Citation Nr: 1321082 Decision Date: 07/01/13 Archive Date: 07/12/13 DOCKET NO. 13-11 543 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from August 1959 to August 1962. This appeal to the Board of Veterans' Appeals (Board) is from a November 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which denied the Veteran's claims of entitlement to service connection for hearing loss and tinnitus. The Board also sees that, in another decision since issued in April 2012, the RO also denied service connection for posttraumatic stress disorder (PTSD), frostbite of the ears, and frostbite of the hands. In response the Veteran filed a timely notice of disagreement (NOD) with that decision denying these other claims and resultantly was provided a statement of the case (SOC) in May 2013. He has not however since filed a substantive appeal (VA Form 9 or equivalent statement) to complete the steps necessary to perfect his appeal of these other claims to the Board. See 38 C.F.R. § 20.200 (2012) (an appeal to the Board consists of a timely filed NOD in writing and, after issuance of an SOC, a timely filed substantive appeal (VA Form 9 or equivalent statement)). As such, the only claims currently on appeal concern whether he is entitled to service connection for hearing loss and tinnitus. The Board also has reviewed the Veteran's electronic ("Virtual VA") file and found that it contains additional medical evidence, but that has been considered by the RO in the March 2013 SOC. Therefore, the Board's consideration of this evidence will not prejudice the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). As a final preliminary matter, the Board notes that the claims file reflects that the Veteran previously was represented by Disabled American Veterans (DAV), as reflected in a November 2011 VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative. But in February 2012, he filed another VA Form 21-22 instead appointing the Florida Department of Veterans Affairs as his representative. In September 2012, he filed yet another VA Form 21-22, this time designating the Veterans of Foreign Wars of the U. S. as his representative. Even more recently, in December 2012, he filed still another VA Form 21-22 naming the American Legion as his representative. Only one organization, representative, agent, or attorney will be recognized at one time in the prosecution of a particular claim, with a few noted exceptions not shown to apply here. 38 C.F.R. § 14.631(e)(1). A power of attorney may be revoked at any time, and unless specifically noted otherwise, receipt of a new power of attorney constitutes a revocation of an existing power of attorney. 38 C.F.R. § 14.631(f)(1). The Board therefore is recognizing this continual change in representation, with the most recent designation in favor of The American Legion. Please also note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate these claims at issue in this appeal has been accomplished. 2. It is as likely as not the Veteran's bilateral hearing loss is the result of his military service, in particular, his repeated exposure to excessively loud noise while in service and consequent injury (i.e., acoustic trauma). 3. His tinnitus is related to his bilateral hearing loss, so also in turn the result of his military service and the acoustic trauma mentioned. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in his favor, the Veteran's bilateral hearing loss is due to injury incurred during his active military service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2012). 2. Resolving all reasonable doubt in his favor, the Veteran's tinnitus is secondary to his service-connected bilateral hearing loss. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In deciding these claims, the Board has reviewed all of the evidence in the Veteran's claims file and Virtual VA electronic folder (e-folder). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss in exhaustive detail each and every piece of evidence submitted by him or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below therefore focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, as regarding his claims. He must not assume the Board has overlooked any pieces of evidence that are not explicitly discussed. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to him). The Board must assess the credibility and weight of all evidence, so both the medical and lay evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive and providing reasons for rejecting any evidence favorable to the Veteran. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, meaning about evenly balanced for and against the claim, with the Veteran prevailing in either event, or whether instead the preponderance of the evidence is against the claim, in which case the claim is denied. Id. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court/CAVC) held that the VCAA notice requirements apply to all elements of a service-connection claim: 1) Veteran status, 2) existence of a disability, 3) a connection between the disability and service, but also the "downstream" 4) disability rating and 5) effective date. Here, though, given the entirely favorable disposition of these claims on appeal, that is, the granting of them in full, the Board need not discuss whether there has been compliance with these duty-to-notify-and-assist obligations. The Board also sees that the March 2013 SOC makes references to an audiology consultation supposedly dated on February 8, 2011 in the Veteran's Virtual VA file. The SOC states the examiner noted that the results of the Veteran's speech recognition testing were inconsistent with his pure tone average. While a February 8, 2011 VA primary care clinic note indicates he was to be scheduled for an audiology consultation, there is no such consultation as described in the SOC in either the paper claims file or the electronic ("Virtual VA") file. In any event, as will be discussed below, the evidence of record sufficiently demonstrates that service connection for bilateral hearing loss and tinnitus is warranted. So the absence of this evidence from the file ultimately is inconsequential and, thus, at most what amounts to harmless error. 38 C.F.R. § 20.1102 (2012). Factual Background and Analysis The Veteran contends that he has current hearing loss and tinnitus disabilities because of repeated exposure to excessively loud noise and consequent injury (acoustic trauma) during his military service. Service connection is granted for disability resulting from personal injury sustained or disease contracted in the line of duty during active military service, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Service connection may be granted for any disease diagnosed after discharge from service when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). A three-element test must be satisfied in order to establish entitlement to direct service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service - the "nexus" requirement. Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases - namely those listed in 38 C.F.R. § 3.309(a) - benefit from a somewhat more relaxed evidentiary standard. See Walker, 708 F.3d at 1339 (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Walker, 708 F.3d at 1338. Thus, if the claimant does not have one of the chronic diseases specifically enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and the "nexus" requirement of the three-element test must be met. Id., at 1338-39. By regulation, sensorineural hearing loss is subject to service connection based on continuity of symptomatology as an "organic disease of the nervous system". Moreover, VBA's M21-1MR has a section titled "Determining Impaired Hearing as a Disability," which includes the following note: "Sensorineural hearing loss is considered an organic disease of the nervous system and is subject to presumptive service connection under 38 CFR 3.309(a)." M21-1MR III.iv.4.B.12.a. Tinnitus, on the other hand, is not a condition identified in § 3.309(a) as chronic, per se, so resultantly is not subject to this alternative continuity of symptomatology proof and pleading exception provided by § 3.303(b). Still, tinnitus is defined as "a noise in the ear, such as ringing, buzzing, roaring, or clicking." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1956 (31st ed. 2007). So by its very nature, tinnitus is an inherently subjective condition. Therefore, the Veteran is competent even as a layman to make this proclamation of continuous tinnitus since service. See Charles v. Principi, 16 Vet. App. 370 (2002) ("ringing in the ears is capable of lay observation"). So service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Also, because sensorineural hearing loss is a chronic disease, per se, it would be entitled to presumptive service connection if manifested to a degree of 10 percent or more within one year of the Veteran's separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a), (b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Medical evidence is generally, though not always, required to associate the claimed condition with the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Velez v. West, 11 Vet. App. 148, 158 (1998); McQueen v. West, 13 Vet. App. 237 (1999). The Court has held that, when aggravation of a nonservice-connected condition is proximately due to or the result of a service-connected condition the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. See Allen v. Brown, 7 Vet. App. 439 (1995). The pertinent regulation states that any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. VA will not however concede a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. See 38 C.F.R. § 3.310(b). As specifically concerning claims of entitlement to service connection for hearing loss, the threshold for normal hearing is from 0 to 20 decibels; higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993) (citing Current Medical Diagnosis & Treatment, Stephen A. Schroeder, et. al. eds., at 110-11 (1988)). But before service connection may be granted for hearing loss, it must be of a particular level of severity. For purposes of applying the laws administered by VA, impaired hearing only will be considered a ratable disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory threshold for at least three of these frequencies 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. The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is "credible", or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether the evidence also is credible). Only if evidence is both competent and credible does it ultimately have probative value. See Layno v. Brown, 6 Vet. App. 465 (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")); Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In certain instances, lay evidence has been found competent with regards to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons equally have been found not competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). Competent medical evidence, as opposed to lay evidence, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza at 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). Considering the pertinent evidence of record in light of the above-noted legal authority, and resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection is warranted for his bilateral hearing loss and tinnitus. His service treatment records (STRs) are unremarkable for complaints regarding or treatment for either hearing loss or tinnitus. In his Report of Medical History at time of enlistment in August 1959, he denied any ear, nose, or throat trouble. On objective physical examination, clinical evaluation of his ears was normal and his hearing was 15/15, so normal, when considering whispered and spoken voice. Audiometric testing was not performed, however, that more comprehensive testing was performed later that same month. Prior to November 1967, service departments used American Standards Association (ASA) units to record puretone sensitivity thresholds in audiometric measurement. Beginning in November 1967, service departments used ISO (ANSI) units. For purposes of comparison, the tables below show the ASA measurements as recorded on examinations dated prior to November 1967, with the comparable ISO (ANSI) measurements in adjacent parentheses. On examination in August 1959, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 For ISO add (+15) (+10) (+10) (+10) (+5) RIGHT 0 (15) 0 (10) 0 (10) 0 (10) 0 (5) LEFT 0 (15) 0 (10) 0 (10) 0 (10) 5 (10) In his later Report of Medical History at time of separation in June 1962, the Veteran again denied any ear, nose, or throat trouble. On objective physical examination, clinical evaluation of his ears again was normal. His pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 For ISO add (+15) (+10) (+10) (+10) (+5) RIGHT 5 (20) 5 (15) 5 (15) Not tested 5 (10) LEFT 5 (20) 5 (15) 5 (15) Not tested 5 (10) While there is no suggestion of hearing loss at any time during his service, the mere absence of evidence of hearing loss in service is not altogether fatal to a claim for this disability. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability (i.e., one meeting the requirements of 38 C.F.R. § 3.385) and a medically sound basis for attributing this disability to service may serve as a basis for granting service connection for hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Likewise, service connection may be granted for tinnitus or other disability diagnosed after service upon a showing of a medical nexus between the disability and injury (including the type of noise exposure claimed) or disease in service. See, e.g., 38 C.F.R. § 3.303(d). The Veteran had a VA audiology examination in October 2010. He gave a history of in-service noise exposure to tank guns (with "40 guns firing on the line"). He reported that hearing protection devices were provided, but were not very effective. He denied occupational or recreational noise exposure to this extent as a civilian. He also reported experiencing recurrent (intermittent) tinnitus since service. Audiometric testing revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 35 45 40 LEFT 30 30 50 55 55 His speech recognition scores using the Maryland CNC Word List were 82 percent in the right ear and 74 percent in the left ear. The diagnosis was bilateral sensorineural hearing loss and tinnitus. The examiner opined that the tinnitus was at least as likely as not a symptom associated with the Veteran's hearing loss. The examiner acknowledged review of the claims file and noted that the Veteran had normal hearing at separation from service. She also acknowledged military acoustic trauma. However, she opined that the Veteran's hearing loss and tinnitus were not caused by or a result of his military acoustic trauma. In providing a rationale for her opinion, she observed that his hearing was "well within normal limits" at the time of separation from service. She added that there was no evidence in the medical literature to support a delayed onset of noise-induced hearing loss. The October 2010 audiometric testing results clearly establish bilateral hearing loss disability as defined by VA regulation, that is, in 38 C.F.R. § 3.385, and the examiner's diagnosis additionally included tinnitus. But aside from that, the Veteran is competent even as a layman to describe the effects of tinnitus. See Charles v. Principi, 16 Vet. App. 370 (2002). The Board also finds his report of current tinnitus to be credible, so ultimately probative. His VA treatment records also reflect findings of hearing loss. Thus, the first element of each service-connection claim is satisfied. Walker, 708 F.3d at 1333. The question remains, however, as to whether there exists a correlation between his current bilateral hearing loss and/or tinnitus and the noise exposure that he concededly had while in service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). While as mentioned his STRs do not document the occurrence of, or treatment for, any specific incident of acoustic trauma, he is competent to assert the occurrence of relevant injury in service, including in this manner, since this is a by-product of his firsthand knowledge of a factual matter. See Washington v. Nicholson, 19 Vet. App. 363 (2005). Specifically, in his August 2010 claim of entitlement to service connection, he reported being exposed to hazardous noise in service as a tank crewman, and he alleged the constant firing of the tank's gun had caused or contributed to his present-day hearing loss. Even the October 2010 VA compensation examiner seems to accept that the Veteran experienced this type of noise exposure during his military service, although she then proceeds to rely entirely on the absence of any subsequent indication of hearing loss or tinnitus in service, as reflected in the STRs, as reason for concluding against the claim. But see Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury and instead relied entirely on the absence of evidence in the STRs to provide a negative opinion). Stated differently, the reasoning for this opinion improperly relies merely on the absence of corroborating medical evidence, such as would be reflected in accompanying treatment records such as STRs, in determining there is no nexus between the Veteran's current disability and his military service, without addressing competent evidence of continuity of symptomatology since the injury in service. Id; see also Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991) (emphasizing that "symptoms, not treatment [for them], are the essence of any evidence of continuity of symptomatology"). The Veteran's DD Form 214 reflects that his military occupational specialty (MOS) was armor crewman and that his military decorations, medals, badges, commendations, citations, and campaign ribbons include first class gunner (tank weapon), expert (rifle), and sharpshooter (pistol). His service personnel records (SPRs) reflect that his principal duties in service included being a tank driver, gunner, and security guard. In light of this confirmatory evidence, the Board, like also apparently the VA compensation examiner, accepts the Veteran's assertions of noise exposure in service in this capacity as both competent and credible and consistent with the circumstances, conditions, and hardships of his service. See 38 U.S.C.A. § 1154(a). The Board also acknowledges that the Veteran has, as he is competent to do, described a continuity of symptomatology of hearing loss and tinnitus since service. See again Charles v. Principi, 16 Vet. App. 370 (2002). Specifically, he stated in his April 2013 substantive appeal (on VA Form 9) that he had had hearing loss and tinnitus ever since his acoustic trauma in service as a tank gunner. The credibility of this report of continuity of symptomatology since the noise trauma in service is somewhat questionable, owing to the fact that in the interim he denied ear trouble in his June 1962 Report of Medical History and, during VA treatment in May 2000, denied a history of disease involving his ears. 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. Rucker v. Brown, 10 Vet. App. 67, 73 (1997). That notwithstanding, he has submitted medical evidence supporting his claim for service connection for bilateral hearing loss. In a December 2010 letter, a private audiologist wrote that the Veteran had been seen for consultation regarding his then recent audiogram. The audiologist stated that the testing had suggested classic hearing loss as a result of noise exposure, commenting that the Veteran was a tank gunner in service. She opined that his audiometric test results were most likely due to excessive noise exposure at a time when hearing protection was inadequate. This December 2010 private opinion obviously conflicts with the October 2010 VA examiner's opinion regarding the purported relationship between the Veteran's bilateral hearing loss and the noise exposure both concede he had in service. In this circumstance, it is the Board's responsibility to assess the credibility and weight to be given the evidence for versus against the claim. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical opinion evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another, so long as the Board provides an adequate statement of reasons or bases. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A medical opinion may not be discounted, however, solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The commenting private audiologist did not indicate review of the claims file. However, in assessing the probative value of a medical opinion, the Board must consider whether the medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Nieves-Rodriguez, 22 Vet. App. at 303-04. In Kowalski v. Nicholson, 19 Vet. App. 171 (2005), the Court indicated the Board may not disregard a favorable medical opinion solely on the rationale it was based on a history given by the Veteran. Rather, as the Court further explained in Coburn v. Nicholson, 19 Vet. App. 427 (2006), reliance on a Veteran's statements renders a medical report not credible only if the Board rejects the statements of the Veteran as lacking credibility. Here, the private audiologist considered the Veteran's history of noise exposure in service and reviewed the results of then recent audiometric testing. Significantly, there is no indication the Veteran has a history of noise exposure other than while in the military, as he denied occupational and recreational noise exposure as a civilian during his October 2010 VA compensation examination. The December 2010 favorable opinion was supported by rationale, specifically, the audiometric test results suggested classic hearing loss as a result of noise exposure. And since there seemingly was only noise exposure in service, certainly only to the indicated level while in service, this then represents the only possible source or cause of the later diagnosed bilateral hearing loss. The October 2010 unfavorable opinion was also in comparison supported by rationale, namely, an absence of evidence in the medical literature supporting the notion of a delayed onset of noise-induced hearing loss and the fact that the Veteran had normal hearing during his military separation examination. However, to reiterate, the Court has held that the absence of indication of hearing loss in service is not fatal to a claim for this disability. See Ledford, 3 Vet. App. at 89 (1992). Both the audiologist who performed the October 2010 VA examination and the private audiologist who provided the December 2010 opinion are competent medical authorities who had access to the pertinent facts at issue in this case, that is, the Veteran's history of noise exposure in service and not since. Likewise, both professionals offered opinions following review of audiometric testing and each opinion was supported by rationale. The Board regards the opinions of the VA and private audiologists sufficient to place the evidence in relative equipoise on the determinative nexus issue regarding cause of the Veteran's claimed bilateral hearing loss in terms of whether it is related or attributable to the noise exposure during his military service. Moreover, in Hensley, the Court posited that where the regulatory threshold requirements for hearing disability are not met until several years after separation from service, the record must include evidence of exposure to disease or injury in service that would adversely affect the auditory system, and post-service test results that meet the criteria of 38 C.F.R. § 3.385. VA rating authorities must evaluate available testimony, clinical data, diagnoses, and any medical opinions relevant to the issue. For example, if the record shows (a) acoustic trauma due to significant noise exposure in service and audiometry test results resulting in an upward shift in tested thresholds in service, though still not meeting the requirements for a "disability" under 38 C.F.R. § 3.385, and (b) post-service audiometry testing produces findings meeting the requirements of 38 C.F.R. § 3.385, rating authorities must consider whether there is a medically sound basis to attribute the post-service findings to the injury in service, or whether they are more properly attributable to intercurrent causes. Hensley, 5 Vet. App. at 159. The Board observes that the Veteran in this case did experience acoustic trauma in service due to noise exposure and the results of his audiometric testing in June 1962 at time of separation, versus those from August 1959 at time of his entrance into service, reflect an upward shift in tested thresholds. He additionally has a current ratable bilateral hearing loss disability as defined by 38 C.F.R. § 3.385, and the December 2010 private opinion provides a medically sound basis to attribute this current bilateral hearing loss disability to the noise exposure in service, as opposed to other possible precipitating factors or sources. So with resolution of all reasonable doubt in the Veteran's favor, the Board concludes that the criteria for service connection for bilateral hearing loss are met. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (an "absolutely accurate" determination of etiology is not a condition precedent to granting service connection, nor is "definite" or "obvious" etiology). Rather, this need only be an "as likely as not" proposition, and in this instance it is for the reasons and bases discussed. Hence, the claim must be granted instead of denied. 38 C.F.R. § 3.102. Turning next to the claim for service connection for tinnitus, the only medical opinion regarding the relationship between the Veteran's current tinnitus and his service comes in the way of the October 2010 VA examiner's, which weighs against the claim for service connection on a direct-incurrence basis. However, the Board has determined herein that the Veteran's current bilateral hearing loss is indeed related to his in-service noise exposure. The October 2010 VA examiner conceded the Veteran's tinnitus is as likely as not a symptom of his hearing loss. This statement, then, in turn provides medical evidence indicating his current tinnitus is proximately due to or the result of, if not aggravated by, his hearing loss disability. There is no other evidence of record attributing tinnitus to another cause. Accordingly, resolving all reasonable doubt in his favor, service connection is additionally warranted for his tinnitus as secondary to the now service-connected bilateral hearing loss. See 38 C.F.R. § 3.310; see also Velez, 11 Vet. App. at 158 and McQueen, 13 Vet. App. 237. ORDER The claim of entitlement to service connection for bilateral hearing loss is granted. The claim for service connection for tinnitus also is granted. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs