is warranted for a disability, VA 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 the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b). In addition to the foregoing general principles, service connection for hearing loss is not granted unless the claimed hearing loss is of a particular level of severity. For purposes of applying the laws administered by VA, hearing impairment will be considered a disability when the thresholds for any of the frequencies at 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; the thresholds at three of these frequencies are 26 or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. A. Right ear hearing loss The Veteran seeks entitlement to service connection for hearing loss in the right ear. After a careful review of the evidence of record, the Board finds that the evidence is against a finding of service connection for a right ear hearing loss disability. In this case, the evidence shows that the Veteran does not currently have a right ear hearing loss that meets the regulatory threshold under 38 C.F.R. § 3.385. In that regard, audiometric testing performed during an August 2009 VA examination revealed the following pure tone thresholds, expressed in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 5 15 20 Speech discrimination testing performed at that time showed speech recognition abilities of 100 percent in the right ear. An October 2012 VA audiological examination revealed the following puretone thresholds, expressed in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 5 20 20 Speech discrimination testing performed at that time showed speech recognition abilities of 100 percent in the right ear. The Board notes that the findings above do not show a hearing loss disability in the right ear for VA purposes. That is, none of the records thresholds was 40 decibels or greater; threshold of at least 26 are not shown in three of the frequencies; and speech recognition scores were not less than 94 percent. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board acknowledges that the Veteran is competent to report his symptoms. Layno, supra. Significantly, while seeking treatment and at the VA examinations, the Veteran has only reported hearing loss in the left ear and not the right ear. To the extent that the Veteran may assert that he has a right ear hearing loss disability, the Board finds that he is not competent to provide such a medical opinion given that this opinion may not be rendered based on the Veteran's personal observation. To qualify as a disability for VA rating purposes, hearing impairment must, by regulation, satisfy a threshold level of impairment. The Veteran, as a lay person, lacks any particular skill or expertise that would render competent audiologic findings. Jandreau v. Nicholson, supra. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (although it is error to categorically reject a non-expert opinion as to etiology, or nexus, not all questions of nexus are subject to non-expert opinion; whether a layperson is competent to provide a nexus opinion depends on the facts of the particular case). In light of the foregoing, the Board finds that the any opinion from the Veteran regarding the presence of a current hearing loss disability has no probative value. The Board assigns greater probative value to the VA audiological examinations, which do not contain findings indicative of a current right ear hearing loss disability as these examinations were conducted by licensed audiologists as required by VA regulation. The Board finds that VA medical opinion is of great probative value as it was prepared by a skilled, neutral, and medical professional in the field of hearing after obtaining a history from the Veteran, reviewing the claims folders, and conducting an audiological evaluation. Accordingly, service connection for right ear hearing loss is denied. B. Circulatory problems The Veteran seeks service connection for circulatory problems of the lower extremities. He claims he has circulatory problems which are secondary to the service connected diabetes mellitus type II. After a careful review of the evidence of record, the Board finds that the preponderance of the evidence is against the claim. Service treatment records and post-service VA and private treatment records are all silent for any complaints of or treatment of any circulatory problems. The Veteran was afforded an arteries and veins VA examination in August 2009. At the time, the Veteran reported complaints of bilateral lower extremities numbness and tingling sensation, with muscle cramps. After a review of the claim file and a physical examination of the Veteran, the examiner provided a diagnosis of "unremarkable." The examiner noted that the Veteran's actual complaints of bilateral lower extremities numbness and tingling sensation are secondary to motor axional neuropathy. He opined that the current claimed circulatory problems are not caused by or a result of the service connected diabetes mellitus type II. At the outset, the Board notes that service connection is already in effect for peripheral neuropathy of the bilateral lower extremities. Therefore, service connection has already been established for the symptoms of numbness and tingling in the bilateral lower extremities. With regards to any other symptoms of a circulatory problem of the bilateral lower extremities which could be service connected, the Board notes that there is no objective and competent finding of a disability of the lower extremities manifested by circulatory problems. Indeed, the August 2009 VA examiner did not provide a diagnosis related to the Veteran's claimed circulatory problems. Moreover, the examiner concluded that the Veteran's claimed circulatory problems were not etiologically related to his diabetes mellitus. Without a diagnosis, service connection cannot be established. See Brammer, supra. As noted above, the Court in Barr, supra, has held that a Veteran is competent to state he has varicose veins. On the other hand, the Board notes that the VA examination report of August 2009 states that the Veteran does not have a circulatory problem of the bilateral lower extremities. The examination was adequate, the examiner entered his findings after an examination of the Veteran, review of the claims file, and an interview of the Veteran. The VA examiner's finding is also competent evidence. As previously noted, once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra. In that regard, the Board notes that the majority of the evidence has pointed to a neurological problem of the bilateral lower extremities rather than a circulatory problem. Indeed, the VA examiner noted neurological tests which showed neuropathy of the bilateral lower extremities. However, nothing in the record shows a circulatory problem. While the Veteran is competent to report problems with his bilateral lower extremities, the Board finds that the diagnosis of a circulatory problem versus a neurological problem is a complex medical question which the Veteran lacks expertise to competently report on. Accordingly, the Board will place greater probative weight on the VA examiner's findings than the Veteran's assertions. Therefore, the Board finds that the Veteran's current allegations of circulatory problems of the bilateral lower extremities are less probative than the findings at the August 2009 VA examination. The Board finds that the observations of skilled professionals are more probative as to the existence of disability and disease or injury. Although the Veteran is competent to report bilateral lower leg problems, his lay statement is far less probative as to the existence of a circulatory problem than the opinion of a skilled professional. See Jandreau, supra. Consequently, the Board finds that the more probative evidence establishes that he does not have a circulatory problem of the bilateral lower legs. Without a finding of a current disability, service connection cannot be granted. C. Hypertension The Veteran seeks service connection for hypertension. Specifically, the Veteran claims that hypertension was caused by his service connected diabetes mellitus type II. After a careful review of the evidence of record, the Board finds that the evidence is against the claim. At the outset, the Board notes that the Veteran has not alleged, and the Veteran has not claimed, that hypertension was incurred in or aggravated by service. Moreover, there is nothing in the record showing that hypertension was incurred within a year from separation from service. Accordingly, there is no evidence to support a finding of service connection on either a direct or presumptive basis. Therefore, the analysis below will focus on whether hypertension was caused by or aggravated by his service connected diabetes mellitus type II. The Board notes that the record is clear that the Veteran has a current diagnosis of hypertension and he is service-connected for type II diabetes mellitus. Therefore, the remaining question is whether competent evidence of a nexus between the service-connected disease or injury (diabetes mellitus) and the current disability (hypertension), is met. VA afforded the Veteran an examination in October 2012. Upon review of the claims folder and evaluation of the Veteran, the examiner stated that the Veteran's hypertension occurred prior to the Veteran's diabetes mellitus type 2 and there is no evidence of renal involvement. The RO sought clarification of the opinion and in an April 2013 opinion, the VA examiner stated that arterial hypertension existed prior to the diagnosis of diabetes mellitus type II and there is no renal involvement which is known to cause aggravation of patients with diabetes mellitus type II with preexisting arterial hypertension. Moreover, he stated that there is no evidence of worsening of the hypertension as the Veteran continues with solely one medication for his treatment. The Board finds this examination reports and opinions to be probative as it was definitive, based upon a complete review of the Veteran's entire claims file, and supported by detailed rationale. Accordingly, the opinion is found to carry significant weight. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The Veteran has not provided any competent medical evidence to rebut the opinion against the claim or otherwise diminish its probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). He has been accorded ample opportunity to furnish medical and other evidence in support of his claim; he has not done so. See 38 U.S.C.A. § 5107(a) (2012) (noting it is a claimant's responsibility to support a claim for VA benefits). Therefore, the claim for service connection for hypertension secondary to diabetes mellitus fails. The Board observes that the Veteran has also established service connection for coronary artery disease related to his diabetes mellitus. However, the Veteran has not asserted that his hypertension is secondary to his coronary artery disease. Similarly, there is nothing in the record to suggest an etiological relationship between the Veteran's hypertension and coronary artery disease. Accordingly, service connection for hypertension as secondary to coronary artery disease is not warranted. In concluding that service connection for hypertension is not warranted on either a direct, presumptive, or secondary basis, the Board acknowledges that it must fully consider the lay assertions of record. In this regard, as noted above, a layperson is competent to report on the onset and continuity of his current symptomatology. See Layno, supra. Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (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. Jandreau, supra. In this case, an assertion as to the etiology of the Veteran's current hypertension is a question unlike testimony as to a separated shoulder, varicose veins, or flat feet, which are capable of direct observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting that lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 308-09 (2007) (finding that lay testimony is competent to establish the presence of varicose veins); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (discussing that unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis. There is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a medical opinion regarding the etiology of his hypertension. See 38 C.F.R. § 3.159 (a)(1) (2012) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran is competent to report what he has experienced, he is not competent to ascertain the etiology of his hypertension as the causative factors for such are not readily subject to lay observation. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); Layno v. Brown, 6 Vet. App. 465 (1994). In this circumstance, the Board gives more credence and weight to the VA examiner's opinion as it was rendered after an evaluation and extensive review of the Veteran's medical history by a licensed physician. In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's disability and any instance of his military service or service-connected disability to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b) (West 2002). ORDER Service connection for a right ear hearing loss disability is denied. Service connection for circulatory problems, claimed as secondary to service-connected diabetes mellitus, type II. Service connection for hypertension, to include as secondary to service-connected type II diabetes mellitus, is denied. REMAND The Board seeks service connection for a left ear hearing loss and tinnitus. After a careful review of the evidence of record, the Board finds that the claims must be remanded for additional development prior to issuing a decision. The Veteran was afforded a VA examination in October 2012. After a review of the claim file and an examination of the Veteran, the examiner opined that left ear hearing loss was not caused by or a result of military service. The examiner noted that at enlistment and separation the hearing test performed, but this test is not a reliable test to identify the presence of hearing loss that is typically found with noise exposure. He also noted the record showed normal hearing in 1986 and mild to severe hearing loss in the left ear since 2008. The examiner acknowledges that the Veteran reported hearing loss in the left ear since June 1964 while still in service, but noted that no hearing test was conducted because the Veteran failed to show up for a hearing test appointment at the time. The examiner finally stated that it is reasonable to conclude that the current hearing loss is due to presbycusis or hearing loss expected form normal aging process. The Board has reviewed the opinion provided and finds that it is not fully adequate for appellate review. In this regard, the Board finds that the examiner did not provide an adequate rationale for the opinion. Indeed, the examiner provided a recitation of facts and a conclusion. Significantly, it appears that the examiner considered the lack of a hearing test in 1964 as evidence against the Veteran's claim. This is particularly disturbing as the examiner himself stated that the whispered tests conducted in service are not reliable to detect hearing loss associated with military noise exposure. After the recitation of facts, the examiner provided a conclusion, but did not provide a reasoning for it. Specifically, the examiner did not discuss the Veteran's noise exposure in service, which was already conceded by the Board, and how the Veteran's reports of hearing loss in service, regardless of a hearing test, may or may not support an inception of left ear hearing loss in service. Accordingly, the Board finds that a new VA medical opinion is needed regarding the etiology of the Veteran's left ear hearing loss disability. With regards to the claim for service connection for tinnitus, the Board notes that tinnitus has been found to be related to the left ear hearing loss. Accordingly, the Board finds that the issue is inextricably intertwined with the issue of service connection for left ear hearing loss and the Board will defer a decision on that issue until after the requested development has been completed. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should obtain a new VA medical opinion with regards to the etiology of the diagnosed left ear hearing loss disability. The opinion should be obtained from a different examiner than the one who conducted the October 2012 VA examination. The examiner should be provided with the claim file and should be given access to the Veteran's Virtual VA file for the review of records contained therein prior to issuing the opinion. The review of the paper and virtual claim files should be noted in the opinion. The examiner must provide an opinion as to whether it is at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's left ear hearing loss disability was incurred in service. The examiner should be advised that noise exposure in service has been conceded. Moreover, the examiner should specifically address the Veteran's complaints of hearing loss in service and whether, regardless of the normal whispered tests on separation, which have been noted to be unreliable, the Veteran's complaints of hearing loss in service are related to or were the precursor to the current left ear hearing loss disability. A complete rationale for any opinion rendered must be provided. 2. After ensuring any other necessary development has been completed as a result of the above instructions, readjudicate the Veteran's claims. If action remains adverse to the Veteran, provide the Veteran with a supplemental statement of the case and allow an appropriate opportunity to respond. Thereafter, the case should be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs