Citation Nr: 1320546 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 09-46 616A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to service connection for left ear hearing loss. 3. Entitlement to service connection for bilateral eye disorder. 4. Entitlement to an initial compensable rating for the service-connected recurrent pruritis with hemorrhoids. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A.M. Ivory, Counsel INTRODUCTION The Veteran had active military service from May 1969 to May 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2009 and June 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. The July 2009 rating decision denied service connection for bilateral hearing loss, a bilateral eye condition, tinnitus, and the reopening the Veteran's claim of entitlement to service connection for a low back injury. During the pendency of the appeal a March 2012 rating decision granted the Veteran service connection for a low back injury with degenerative changes and assigned an initial rating of 20 percent effective January 15, 2009. Also during the pendency of the appeal, a September 2012 rating decision granted the Veteran service connection for tinnitus with an initial 10 percent rating effective January 15, 2009. Thus, the Board finds that the grants of service connection for a low back injury and tinnitus represent full grants of benefits sought on appeal and therefore, those issues are no longer before the Board. The June 2010 rating decision granted the Veteran service connection for recurrent pruritis with hemorrhoids and assigned a noncompensable evaluation effective August 19, 2009. The Board has also conducted a review of the Virtual VA paperless claims processing system with regard to the present appeal. The issues of entitlement to service connection for right ear and left ear hearing loss, and entitlement to an increased rating for are remanded to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran's bilateral eye disorder is not related to his military service. 2. The Veteran's recurrent pruritis with hemorrhoids more nearly approximate mild or moderate hemorrhoids; throughout the appeal period, the Veteran's disability has not been manifested by large or thrombotic haemorrhoids that are irreducible, with excessive redundant tissue, or evidencing frequent recurrences or by persistent bleeding with secondary anemia or fissures. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral eye disorder have not been met. 38 U.S.C.A. § 1110, 1131, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria for an initial compensable evaluation for recurrent pruritis with hemorrhoids have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.10, 4.20, 4.114 including Diagnostic Code 7336 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act (VCAA), codified, in part, at 38 U.S.C.A. § 5103, was signed into law on November 9, 2000. Implementing regulations were created and are codified as amended at 38 C.F.R. § 3.159 (2012). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012). The United States Court of Appeals for Veterans Claims (Court) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a) (West 2002), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The RO sent the Veteran correspondence in February 2009 and December 2009 that complied with the above notice requirements. The letters indicated the types of information and evidence necessary to substantiate the claims, and the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. The February 2009 and December 2009 letters also informed the Veteran of the criteria pertaining to disability rating and effective date elements of his claims. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also Mayfield and Pelegrini, both supra. Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claims at this time. All relevant evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, to the extent possible. The evidence of record includes the Veteran's service treatment records, private treatment reports, VA examinations, and statements from the Veteran and his representative. The Veteran was afforded VA examinations for his claims of entitlement to service connection for a bilateral eye disorder in July 2010 and July 2011. The Board finds that these VA examinations were a thorough and contemporaneous examination of the Veteran that took into account records of service treatment records, contentions by the Veteran, reports of examination upon entrance and separation, and records of post-service examination and treatment. Lineberger v. Brown, 5 Vet. App. 367 (1993); Waddell v. Brown, 5 Vet. App. 454 (1993); Caffrey v. Brown, 6 Vet. App. 377 (1994). The Veteran was afforded VA examination in June 2010 and April 2012 for his service-connected recurrent pruritis with hemorrhoids; the Board finds that these examinations are adequate because the medical findings are stated in terms conforming to the applicable rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994). The Veteran has not indicated that he has any further evidence to submit to VA, or which VA needs to obtain. There is no indication that there exists any additional evidence that has a bearing on this case that has not been obtained. The Veteran and his representative have been accorded ample opportunity to present evidence and argument in support of his appeal. Thus, the Board finds that VA has obtained, and made reasonable efforts to obtain, all evidence that might be relevant to the issues herein decided, and that VA has satisfied the duty to assist. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2012). II. Analysis A. Service Connection for a Bilateral Eye Disorder Service connection may be granted for disability resulting from disease or injury incurred or aggravated during a Veteran's active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 C.F.R. § 3.303(d). Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). When such chronic diseases are at issue, the second and third elements for service connection may be established by showing continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a). Id. 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran asserts that he has a bilateral eye condition that is due to his military service, specifically to an injury during service. However, after a careful review of the Veteran's claims file the Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for a bilateral eye condition. In a May 1969 service treatment report, it was noted that the Veteran had naked 20/20 vision of the bilateral eyes. However, in February 1970, the Veteran was seen at the dispensary for a small scleral hemorrhage. In March 1970, a scleral-conjunctive hemorrhage was noted, and it was stated that light was painful to the left eye, although vision appeared normal. On the Veteran's February 1971 Report of Medical Examination for Separation the Veteran's eyes were evaluated to be normal, and distant vision was noted to be 20/25 bilaterally. An April 1971 service treatment record indicated that the Veteran was struck on the left eye the previous night and that he should be placed on limited duty. There are no service treatment records after this date, but the Veteran indicated in May 1971 that there had been no change in his medical condition since his last separation examination. After service separation, a June 1994 VA examination indicated that his pupils equal, round, react to light; that extraocular movements were intact; and that his eyes were anicteric and negative for fundi. Various treatment reports in 2006 and 2007 from the Veteran's private physician, who was treating the Veteran for low back pain and hypertension, also noted that the eyes were within normal limits. Furthermore, routine review of the eyes and ophthalmic examinations did not reveal any abnormalities in private treatment reports from September 2007 through December 2008. At the Veteran's July 2010 VA examination, it was noted that the Veteran had a history of blunt trauma to the left side of the head and blurred vision since April 1971. He reported that, bilaterally, his eyes felt weak and that he could not keep them open and his visual symptoms were glare, blurring, and impaired night vision; he also felt like his left eye wanted to go to the right. Funduscopic examination findings and slit lamp findings were abnormal, but there was no visual field defect. The Veteran was diagnosed with macular degeneration, not otherwise specified. The associated problem was blurred vision. The VA examiner stated that it was less likely as not that the Veteran's blurred vision was caused by or the result of head trauma, although the examiner stated that damage of this kind was possible from blunt trauma. Because the examiner determined that blunt trauma was a possible cause but failed to explain further, an addendum opinion was sought in July 2011. The examiner concluded that that it was possible, but unlikely, that the Veteran's head trauma caused his claimed condition. As rationale therefore, the examiner explained that there was some maculopathy in each eye, and, in the cases of blunt trauma, it is unlikely that both eyes will be affected. After a careful review of the Veteran's claims file the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a bilateral eye disorder. Although the Veteran was seen during service for an injury to the left eye, no abnormalities were noted upon his separation examination and he expressly denied any change in status in May 1971, following the left eye injury. In addition, post-service private treatment records from 2006 through 2008 all reflected normal findings related to the eye and were without mention of any abnormality or complaints. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment of the claimed condition for many years after service). A layperson is competent to state symptoms that can be observed through the senses. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); (Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). The Board, however, retains the discretion to determine the credibility and weight of all the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). While the Veteran did have an in-service injury, the Board finds his reports of eye-related symptoms since service to lack credibility. As stated above, his contention that he had blurred vision ever since service is inconsistent with the statement he made in May 1971 and the private treatment records after service discharge. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (Credibility can be generally evaluated by a showing of interest, bias, or inconsistent statement, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony). These earlier records were generated with a view towards ascertaining the appellant's then-state of physical fitness and are of increased probative value. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that, although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). The Board therefore finds that the Veteran's lay statements are not credible or probative regarding the onset and etiology of his current bilateral eye disability. The Board finds the July 2011 VA addendum opinion to be highly probative regarding the question of whether the Veteran's eye disability is related to service, and the VA examiner concluded that it was unlikely related to the in-service trauma because he had maculopathy in both eyes and, with the nature of the Veteran's in-service injury, maculopathy would not occur in both eyes. This negative medical opinion is supported by a detailed and adequate rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Consequently, the Board assigns great probative value to the VA examiner's opinion, which is not contradicted by any other probative evidence of record. As a final matter, to the extent that the Veteran has experiences any decrease in visual acuity, congenital or developmental defects, including refractive error of the eye, are not disease or injuries within the meaning of applicable legislation. 38 C.F.R. § 3.303(c). VA regulations specifically prohibit service connection for refractory errors of the eyes unless such defect was subjected to a superimposed disease or injury which created additional disability. See 38 C.F.R. §§ 3.303(c), 4.9; VAOPGCPREC 82-90, 55 Fed. Reg. 45,711 (1990). Therefore, any diminished visual acuity is not subject to service-connection. For all the reasons set forth above, the Board finds that there is no probative evidence of record that relates the Veteran's bilateral eye disability directly to his military service, and the only probative opinion of record is against the Veteran's claim. Thus, service connection for a bilateral eye disorder must be denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a bilateral eye disability. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. B. Increased Rating for Recurrent Pruritis with Hemorrhoids Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. When considering functional impairment caused by a service-connected disorder, evaluations should be based on an assessment of the lack of usefulness, and adjudicators should consider the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath, 1 Vet. App. at 594. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court noted an important distinction between an appeal involving a veteran's disagreement with the initial rating assigned at the time a disability is service connected. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection, and consideration of the appropriateness of "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126. The June 2010 rating decision granted the Veteran service connection for recurrent pruritis with hemorrhoids and assigned an initial noncomepnable rating effective August 19, 2009. The Veteran disagreed with this rating and alleges that he should be provided a compensable rating for recurrent hemorrhoids. The Veteran's service-connected recurrent pruritis with hemorrhoids have been rated under 38 C.F.R. § 4.114, Diagnostic Code 7336, which provides ratings for internal or external hemorrhoids. A noncompensable rating is warranted for mild or moderate hemorrhoids. A 10 percent disability rating is warranted for large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent disability rating is warranted for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. The Board notes that the terms "mild," "moderate" and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. In this case, the Board finds that the Veteran's disability more nearly approximates mild or moderate hemorrhoids. The weight of the evidence does not establish that the Veteran's disability has been manifested by either large or thrombotic haemorrhoids that are irreducible, with excessive redundant tissue, or evidencing frequent recurrences or by persistent bleeding with secondary anemia or fissures. In this regard, at the June 2010 VA examination, the Veteran's symptoms were described as anal itching, burning, difficulty passing stool, pain, and occasional bleeding from the hemorrhoids. Significantly, there was no history of thrombosis, and physical examination revealed a single 3mm hemorrhoid that was reducible. There was no evidence of bleeding, fissures, or excessive redundant tissues. At the April 2012 VA examination, it was specifically stated that the Veteran's hemorrhoids were mild or moderate and were manifested by slight tenderness and erythema noted to the rectal area. The VA examiner specifically did not check the box that stated that they were large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences. Nor did the examiner check the box that indicated that there was persistent bleeding or secondary anemia or fissures. Thus, even contemplating the Veteran's symptoms and statements asserting recurrent hemorrhoids, the evidence does not establish that the Veteran's symptoms more nearly approximate a compensable rating under the diagnostic criteria. The Board recognizes that in exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). It is noted that the Veteran is service connected pruritis, and, in April 2012, it was stated that the Veteran's pain increased upon prolonged sitting and walking when his hemorrhoids were present and he complained of anal itching, burning, pain, and difficulty passing stool, which are not symptoms that are separately and distinctly written within Diagnostic Code 7336. However, these symptoms are nonetheless reasonably encompassed by the rating criteria's contemplation of "mild to moderate" hemorrhoids, and the rating criteria allow for higher ratings when more severe symptomatology is shown, such as when hemorrhoids are irreducible or cause excess bleeding. As the rating criteria reasonably describe the Veteran's disability and symptomatology, the threshold factor for extraschedular consideration under step one of Thun has not been met. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). In addition, the Veteran's disability also has not been shown to have resulted in any loss or inability to maintain gainful employment at any time during the appeal period. Rather, VA examination reports reflect that the Veteran stopped working due to his back. As such, the Board finds that it need not further address whether a total disability based on individual unemployability (TDIU) is established. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In light of the above discussion, the Board finds that a compensable rating is not warranted for the Veteran's service-connected recurrent pruritis with hemorrhoids. As such, the claim is denied. ORDER Service connection for a bilateral eye condition is denied. A compensable rating for the service-connected recurrent pruritis with hemorrhoids is denied. REMAND Although the Board regrets the additional delay, a remand is necessary for the Veteran's remaining claims of right ear and left ear hearing loss to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Right Ear Hearing Loss With regard to the right ear, the Board notes that the VA examiners, especially in the October 2010 examination report and July 2012 addendum, stated that there was "no evidence of threshold shift [] evident from enlistment to separation from the military." However, a review of the Veteran's separation examination notes that the audiometer findings were reported in ASA units. Significantly, the entrance examination is presumed to have been reported using ISO units, as it is a service department record developed after October 31, 1967, and does not state otherwise. Therefore, the Veteran's separation results must also be converted to ISO units. When converted to ISO units, the Veteran's right ear hearing at separation was as follows: 15 decibels at 500 Hertz, 10 decibels at 1000 Hertz, 10 decibels at 2000 Hertz, and 20 decibels at 4000 Hertz. Because the Veteran's hearing appears to have undergone a 10 decibel change at the 500, 2000, and 4000 Hertz levels, and a 5 decibel change at the 1000 Hertz level, an addendum opinion is required to ascertain whether or not this change is of any significance to the etiology of the Veteran's current right ear hearing loss. See Reonal v. Brown, 5 Vet. App. 458, 460 (1993) (a medical opinion based on inaccurate factual premise has no probative value). Left Ear Hearing Loss Every Veteran shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b). A preexisting injury or disease will be considered to have been aggravated by service where there is an increase in disability during such war service, unless there is clear and unmistakable evidence that the increase in disability is due to the natural progress of the condition. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Also, the threshold for normal hearing is between 0 and 20 decibels, and higher threshold shows some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). On the Veteran's September 1968 Report of Medical Examination for Pre-Induction, with a physical inspection in May 1969, it was noted that the Veteran had defective hearing but was fit for military service. The Veteran's audiometry scores for the left ear were 5 decibels at 500 Hertz, 0 decibels at 1000 Hertz, 0 decibels at 2000 Hertz, 5 decibels at 3000 Hertz, and 55 decibels at 4000 Hertz. The Board finds that at the time of the Veteran's entry into his military he had a diagnosis of left ear hearing loss under 38 C.F.R. § 3.385, and it meets the definition of a preexisting condition. Thus, the Veteran had left ear hearing loss disability noted at the time of his entrance into the military. At the Veteran's February 1971 Report of Medical Examination for Separation, his audiometry scores for the left ear, when converted to ISO units, were as follows: 15 decibels at 500 Hertz, 10 decibels at 1000 Hertz, 10 decibels at 2000 Hertz, and 50 decibels at 4000 Hertz. At an October 2010 VA audiology examination, the VA examiner stated that at the time of his enlistment the Veteran had moderate hearing loss at 4000 Hertz in the left ear and at the time of his discharge from the military there was no threshold shift evident. The examiner noted that a brief review of the present audiogram demonstrates bilateral sensorineural hearing loss, possibly consistent with noise exposure; however, due to the stable hearing evident in the left ear at the time of his discharge it would be less likely as not that the hearing loss was the result of his military duty. In July 2012 a VA addendum opinion, the examiner also explained that due to the lack of threshold shift at either ear during his military service, it is less likely as not that the preexisting hearing loss in the left ear was aggravated by the Veteran's military service. However, it appears that neither of these opinions contemplated the separation examination results after they were converted to ISO units. See Reonal v. Brown, 5 Vet. App. 458, 460 (1993) (a medical opinion based on inaccurate factual premise has no probative value). Moreover, given the application of 38 U.S.C.A. § 1153 in this case and consideration of the presumption of soundness doctrine, a medical opinion is necessary to determine whether the Veteran's preexisting left ear disability underwent a permanent increase in service and, if so, whether clear and unmistakable evidence exists that any such increase was due to the natural progress of the disease. Accordingly, the case is REMANDED for the following actions: 1. Obtain and associate with the claims file all updated VA, and private treatment records with any necessary authorization from the Veteran, that are relevant to the Veteran's claims for service connection for right ear and left ear hearing loss. 2. Return the claims file, to include a copy of this remand, to the VA examiner who provided the July 2012 VA addendum opinion in order to provide an additional addendum opinion on the Veteran's right ear and left ear hearing loss. The entire claims file must be made available to the examiner for review. If necessary, all appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. The VA examiner should answer all of the following questions: A) Is it at least as likely as not that the Veteran's current right ear hearing loss is related to service? In responding to this question, the examiner must discuss ISO-converted units of the Veteran's separation audiology report reflecting an increase at all reported threshold levels for the right ear. B) Is it as least as likely as not that the Veteran's left ear hearing loss permantly increased during his active duty service? In responding to this question, the examiner must discuss ISO-converted units of the Veteran's separation audiology report reflecting an increase at the 500, 1000, and 2000 Hertz levels for the left ear. C) If so, was the left ear hearing loss CLEARLY AND UNMISTAKABLY aggravated beyond its natural progression by his military service? Any opinions expressed must be accompanied by a complete rationale. If an opinion cannot be given without resorting to mere speculation than the VA examiner must state so and further provide a reason for such conclusion. If the July 2012 VA examiner is unavailable, another qualified examiner should be requested to provide the same opinion. If a new VA examination needs to be conducted in order to obtain such an opinion, then one should be scheduled. Following a review of the relevant evidence in the claims folder and the clinical evaluation, the new examiner should answer the above questions. 3. The RO should review the claims file to ensure that all the foregoing requested development is completed, and, thereafter, arrange for any additional development indicated. The RO should then readjudicate the remaining claims on appeal. If any benefit sought remains denied, the RO should issue an appropriate SSOC (Supplemental Statement of the Case) and provide the Veteran and his representative the requisite time period to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. No action is required of the appellant unless he is notified. The purposes of this remand are to ensure notice is complete, and to assist the Veteran with the development of his claims. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the appellant until further notice. The Board takes this opportunity to advise the appellant 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 remaining claim. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The appellant is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. 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). ______________________________________________ K. GIELOW Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs