Citation Nr: 1320904 Decision Date: 06/28/13 Archive Date: 07/05/13 DOCKET NO. 09-48 717 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for a bilateral eye disorder (claimed as decreased vision) 2. Entitlement to service connection for headaches. 3. Entitlement to service connection for a back disorder. 4. Entitlement to service connection for sterility and erectile dysfunction. 5. Entitlement to service connection for hypertension. 6. Entitlement to service connection for a skin disorder, including rashes and growths. 7. Entitlement to service connection for nail fungus in the bilateral hands and feet. 8. Entitlement to service connection for recurrent hemorrhoids. 9. Entitlement to service connection for bilateral hearing loss. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD L. Crohe, Counsel INTRODUCTION The Veteran served on active duty from November 1967 to November 1969 with combat service in Vietnam. The Veteran was awarded the Combat Infantryman Badge, the National Defense Service Medal, Vietnam Service Medal with two Bronze Stars, and the Vietnam Campaign Medal with a 60 Device and two Overseas Service Bars. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, MD, which denied service connection for a back condition, nail fungus of the bilateral hands and feet, post traumatic stress disorder (PTSD), skin growths and rashes, sleep disturbances to include sleep walking, sterility and erectile dysfunction, bilateral hearing loss, chronic headaches, decreased vision, depression, recurrent hemorrhoids, and hypertension. The Veteran perfected his appeal regarding all issues, however, in March 2011, the RO granted service connection for PTSD (claimed as PTSD, depression, and sleep disturbance to include sleep walking) and assigned a 50 percent disability rating, effective February 4, 2008. As this is a full grant of the benefits sought this matter is no longer on appeal. The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The issues of entitlement to service connection for headaches, bilateral hearing loss, a back disorder, sterility and erectile dysfunction, hypertension, skin rashes and growths, nail fungus, and hemorrhoids are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT The evidence of record is against a finding that that the Veteran's reports of decreased vision of either eye was subjected to a superimposed disease or injury while on active duty which created additional disability or that any current bilateral eye disorder, beyond a refractive error, such as conjunctivitis is due to his military service. CONCLUSION OF LAW Bilateral eye disabilities were not incurred or aggravated during military service. 38 U.S.C.A. §§ 1110, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 4.9 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and 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 the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, a section 5103(a) notice should also advise a claimant of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, required notice was provided by a letter dated in April 2008, which informed the Veteran of all the elements required by the Pelegrini II Court as stated above. The letter also informed the Veteran how disability ratings and effective dates were established. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service treatment records (STRs) and private treatment records have been obtained. The record does not suggest nor has it been alleged by the Veteran that there are missing pertinent treatment records. Therefore, there is no prejudice to the Veteran is adjudicating his eye claim at this time. Additionally, the Veteran was offered the opportunity to testify at a hearing before the Board, but he declined. While a VA medical opinion was not provided in this case, the Federal Circuit Court of Appeals (Federal Circuit) has recognized that there is not a duty to provide an examination in every case. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Rather, the Secretary's obligation under 38 U.S.C. § 5103A(d) to provide the Veteran with a medical examination or to obtain a medical opinion is not triggered unless there is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability. See McLendon v. Nicholson, 20 Vet. App.79, 81 (2006). The record in this case is negative for any indication, other than the Veteran's own assertion that he has a chronic eye disability, and he has only alleged that he has decreased vision, which is considered a congenital or developmental defect not subject to service connection. As such, the Veteran's lay statements are insufficient to trigger VA's duty to provide an examination with an opinion. See Waters, 601 F.3d 1274. VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. II. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a Veteran must show: "(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"--the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even in cases where the disability resolves prior to the Secretary's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321-323 (2007). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002). The Veteran filed for service connection for a "decreased vision" in February 2008. However, he didn't claim that he had any other chronic eye condition beyond a refractive error. He provided no explanation as to why he felt that he had a chronic eye disability that either began during or was otherwise caused by his military service. In regards to the Veteran's complaints of decreased vision, the Board notes that a refractive error is considered a congenital or developmental defect not subject to service connection. In this regard, for purposes of entitlement to benefits, the law provides that refractive errors of the eyes are developmental defects, and that congenital or developmental defects are not disease or injury within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9. In the absence of superimposed disease or injury, service connection may not be allowed for congenital or developmental defects, including refractive error of the eyes, even if visual acuity decreased in service, as this is not a disease or injury within the meaning of applicable legislation relating to service connection. That is, VA regulations specifically prohibit service connection for congenital or developmental defects, including refractory errors of the eyes, unless such defect was subjected to a superimposed disease or injury that created additional disability. See 38 C.F.R. § 3.303(c); VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury); Carpenter v. Brown , 8 Vet. App. 240, 245 (1995); Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993)). No aggravation or trauma has been alleged in this case. Service treatment records include a November 1967 entrance Report of Medical History, on which the Veteran indicated that he had eye trouble and was color blind. He reported that he did not wear glasses or contact lenses. November 1967 entrance and August 1969 separation Reports of Medical Examinations showed on clinical evaluations that his eyes were normal and his distant vision as 20/20, bilaterally on both examinations. On August 1969 separation Report of Medical History, he indicated that he was not color blind and did not wear glasses or contact lenses. The separation report noted that the Veteran had a head injury in an automobile accident in the Republic of Vietnam with a loss of memory. However, no eye related symptoms were reported in conjunction with the automobile accident or at any point in the Veteran's service. Initially, the Board notes that the service treatment records are negative for any superimposed injury or disease to either eye. Additionally, neither the Veteran nor his representative have presented any lay assertions regarding additional disability due to a disease or an injury in service. The Board notes that the Veteran's uncorrected vision remained within normal limits at 20/20 during his entire military service. Furthermore, the Board finds these negative service treatment records more competent and credible than any lay claims that may be found in the record regarding an eye condition manifested by decreased vision that began in service. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact). The Board has considered the Veteran's complaints of decreased vision, however, the post-service record is negative for any complaints, treatment, or diagnoses related to decreased vision. See McClain, supra. The post-service record is also negative for a medical opinion linking any decreased vision of either eye to an established injury, disease, or event of service origin. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(d) ; Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992) (establishing service connection requires finding a relationship between a current disability and events in service or an injury or disease incurred therein). Therefore, the Board finds that service connection for decreased vision due to a refractive error of the eyes may not be granted based on a superimposed disease or injury causing additional disability under VAOPGCPREC 82-90. As to service connection for all other chronic eye disorders, beyond any refractive errors, the post-service record is negative for diagnoses of chronic disorders in either eye until the Veteran was seen for complaints of redness in the left eye with a diagnosis of conjunctivitis of the left eye in August 2004, approximately 35 years since his discharge from service. He was seen again in May 2005 with complaints of redness in his eye and a diagnosis of right eye conjunctivitis. In this regard, evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). As previously noted, the service treatment records are negative for a diagnosis of right and/or left eye disorders, including conjunctivitis. Furthermore, the record is negative for a medical opinion linking the Veteran's post-service eye condition, including conjunctivitis to an established injury, disease, or event of service origin while on active duty. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(d); Rabideau, supra. Beyond the Veteran's reports of having decreased vision, the Board notes that neither the Veteran nor his representative have alleged that the Veteran has an eye disability, including conjunctivitis that is related to service or that he has redness in the eyes or other symptoms since service. Therefore, the Board finds that entitlement to service connection for a chronic eye disorder, other than decreased vision/refractive error, must also be denied. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303; Rabideau, supra. In reaching the above conclusion, the Board also considered the doctrine of reasonable doubt. 8 U.S.C.A. § 5107(b). However, as the preponderance of the evidence is against the claim, the doctrine is not for application. See also, e.g., Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, Veteran's claim is denied. ORDER Service connection for a bilateral eye disorder is denied. REMAND The Veteran served in Vietnam and is presumed to have been exposed to herbicides, including Agent Orange. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307. Headaches Post service private treatment records dated in May 2005 included an assessment of headaches. A December 2009 record noted that the Veteran was initially seen in February 1998 for headaches. Thus, the Veteran has current signs and symptoms of headaches. The Veteran's service treatment records reflect that his headaches pre-existed service. On November 1967 entrance Report of Medical History, the Veteran indicted that he had frequent or severe headaches; dizziness or fainting spells; ear, nose, or throat trouble, but denied hearing loss. The physician noted that the Veteran had occasional headaches and dizziness; he was struck on the top of his head. In November 1967, he was referred to the surgical clinic due to a 2 cm cystic lesion with a keratotic center on his scalp. The record noted that he had headaches related to the cyst on his head. In October 1968, he had complaints of headaches and light headedness along with chills, appetite loss, and abdominal cramps. The impression was probable parasite infestation. A history of frequent cephalgia controlled with prescription drugs was noted on August 1969 separation Report of Medical History. The record noted that he had a history of dizziness while he was in the Republic of Vietnam for which he was treated for gastrointestinal parasites. He was in an automobile accident as a child without sequelae other than cephalalgia. He had a head injury in an automobile accident in the Republic of Vietnam with a loss of memory for two hours. On November 1969 Statement of Medical Condition, the Veteran reported that his headaches had changed. Because the headaches were identified when the Veteran was accepted for service, the presumption of soundness at service entrance is not for application. 38 U.S.C.A. §§ 1111, 1137 (West 2002). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. §§ 1153, 1137 (West 2002); 38 C.F.R. § 3.306(a) (2012). 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. §§ 3.304, 3.306(b) (2012). The question of whether the Veteran's pre-existing headache disorder was aggravated in service is a complex medical question that requires a medical opinion; hence a VA examination is indicated. Back Disorder, Sterility and Erectile Dysfunction, Hypertension, Skin Rashes and Growths, Nail Fungus, and Hemorrhoids Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, at 83. Service treatment records (STRs) include a November 1967 entrance Report of Medical examination that documented the Veteran's blood pressure as 114/72. A November 1967 treatment record showed that he was referred to the surgical clinic due to a 2 cm cystic lesion with a keratotic center on his scalp. He was diagnosed with squamous papilloma (benign) with chronic inflammation. In September 1968, he was treated for contact dermatitis of the foreskin. On August 1969 separation Reports of Medical History, the physician noted that the Veteran had hemorrhoids in 1967 that were controlled with prescription drugs. On August 1969 separation Report of Medical Examination, his blood pressure was 132/80. Overall, the STRs reflect an increase in the Veteran's blood pressure and treatment for skin conditions and hemorrhoids. Post service private treatment records reflect treatment for back pain and degenerative disc disease and arthritis of the lumbar spine, erectile dysfunction, hypertension, skin rash in his fingers/hands, toe nail fungus, and a fungal infection of his finger nails. Thus the Veteran has current signs and symptoms of a back condition, erectile dysfunction, hypertension, skin rashes and nail fungus. The Board notes that the record is not clear as to whether or not the Veteran has recurrent hemorrhoids and his service treatment records did not document any complaints or treatment related to sterility, erectile dysfunction, or his back. However, on his February 2008 claim, the Veteran indicated that his back disorder, sterility and erectile dysfunction, hypertension, recurrent hemorrhoids, skin rashes and growths, as well as his nail fungus disorders began in 1968, during active duty, and have continued since that time. These statements along with the evidence trigger VA's duty to provide an examination. An examination is needed to determine whether the current disabilities began in service, or are otherwise related service, including Agent Orange exposure. Bilateral Hearing Loss The Veteran contends that he his bilateral hearing loss began in service and has continued since that time. In a May 2013 Informal Hearing Presentation, the Veteran's representative indicated that the Veteran was exposed to acoustic trauma related to arms fire as well as combat. A review of the Veteran's November 1967 entrance examination and August 1969 separation examination suggest that the Veteran's hearing acuity decreased during service. A head injury in an automobile accident in the Republic of Vietnam with a loss of memory for two hours was also noted on August 1969 separation Reports of Medical History. Additionally, his DD Form 214 shows that he was awarded the Marksman (M-16), and Expert (M-14) Ribbon/Badge. He was also awarded the Combat Infantryman Badge (CIB) for his combat service in the Republic of Vietnam. While the medical record does not document a current hearing loss disability, the Veteran has indicated that he had bilateral hearing loss since service. He is competent to testify as to observable symptoms such as decreased hearing, and hearing loss is the type of disorder associated with symptoms capable of lay observation. Charles v. Principi, 16 Vet. App. 370 (2002); Falzone v. Brown, 8 Vet. App. 398, 403 (1995). In this case, the Veteran has not been afforded a VA examination in connection with his claimed bilateral hearing loss. In light of the Veteran's combat exposure, as well as some indication of current hearing loss, there remains some question as to whether the Veteran has a current hearing loss disability and, if so, is it attributable to his period of active military service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, an examination and opinion are necessary prior to final appellate review. See Charles v. Principi, 16 Vet. App. 370 (2002). The Veteran is hereby advised that failure to report for any scheduled examination, without good cause, may well result in denial of the claim (as the original claim for service connection will be considered on the basis of the evidence of record). See 38 C.F.R. § 3.655 (2012). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. If the Veteran fails to report to a scheduled examination, the RO should obtain and associate with the claims file a copy(ies) of the notice(s) of the examination sent to him by the pertinent VA medical facility. While the matter is on remand, to ensure that all due process requirements are met, and that the record before the physician is complete, the RO/AMC should also give the Veteran another opportunity to provide information and/or evidence pertinent to the claim on appeal. The RO/AMC's letter to the Veteran should explain that he has a full one-year period for response. See 38 U.S.C.A. § 5103(b)(1) (West 2002); but see also 38 U.S.C.A. § 5103(b)(3) (West Supp. 2012) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). Thereafter, the RO should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159 (2012). The actions identified herein are consistent with the duties imposed by the Veterans Claim Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). However, identification of specific actions requested on remand does not relieve the RO/AMC of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the RO/AMC should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claim on appeal. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization to enable it to obtain any additional evidence pertinent to the claim on appeal that is not currently of record. The RO/AMC should also clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 2. If the Veteran responds, the RO/AMC should assist him in obtaining any additional evidence identified by following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, the RO/AMC should notify the Veteran and his representative of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 2. After all records and/or responses received from each contacted entity have been associated with the claims file, schedule the Veteran for an appropriate VA examination or examinations in order to determine whether his headaches were aggravated by service. The claims file, including this remand and any relevant records in Virtual VA must be made available to and be reviewed by the examiner; consideration of such should be reflected in the completed examination report or in an addendum. All tests deemed necessary should be conducted and the results reported in detail. The examiner should opine whether it is at least as likely as not (50 percent probability or more) that the Veteran's headache disorder was aggravated by service. If the Veteran's headache disorder was aggravated during service, the examiner should also opine as to whether the increase in the disability was the result of the natural progression of the disease. The examiner should comment on the service treatment records that document reports of headaches related to a cyst on the scalp, and a probable parasitic infection. Additionally, on August 1969 separation Report of Medical History, a physician noted that the Veteran had a history of dizziness while he was in the Republic of Vietnam for which he was treated for gastrointestinal parasites. He had a head injury in an automobile accident in the Republic of Vietnam with a loss of memory for two hours. On November 1969 Statement of Medical Condition, the Veteran reported that his headaches had changed. The examiner must provide a rationale for each opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered in formulating any opinions. 3. After all records and/or responses received from each contacted entity have been associated with the claims file, schedule the Veteran for an appropriate VA examination or examinations in order to determine whether his hypertension, back disorder, sterility and erectile dysfunction, hemorrhoids, skin disorder and nail fungus are related to service, including Agent Orange exposure, or were caused or aggravated by a service-connected disability. The claims file, including this remand and any relevant records in Virtual VA must be made available to and be reviewed by the examiner; consideration of such should be reflected in the completed examination report or in an addendum. All tests deemed necessary should be conducted and the results reported in detail. Following review of the claims file and examination of the Veteran, the examiner should identify all hypertensive, back, sterility and erectile dysfunction, hemorrhoids, skin, and nail fungus disorders found. The examiner should opine: a) whether it is at least as likely as not (50 percent probability or more) that any hypertensive, back, sterility and erectile dysfunction, hemorrhoids, skin, and nail fungus disorders identified began in service or are related to service, including Agent Orange exposure. In regards to hypertension, the examiner should specifically comment on the increased blood pressure readings from his entrance examination in November 1967 (reported as 114/72) to his separation examination in August 1969 (reported as 132/80). In regards to any skin disorder and nail fungus, the examiner should specifically comment on the documented in-service treatment 2 cm cystic lesion with a keratotic center on the Veteran's scalp diagnosed as squamous papilloma (benign) with chronic inflammation and contact dermatitis of the foreskin. In regards to any recurrent hemorrhoids, the examiner should specifically comment on the August 1969 separation Reports of Medical History, in which a physician noted that the Veteran had hemorrhoids in 1967 that were controlled with prescription drugs. The absence of evidence of treatment in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. b) If the examiner finds that the Veteran's hypertensive, back, sterility and erectile dysfunction, recurrent hemorrhoids, skin, and nail fungus disorders are not related to service, including Agent Orange exposure, the examiner should also opine as to whether it is at least as likely as not (50 percent probability or more) that the disabilities are caused or aggravated by a service-connected disability (the Veteran is currently service-connected for PTSD with depression, and sleep disturbance). c) If aggravation is shown, the examiner should comment on any evidence of record created prior to the aggravation that shows a baseline of the disabilities prior to the aggravation. The examiner must provide a rationale for each opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered in formulating any opinions. If the examiner rejects the Veteran's reports, the examiner should provide a reason for doing so. 4. After all records and/or responses received from each contacted entity have been associated with the claims file, schedule the Veteran for a VA audiological examination to determine whether he has bilateral hearing loss and whether it is the result of a disease or injury in service. The claims file and any relevant records in Virtual VA must be made available to the examiner for review. After examining the Veteran and reviewing the claims file, the examiner should opine whether it is at least as likely as not (a 50 percent or higher degree of probability) that any current hearing loss began in service or is otherwise related to service, including combat noise exposure and arms fire during service. The occurrence of the noise exposure and symptoms reported by the Veteran should be presumed. The examiner should also comment on any change in the Veteran's hearing acuity from the November 1967 entrance examination and the August 1969 separation examination. The examiner should provide reasons for the opinions that take into account the Veteran's reports of in-service injuries and symptoms and symptoms since service. The absence of supporting treatment records is not a sufficient reason, by itself, for rejecting the Veteran's reports. 5. The Agency of Original Jurisdiction (AOJ) should review the examination reports to ensure that they contain the information requested in this remand and are otherwise complete. 6. If any benefit on appeal remains denied, the AOJ a Supplemental Statement of the Case should be issued to the Veteran and his representative. The requisite period of time for a response should be afforded. Thereafter, the case should be returned to the Board for further appellate action, if otherwise in order. 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' United States Court of Appeals for Veterans Claims for additional development or other Appeals or by the Un appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ J.A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs