Citation Nr: 1318548 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 09-45 524 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected Type II diabetes mellitus. 2. Entitlement to service connection for bilateral hearing loss. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Elwood, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1970 to January 1974, which includes service in the Republic of Vietnam. These matters initially came before the Board of Veterans' Appeals (Board) from March and June 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In the March 2009 decision, the RO denied entitlement to service connection for hypertension. In the June 2009 decision, the RO denied entitlement to service connection for bilateral hearing loss. The Veteran testified before the undersigned at a February 2011 videoconference hearing. A transcript of that hearing has been associated with his claims folder. In April 2011, the Board denied the claim of service connection for bilateral hearing loss and remanded the claim of service connection for hypertension for further development. The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (Court). In February 2012, the Court set aside the Board's April 2011 decision and remanded the case for readjudication in compliance with directives specified in a February 2012 Joint Motion filed by counsel for the Veteran and VA. In February 2013, the Board remanded these matters for further development. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claims. The documents in this file have been reviewed and considered as part of this appeal. The issue of entitlement to service connection for bilateral hearing loss is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT Hypertension did not have its clinical onset in service and is not otherwise related to active duty; it was not exhibited within the first post service year and is not etiologically related to a service-connected disability. CONCLUSION OF LAW Hypertension was not incurred or aggravated in service; it may not be presumed to have been incurred therein; and it is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113(b), 1116, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 4.104, Diagnostic Code (DC) 7101, Note (1) (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Under the VCAA, 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; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a pre-adjudication letter dated in August 2008, the RO notified the Veteran of the evidence needed to substantiate his claim of service connection for hypertension on a direct basis. He was notified of the evidence needed to substantiate his claim on a secondary basis by way of a December 2009 letter. The August 2008 letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The claimant's Veteran status has been substantiated. He was notified of all other elements of the Dingess notice, including the disability rating and effective date elements of his claim, in the August 2008 letter. There was a timing deficiency in that the December 2009 letter was sent after the initial adjudication of the claim of service connection for hypertension. This timing deficiency was cured by readjudication of the claim in a March 2010 statement of the case. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The Court has held that the provisions of 38 C.F.R. § 3.103(c)(2) (2012) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the Veteran's February 2011 hearing, the undersigned identified the issues on appeal at that time (including entitlement to service connection for hypertension), informed the Veteran of the information and evidence required to substantiate a claim of service connection on a direct basis, and asked him about the treatment received for his hypertension to ensure that all relevant records had been obtained. Further, the Veteran provided testimony as to the symptoms and history of his hypertension and the treatment provided for the disability, thereby demonstrating actual knowledge of the ability to identify and submit additional relevant evidence. The duties imposed by Bryant were thereby met. VA obtained the Veteran's service treatment records, pertinent service personnel records, and all of the identified relevant post-service private medical records. The Veteran has not reported, and the evidence does not otherwise reflect, any relevant post-service VA medical treatment for hypertension. In addition, the Veteran was afforded a VA examination to assess the nature and etiology of his hypertension and opinions have been obtained concerning the etiology of the disease. In its April 2011 and February 2013 remands, the Board instructed the agency of original jurisdiction (AOJ) to, among other things: obtain the Veteran's service personnel records, afford him a VA examination to assess the etiology of his current hypertension, and obtain opinions as to whether his hypertension was caused or aggravated by his service-connected diabetes mellitus. As explained above, all pertinent service personnel records have been obtained and associated with the Veteran's claims file. Also, he was afforded a VA examination in May 2011 and opinions were obtained as to whether his hypertension was caused or aggravated by his diabetes mellitus. Thus, the AOJ substantially complied with all of the Board's relevant April 2011 and February 2013 remand instructions and VA has no further duty to attempt to obtain any additional records or conduct additional examinations with respect to the claim being decided herein. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Analysis Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires (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 present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Service connection is also provided for a disability which is proximately due to, the result of, or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. VA has amended 38 C.F.R. § 3.310 to reflect that it will not concede aggravation unless certain additional conditions are met. 38 C.F.R. § 3.310(b). As explained below, the Board finds that there is no competent evidence that a service-connected disability caused or aggravated the Veteran's current hypertension. Hence, it is not necessary to determine which version of 38 C.F.R. § 3.310 is applicable in this case. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element for certain chronic disabilities listed in 38 C.F.R. § 3.309(a), including hypertension, is through a demonstration of continuity of symptomatology. See Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.309(a). In relevant part, 38 U.S.C.A. § 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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 v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (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")). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A veteran, who, during active military service, served in Vietnam during the period beginning in January 1962 and ending in May 1975, is presumed to have been exposed to herbicides. 38 C.F.R. §§ 3.307, 3.309. If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected even though there is no record of such disease during service: chloracne or other acneform disease consistent with chloracne, Type 2 diabetes, Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as hypertension, are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). Notwithstanding the foregoing presumptions, a claimant is not precluded from establishing service connection with proof of direct causation. 38 U.S.C.A. § 1113(b); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. The term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater and isolated systolic hypertension means systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of 90 mm. 38 C.F.R. § 4.104, DC 7101, Note (1). In this case, the May 2011 VA examination report includes a diagnosis of hypertension. Also, examination reports from Cumberland View Clinic dated in April and November 2008 and a May 2009 VA examination report reveal elevated blood pressure readings (175/103, 161/96, and 158/91, respectively). Thus, current hypertension has been demonstrated. As the Veteran served in Vietnam, he is presumed to have been exposed to herbicides, including Agent Orange. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307. However, hypertension is not a condition listed in 38 C.F.R. § 3.309(e). Presumptive service connection on the basis of his presumed exposure to herbicides is, therefore, not warranted. 38 C.F.R. § 3.309(e); see also 68 Fed. Reg. 27,630-41 (May 20, 2003) (stating that the Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted). The Veteran does not primarily contend, and the evidence does not otherwise reflect, that his hypertension is directly related to service. However, the Board does note that he contended in his July 2008 claim (VA Form 21-526) that his hypertension was related to herbicide exposure in service, that the disease had its onset in 1970, and that he had been treated for the disease from 1970 to 2008. Thus, he appears to have alluded to a continuity of symptomatology. The evidence reflects that the Veteran was engaged in combat while in service in Vietnam. Where a veteran engaged in combat, satisfactory lay evidence that an injury or disease was incurred in service will be accepted as sufficient proof of service connection where such evidence is consistent with the circumstances, conditions, or hardships of service. 38 U.S.C.A. § 1154(b) (West 2002). Section 1154(b) sets forth a three step sequential analysis that must be undertaken when a combat veteran seeks benefits under the method of proof provided by the statute. First, it must be determined whether the veteran has proffered "satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease." Second, it must be determined whether the proffered evidence is "consistent with the circumstances, conditions, or hardships of such service." Finally, if the first two requirements are met, VA shall accept the veteran's evidence as "sufficient proof of service connection," even if no official record of such incurrence exists. In such a case, a factual presumption arises that the alleged injury or disease is service-connected. Collette v. Brown, 82 F.3d 389, 393 (Fed. Cir. 1996); 38 C.F.R. § 3.304 (2012). Although the Veteran served in combat, he does not contend, nor does the evidence indicate, that hypertension was incurred in combat with the enemy. Hence, the provisions of 38 U.S.C.A. § 1154(b) are inapplicable in this case. Nevertheless, the presumptions of 38 U.S.C.A. § 1154(b) do not extend to the nexus element of a claim of service connection. Wade v. West, 11 Vet. App. 302 (1998); Turpen v. Gober, 10 Vet. App. 536 (1997). The Veteran is competent to report a physician's diagnosis of hypertension as well as a continuity of symptomatology. However, his report must be weighed against the objective evidence of record and its credibility must be assessed. Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. There is no evidence of any complaints of or treatment for hypertension in the Veteran's service treatment records and there were no elevated blood pressure readings (as defined in 38 C.F.R. § 4.104, DC 7101, Note (1)) recorded during service. Further, his November 1973 separation examination was normal and a blood pressure reading of 114/56 was recorded at the time of separation. If a chronic disease, such as hypertension, is shown in service and at any time thereafter, service connection will be conceded. 38 C.F.R. § 3.303(b). There must, however, be sufficient observations in service to identify the disease entity. Id. As discussed above, there is no evidence showing any diagnosed hypertension in service. Hence, service connection cannot be granted on this basis here. The objective evidence otherwise indicates that the Veteran's current hypertension did not manifest until many years after service. The first post-service clinical evidence of possible hypertension is a February 2007 treatment record from Ligon Medical Clinic which includes an elevated blood pressure reading of 150/92. There is no clinical evidence of any earlier hypertension following service. The absence of any evidence of hypertension for over 30 years after service weighs the evidence against a finding that the Veteran's current hypertension was present in service or in the year or years immediately after service. Moreover, the Veteran has provided varying statements as to the history of his hypertension. For example, he contended in his July 2008 claim that hypertension had its inset in 1970 and that he had been treated for the disease from 1970 to 2008. However, his service treatment records include a medical history form dated in September 1973 on which he reported that he was not being treated for, nor had he ever been treated for, high blood pressure. Also, he reported during the February 2011 hearing that he was diagnosed as having hypertension approximately two to two and a half months after he was diagnosed as having diabetes. His medical records, including the October 2008 VA examination report, indicate that diabetes had its onset in 2008. In light of the absence of any objective evidence of complaints of or treatment for hypertension in service or for over three decades after service, the fact that the Veteran's November 1973 separation examination was normal and reflected a blood pressure reading which was within normal limits, and his inconsistent and contradictory statements concerning the history of his hypertension, the Board concludes that his reports concerning the history of his hypertension, including any report of a continuity of symptomatology since service, are not credible. Thus, neither the clinical record nor the lay statements of record establish a continuity of symptomatology in this case, precluding an award of service connection on this basis. The Veteran primarily contends that his hypertension is related to his service-connected diabetes mellitus. In this respect, there are conflicting medical opinions as to whether any such relationship exists. The Board, therefore, must weigh the credibility and probative value of this evidence, and in so doing, may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). The Board must account for the evidence it finds persuasive or unpersuasive and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 29-40 (1994). The October 2008 VA examination report includes an opinion that the Veteran's hypertension was not a complication of his diabetes. This opinion was based on the fact that the hypertension was diagnosed at the same time as the diabetes. The physician who conducted the October 2008 VA examination also opined that the Veteran's hypertension was not worsened or increased by his diabetes. However, no further explanation or reasoning accompanied this opinion. In a March 2010 letter, Melinda Phillips-Freeman MSN, APN, BC opined that the Veteran's hypertension was "a secondary condition of his diabetes mellitus." She reasoned that studies had shown that diabetes and hypertension tend to occur together because they share certain physiological traits. The effects caused by each disease process tend to make the other disease more likely to occur. In the case of diabetes and high blood pressure, these effects include, but are not limited to, increased fluid volume (since diabetes is an inflammatory disease), increased arterial stiffness or atherosclerotic disease, and impaired insulin levels. An increase in the total amount of fluid in the body and the increased arterial stiffness or atherosclerotic disease which is prominent in diabetes patients tends to raise blood pressure. Also, impaired insulin levels can directly cause increases in blood pressure. The May 2011 VA examination report includes an opinion that the Veteran's hypertension was not likely ("less likely as not"/"less than 50/50 probability") caused by or a result of his diabetes mellitus. Although the physician who provided the opinion explained that he did not see any evidence that the Veteran's diabetes caused or aggravated his hypertension, he did not otherwise provide any specific explanation or reasoning for his opinion. In April 2013, a VA physician reviewed the Veteran's claims file (including the March 2010 letter from Melinda Phillips-Freeman) and medical literature and opined that his hypertension was not likely ("less likely than not") caused or aggravated beyond its natural progression by his diabetes. As to causation, the physician reasoned that although diabetes can contribute to atherosclerosis and damage to blood vessel walls, there was no evidence that this in fact resulted in hypertension. The only mechanism by which diabetes is known to cause hypertension is by way of secondary diabetic renal disease. It is by way of adversely affecting renal function that diabetes directly causes an increase in one's blood pressure to a pathologic degree. In this case, there was no evidence that the Veteran had diabetic renal disease, as evidenced by his normal glomelular filtration rate in May 2011. Also, he did not exhibit any other signs of renal dysfunction. With respect to aggravation, the physician explained that the Veteran did not exhibit any signs of diabetic renal disease in 2011. Thus, there was no mechanism by which his diabetes could have aggravated his hypertension. The April 2013 physician also specifically acknowledged the March 2010 opinion given by the Veteran's private treatment provider. He concluded that medical literature and the pathophysiology of hypertension was such that the opinion was inaccurate. The October 2008 opinion that the Veteran's hypertension was not a complication of his diabetes and the March 2010 and April 2013 opinions are all accompanied by specific rationales that are not inconsistent with the evidence of record. Thus, these opinions are entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). It is unclear as to what evidence was reviewed by the medical professional who provided the March 2010 opinion. The April 2013 opinions, however, were explicitly based upon a review of medical literature and the Veteran's medical records and reported history. The physician who provided these opinions specifically acknowledged the March 2010 opinion and explained that medical literature and the pathophysiology of hypertension was such that this opinion was inaccurate. Thus, the Board finds that the April 2013 opinions are more probative than the March 2010 opinion as to whether the Veteran's hypertension is related to his diabetes. Although the October 2008 and May 2011 opinions are of limited probative value because they are not accompanied by any specific explanation or reasoning, they at least support a conclusion that the Veteran's hypertension was not caused or aggravated by his service-connected diabetes. The Veteran has expressed his belief that his hypertension is related to his service-connected diabetes. However, as a lay person, he can only comment as to symptoms and immediately-observable relationships. He lacks the expertise in this case, not involving such an immediately observable cause-and-effect relationship, to conclude that his hypertension is related to his service-connected diabetes, as opposed to some other cause. Rather, it would require medical expertise to evaluate the hypertension, consider all the potential causes, and determine that one was a more likely cause than another. Hence, the Veteran's opinion on this question is not competent evidence. 38 C.F.R. § 3.159(a)(1), (2) (2012). There is no other evidence of a relationship between the Veteran's current hypertension and service (including herbicide exposure in service) or a service-connected disability, and neither the Veteran nor his representative have alluded to the existence of any such evidence. The Board does acknowledge that, in its January 2013 statement, the Veteran's representative referenced medical literature pertaining to a possible relationship between hypertension and diabetes. A copy of such literature was included with the statement. However, generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case, does not provide competent evidence to satisfy the nexus element for an award of service connection. See Sacks v. West, 11 Vet. App. 314 (1998). In this case, no medical professional has specifically related any such information contained in the submitted medical literature to the Veteran. Also, as discussed above, the record fails to demonstrate any credible evidence of a continuity of symptomatology. Thus, the preponderance of the evidence is against a finding that the Veteran's current hypertension is related to service, manifested in service, manifested within a year after his January 1974 separation from service, or was caused or aggravated by a service-connected disability. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim. The benefit-of-the-doubt doctrine is therefore not for application in this case and the claim of service connection for hypertension must be denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57. ORDER Entitlement to service connection for hypertension is denied. REMAND Once the Secretary undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, he must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The February 2012 Joint Motion directed that a new opinion be obtained concerning the etiology of the Veteran's hearing loss. The medical professional providing the opinion was to comment on the evidence of an in-service shift in the Veteran's hearing levels, as evidenced by the differences between the audiometric findings during his August 1969 entrance examination and his November 1973 separation examination. In accordance with the Joint Motion, the Veteran was afforded a VA audiological examination in March 2013 to assess the nature and etiology of his claimed hearing loss. He was diagnosed as having bilateral sensorineural hearing loss as defined by VA. See 38 C.F.R. § 3.385 (2012). The audiologist who conducted the examination opined that the hearing loss was not likely (not "at least as likely as not"/"50 percent probability or greater") caused by or a result of service. She reasoned that the Veteran's hearing remained within normal limits during service. Although the etiology of his hearing loss was unknown, he did have a 27 year history of occupational noise exposure which could have contributed to the hearing loss. The March 2013 opinion is inadequate because it is entirely based on a lack of objective clinical evidence of hearing loss in the Veteran's service treatment records and does not reflect consideration of his reports of noise exposure in service. A medical opinion based solely on the absence of documentation in the record is inadequate and a medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). Moreover, the March 2013 examiner did not comment on the evidence of an in-service shift in the Veteran's hearing levels during service, as directed by the Joint Motion. Thus, a remand is necessary to obtain a new opinion as to the etiology of the Veteran's hearing loss. VA regulations provide that where an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. 38 C.F.R. § 4.2 (2012); see 38 C.F.R. § 19.9 (2012). Where the Board makes a decision based on an examination report which does not contain sufficient detail, remand is required "for compliance with the duty to assist by conducting a thorough and contemporaneous medical examination." Goss v. Brown, 9 Vet. App. 109, 114 (1996); Stanton v. Brown, 5 Vet. App. 563, 569. Accordingly, the case is REMANDED for the following action: 1. Ask the examiner who conducted the March 2013 VA audiological examination to review the claims file, including this remand and any relevant records contained in the Virtual VA system, and provide a new opinion as to the etiology of the Veteran's current bilateral hearing loss. For any current hearing loss identified (i.e. any hearing loss diagnosed since July 2008), the opinion provider shall indicate whether it is at least as likely as not (50 percent probability or more) that the hearing loss had clinical onset in service, had its onset in the year immediately following service (in the case of any sensorineural hearing loss), is related to the Veteran's conceded noise exposure in service, or is otherwise the result of a disease or injury in service. In formulating the above opinion, the opinion provider shall acknowledge and comment on the Veteran's reports of noise exposure in service and the apparent shift in his hearing levels during service as evidenced by the audiometric findings during his August 1969 entrance examination and his November 1973 separation examination. For purposes of the above opinion, the Veteran's reports of noise exposure in service shall be presumed to be accurate. The absence of evidence of treatment for hearing loss in the Veteran's service treatment records or for years after service cannot, standing alone, serve as the basis for a negative opinion. The opinion provider must provide reasons for each opinion given. If the March 2013 examiner is unavailable or otherwise unable to provide the requested opinion, the Veteran shall be afforded a new VA examination to obtain the necessary opinion. 2. If the benefit sought on appeal remains denied, the AOJ shall issue a supplemental statement of the case. After the Veteran is given an opportunity to respond, the case shall be returned to the Board. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). 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 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). ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs