Citation Nr: 1326248 Decision Date: 08/19/13 Archive Date: 08/26/13 DOCKET NO. 10-07 255 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a hand condition (claimed as cracking cuticles), to include as secondary to herbicide exposure. 2. Entitlement to service connection for a bilateral hearing loss disability. 3. Entitlement to an initial rating in excess of 30 percent prior to December 7, 2009, and 50 percent from December 7, 2009 to September 21, 2012, for a service-connected posttraumatic stress disorder (PTSD) with depression and generalized anxiety disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1967 to April 1969. He was awarded a Bronze Star Medal with a "V" Device. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver Colorado. In that decision, the RO denied the Veteran's claims for service connection for a hand disability and a bilateral hearing loss disability, and granted service connection for PTSD with depression and generalized anxiety disorder and assigned an initial 30 percent disability rating, effective October 16, 2008. In a January 2010 rating decision, the RO increased the assigned evaluation for the Veteran's service-connected acquired psychiatric disorder, to include PTSD, to 50 percent, effective December 7, 2009. In the December 2012 supplemental statement of the case (SSOC), the RO increased that evaluation to 100 percent, effective September 21, 2012. As the January 2010 increase did not represent a total grant of benefits sought on appeal, the claim for increase dating prior to September 21, 2012, remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). In May 2013, the Veteran and his spouse testified at a Videoconference hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript has been associated with the claims file. At the hearing, additional evidence was submitted, accompanied by a waiver of initial RO consideration. This evidence will be considered by the Board in adjudicating this appeal. See 38 C.F.R. § 20.1304 (2012). The issue of entitlement to service connection for a bilateral hearing loss disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. At the May 2013 Videoconference hearing, the Veteran withdrew his appeal as to the issue of entitlement to service connection for a hand condition (claimed as peeling and cracking cuticles), to include as secondary to herbicide exposure. 2. Prior to September 21, 2012, the evidence is in equipoise as to whether Veteran's PTSD with depression and generalized anxiety disorder resulted total social and occupational impairment. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal by the Veteran concerning the issue of entitlement to service connection for a hand condition (claimed as peeling and cracking cuticles), to include as secondary to herbicide exposure, have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 2. Resolving any doubt in the Veteran's favor, the criteria for a disability rating of 100 percent for PTSD with depression and generalized anxiety disorder prior to September 21, 2012, have been met. 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist In light of the Veteran's request to withdraw his appeal as to the issue of entitlement to service connection for a hand disability, and the fully favorable determination as to the issue of entitlement to an increased initial rating for service-connected PTSD with depression and generalized anxiety disorder, no further discussion of compliance with VA's duty to notify and assist is necessary at this time. II. Legal Criteria and Analysis A. Withdrawal - Service Connection for a Hand Condition Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b). At the May 2013 Videoconference hearing, the Veteran testified that he wished to withdraw his appeal as to the issue of entitlement to service connection for a hand condition (claimed as peeling and cracking cuticles), to include as due to herbicide exposure. In light of that fact, there remains no allegation of error of fact or law for appellate consideration with respect to the claim of entitlement to service connection for a hand condition, to include as due to herbicide exposure and the appeal is withdrawn as it pertains to that issue. Accordingly, the Board does not have jurisdiction to review the appeal as to that issue and it is dismissed as it pertains to the same. B. Increased Initial Rating - PTSD with depression and generalized anxiety disorder Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002). Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the issue involves the assignment of an initial rating for a disability following the initial award of service connection for that disability, as is the case here, the entire history of the disability must be considered and, if appropriate, staged ratings may be applied. Fenderson v. West, 12 Vet. App. 119 (1999). If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). As noted above, the current appeal stems from a July 2009 rating decision in which the RO granted entitlement to service connection for PTSD with depression and generalized anxiety disorder. An initial 30 percent evaluation was assigned for that disability pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran disagreed with the initial 30 percent evaluation assigned. In subsequent decisions, the RO increased the assigned disability rating to 50 percent, effective December 7, 2009, and to 100 percent, effective September 21, 2012. The Veteran contends that the initial 30 percent disability rating assigned for the period dating prior to December 7, 2009, and the 50 percent disability rating assigned from December 7, 2009 to September 21, 2012, do not accurately depict the severity of his symptomatology during those time periods. He claims that symptomatology associated with his service-connected PTSD with depression and generalized anxiety disorder has resulted in total occupational and social impairment warranting the assignment of a 100 percent disability rating effective October 16, 2008, the date his claim for service connection was received. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). Under Diagnostic Code 9411, which is governed by a General Rating Formula for Mental Disorders, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as depressed mood; anxiety, suspiciousness, panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions and recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name. Id. In evaluating psychiatric disorders, it must be shown that industrial impairment is the result of actual manifestations of the service-connected psychiatric disorder. The severity of a psychiatric disability is based upon actual symptomatology, as it affects social and industrial adaptability. Two of the most important determinants of disability are time lost from gainful employment and decrease in work efficiency. 38 C.F.R. § 4.130 (2012). The Secretary, acting within his authority to "adopt and apply a schedule of ratings," chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the Diagnostic Code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (1992). In assessing the evidence of record, it is important to note that the GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A score of 41-50 is assigned where there are, "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A score of 51-60 is assigned where there are moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflict with peers or co-workers). Id. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Turning to the evidence, prior to September 21, 2012, the Veteran's psychiatric disability was manifested by symptoms such as anxiety, flashbacks, nightmares, intrusive thoughts, hypervigilance, concentration problems, loss of interest, exaggerated startle response, feelings of guilt, memory problems, outbursts of anger and irritability, obsessive thoughts about his anger; an inability to cope with anxiety; and intermittent suicidal ideation. In addition to PTSD, medical professionals have diagnosed various anxiety and mood disorders as well as personality disorders. The Board is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). All psychiatric symptoms will be considered in the rating assigned in the absence of medical evidence attributing such symptoms to a disorder other than PTSD with depression and generalized anxiety disorder. VA psychiatric treatment records suggest that the Veteran stopped working sometime between 2002 and 2004, following diagnosis and treatment for colon cancer. The Veteran initially sought VA mental treatment in September 2008 due to depression and anger dating since his military service, which had worsened in recent months. He had started to become angry with strangers and his wife. He had recently been summonsed to appear in court for disorderly conduct related stopping and confronting a neighbor who was driving erratically. He denied any history of suicidal or homicidal ideations, but he was anxious and sometimes felt like there is no way out. In October 2008, the Veteran began individual VA psychotherapy with GM, LCSW. He and his wife were struggling financially and losing their home. In December 2008, the Veteran was planning to file for bankruptcy. He was very tense, frustrated, angry, and had "acted out some physically." His psychiatric symptoms were strong and moderate-to-severe in degree. He had a hard time obtaining and holding a job related to problems with authority. He tended to burn bridges, not always think about what he said, and isolate himself. Diagnostic impression was PTSD with some secondary personality disorder not otherwise specified (NOS). His GAF score was 50. In December 2008, the Veteran underwent a VA psychiatric examination to determine the nature and etiology of his PTSD with depression and generalized anxiety disorder. His military service history was reviewed, to include significant combat exposure during service in Vietnam. Mental status examination showed that the Veteran's speech was quite circumstantial with many details that caused him to become somewhat tangential, otherwise, his thought process and communication were good. He was periodically tearful, and he demonstrated moderate dysphoria and anxiety, and a great deal of anger. Occupationally, the Veteran obtained his associates degree in business management, attended auto body technician school, and began an automotive sales and restoration business, which he lost in 1988. He subsequently got into the insurance and financial services industry and started his own business doing insurance sales. In 2002, he was diagnosed with and treated for colon cancer, and he had not worked since. He had tried several jobs between 1988 and 2000, but had very little productivity. He felt like he had been unable to work due to diminished motivation secondary to his "PTSD symptomatology." The December 2008 VA examiner diagnosed PTSD with associated depression and generalized anxiety disorder related to his military service. The examiner also diagnosed personality disorder NOS with some minor personality factors involved. His GAF score was 53. The examiner opined that the Veteran's psychiatric symptoms resulted in occasional decrease in work efficiency or intermittent periods of an inability to perform occupational tasks due to signs and symptoms, but he generally functioned satisfactorily. The examiner acknowledged that the Veteran's PTSD, anxiety, and depression had made it very difficulty for him to work. He had tried a number of jobs, however, his psychiatric symptoms, especially with increased depression, anxiety, and obsessional thought, significantly interfered as they made it more difficult for him to deal with many of the unusual conflicts of life. It was hard to state whether he could obtain some kind of employment. On a PTSD checklist-stress specific version, the Veteran marked all but 3 items as "extremely disturbed." In February 2009, the Veteran experienced ongoing anxiety and depression, which increased during times of anger. He frequently found himself apologizing to family and friends for his displaced anger. He felt out of control at times. He was taking medication for assistance with chronic sleep impairment. He was better able to control his anger with adequate sleep. His therapist stated that in addition to PTSD, part of the his problem was an adjustment disorder. His GAF score was 47. In June 2009, it was noted that the Veteran had worked a little bit in January 2009, but not since. He had experienced difficulty working since 2002 when he was diagnosed with cancer, however, his sporadic work history prior to 2002 was reflective of the effects of his PTSD and a compromised ability to deal with others. His military traumas continued to haunt him, which had both social and economic impacts. Diagnoses at that time included PTSD, recurrent major depression, and some obsessive compulsive personality disorder symptoms. His GAF score was 50. In September 2009, it was noted that the Veteran had never really been able to work effectively except as being his own boss, and even then, he had not been able to make a lot of money. His therapist, GM, LCSW, opined that he had no ability to maintain full-time or part-time employment unless he was able to work for himself or his wife, who was self employed in real estate. The rationale provided was that his strong, moderate-to-severe symptoms of PTSD resulted in difficulties functioning socially and dealing with others due to a very bad temper. Diagnostic assessment included PTSD, adjustment disorder with mixed mood, probable generalized anxiety disorder probably directly related to PTSD. His GAF score was 50. An exacerbation of symptoms was noted in November 2009, which was attributed to the poor economy. The Veteran truly believed that he was totally disabled. His therapist reiterated that he had not been able to sustain work and he was, at the very least, unemployable. On December 7, 2009, the Veteran underwent an additional VA QTC examination to determine the nature and severity of his service-connected acquired psychiatric disorder, to include PTSD. The Veteran felt that his psychological condition had deteriorated since the December 2008 examination, which he attributed to loss of his home and income. Occupationally, the Veteran was unemployed, although he later indicated that he technically maintains his business in insurance sales but he had not made much money from this in quite a while ($5,000 - $6000 per year in the last two years). He primarily lived off of his wife's income, who was a successful real estate agent. Within the last year, he was reportedly summonsed for harassment, however, the charge was dismissed. On mental status examination in December 2009, the Veteran became readily tearful when discussing his military service. He denied homicidal ideation but acknowledged occasional suicidal feelings and some survivors guilt. His mood was depressed and his affect was rather flat and occasionally tearful. His GAF score was 50. The examiner considered the Veteran's psychiatric symptoms to be in the category of occupational and social impairment with reduced reliability and productivity. The examiner stated that the Veteran clearly displays significant symptoms of PTSD directly related to his military service. A minor deterioration in his quality of life was noted since his last psychiatric examination one year prior, though his quality of life was already in significant turmoil as he had just lost the family farm and had started bankruptcy proceedings. The Veteran continued to contribute very little to the family finances. His PTSD symptoms made it difficult for him to be successful in employment that required extensive contact with either the public or co-workers. His decision to go into insurance sales was never a particularly good fit primarily due to the required social contact. The examiner agreed with the Veteran's treating therapist that it would be difficult for him to work for an employer due to his ready irritability and mistrust. It was felt that he could be more successful doing independent work that does not require constant contact with the public and provides a supportive work environment without significant stress. A January 2010 individual therapy note shows that the Veteran's therapist noted an additional psychiatric disorder of "some obsessive compulsive personality disorder." His GAF score was 50. In February 2010, the Veteran continued to have moderate-to-severe symptoms of PTSD, which included loss of sleep, irritability, rage, and anger. He relived some trauma experiences and was acutely aware of things that triggered his negative responses, which he tried to avoid, but had a difficult time doing so. He had a difficult time keeping a job. His therapist reiterated his opinion that the Veteran is unemployable. In June 2010, the Veteran's therapist believed that he was a possible risk to himself and others. On evaluation the following day, his stressors included his marriage, however, his finances and PTSD were equally disruptive. His wife described the Veteran's extreme anger and passive aggressive behavior. His behavior ruined what were otherwise good times. He would brood for days and become more angry with any attempt to calm him down. His anger had increased with his financial stress. Issues related to his financial situation were a major contributor to his problems. A subsequent June 2010 social work note indicated that the Veteran's PTSD, combined with his difficulty focusing and working with others, had prevented him from maintaining steady employment. His GAF score was 50. In August 2010, the Veteran's therapist indicated that his GAF score is 50 most of the time, however, it drops way below 50 at times. Through September 21, 2012, the Veteran received continuous counseling and medication treatment for his psychiatric disability. He experienced periodic exacerbations of psychiatric symptomatology. His psychiatric symptomatology was described as moderate-to-severe at worst and his GAF score was consistently reported as 45. In April 2011, his PTSD symptoms remained very intrusive and got in his way most every time he was under any stress or pressure. An August 2011 individual therapy note indicated that the Veteran was pretty much debilitated by his PTSD symptoms and he was incapable of relationships and work. His psychiatric symptoms were stated to be moderate at best, however, they were severe in degree most of the time. He was looking for work when he could. In medical source statements in support of the Veteran's claim for SSA disability benefits, dated in December 2011 and August 2012, the Veteran's VA psychiatric treatment providers opined that he is unable to exist in a work environment that involves following instructions, meeting deadlines, and responding appropriately to demands due to his moderately severe emotional labiality and inability to withstand anxiety due to PTSD. During the May 2013 hearing, the Veteran and his wife testified that his psychiatric symptoms have remained essentially the same through the appellate period, to include the period dating from September 2012, for which he is receiving a 100 percent evaluation. He indicated that his psychiatric symptomatology results in total social and occupational impairment due to his inability to work with people since his discharge from military service. He reportedly closed his self owned and operated insurance company in 2004. He indicated that he could not work for a private insurance company because his psychiatric symptomatology prevents him from being able to cope with the demands of a fast paced working environment where he is constantly shifting gears and changing tasks. Since 2004, he had helped past clients on a very inconsistent basis. He did not really do business with them, rather, he referred them elsewhere. He asserted that VA psychiatric treatment records support the assignment of a 100 percent evaluation since the date that his claim for service connection for such was received in October 2008. Following a review of the record, the Board finds that the evidence is in equipoise as to whether prior to September 21, 2012, the Veteran's PTSD resulted total occupational and social impairment. Therefore, a 100 percent disability rating is assigned for the Veteran's service-connected PTSD with depression and generalized anxiety disorder. The Board acknowledges that the Veteran's PTSD with depression and generalized anxiety disorder is not manifested any symptoms listed in the diagnostic code for the assignment of a 100 percent evaluation for his psychiatric disability. Notwithstanding the foregoing, the GAF scores assigned prior to September 21, 2012, ranged from 45 to 60, which is indicative of moderate to serious symptoms. As noted above, his VA psychiatric treatment provider throughout the duration of the claim has indicated that his symptoms are mostly severe in degree rather than moderate. Moreover, he indicated that although the Veteran's GAF score was consistently documented to be 50 during much of his claim, which the Board notes is consistent with an inability to keep a job, his GAF scores were also known to drop significant below 50 at times. Moreover, it was frequently noted that the Veteran is unable to cope with stress and people without experiencing significant anger and sometimes explosive episodes. As noted above if, as in this case, the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the Diagnostic Code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (1992). In this case, since as early as 2009, the Veteran's VA psychiatric treatment providers have frequently and consistently stated that the Veteran's PTSD with anxiety and generalized anxiety disorder result in his inability to obtain and maintain employment due to his significant anger, his inability to cope with stress, and his inability to deal with other people. In sum, prior to September 21, 2012, the evidence of record is in relative equipoise as to whether the frequency, duration, and severity of the Veteran's psychiatric symptomatology results total occupational and social impairment. Therefore, the Board finds that the criteria for the assignment of a 100 percent disability rating for PTSD with depression and generalized anxiety disorder is warranted prior to September 21, 2012. ORDER The appeal as to the denial of entitlement to service connection for a hand condition (claimed as peeling and cracking cuticles), to include as due to herbicide exposure, is dismissed. For the period dating prior to September 21, 2012, entitlement to a 100 percent disability rating for PTSD with depression and generalized anxiety disorder is granted subject to the laws and regulations governing the payment of monetary benefits. REMAND The Veteran contends that he is entitled to service connection for a bilateral hearing loss disability related to hazardous noise exposure that he endured during military service. His DD Form 214 shows that he worked as an air crew chief and aircraft maintenance mechanic in the United States Air Force for approximately a year and half, during which he was awarded a Bronze Service Star with a "V" device for actions performed in combat during service in Vietnam from June 1968 to April 1969. A review of the record shows that at the time of the Veteran's enlistment on active duty service, he was called from inactive duty. Upon discharge from active military service in November 1967, he was transferred to the Army National Guard of Colorado. His DD Form 214 also shows a terminal date of Reserve service obligation of October 17, 1973. The Veteran has submitted documentation showing that he was honorably discharged from the United States Air Force on that date. Although service treatment records and examination reports pertaining to the Veteran's active military service have been obtained, there is no indication that a request for records has been made pertaining to any service in the Air National Guard or Air Force Reserve. A determination as to whether any service examination reports or audiological evaluations were performed at any time following the Veteran's discharge from active service is especially important given the Veteran's assertion in March and May 2009 statements that he underwent private audiological evaluation in 1969, for which any associated clinical records or reports are unavailable for review, within one year of his discharge from active service, which were indicative of some degree of diminished hearing acuity. In addition, the Veteran's representative has repeatedly asserted that the absence of objective evidence of a hearing loss disability during the Veteran's active military service is not fatal to his claim for service connection for his current bilateral hearing loss disability. In this regard, during the December 2008 VA audiological examination, the Veteran reported a significant history of military noise exposure during his active military service, and post-service occupational and recreational noise exposure was denied. He recalled that he often experienced frequent shifts in hearing and tinnitus during his military service. In a February 2009 addendum opinion, the examiner opined that because audiometric findings on the Veteran's enlistment and separation showed normal hearing sensitivity bilaterally, his current bilateral hearing loss disability is less like than not related to his military noise exposure because audiometric findings on the Veteran's enlistment and separation examinations showed. The Veteran was afforded an additional VA audiological examination in September 2012. Following a review of the claims file and audiological examination of the Veteran, the examiner opined that the Veteran's current bilateral hearing loss disability is less likely than not related to his military noise exposure. She reasoned that audiological evaluations at the time of enlistment and separation showed normal hearing sensitivity bilaterally, and there was no evidence of a significant shift in hearing thresholds during service. Unfortunately, neither VA examiner has addressed the significance, if any, of the Veteran's recollection that he often experienced frequent shifts in hearing during his military service. The Veteran is competent to report any temporary changes in hearing acuity noticed by him during service. See 38 U.S.C.A. § 1154(b). As the Veteran is presumed to be credible as to reported his experiences during military service, the Board finds that the Veteran had did experience temporary changes in his hearing acuity during service. In this regard, as noted by the Veteran's representative, the absence of in-service evidence of a hearing disability during service (i.e., one meeting the requirements of 38 C.F.R. § 3.385) is not always fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service (as opposed to intercurrent causes). See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). In light of the foregoing, it is necessary to obtain an addendum opinion as to the etiology of the Veteran's current bilateral hearing loss disability, which discusses the significance, if any, of the Veteran's report that he often experienced shifts in his hearing during military service, and whether the temporary shifts in hearing described by the Veteran during military service may represent the onset of or otherwise be related to the Veteran's currently diagnosed bilateral hearing loss disability. In doing so, the examiner must presume that the Veteran's report of changes in hearing acuity during his active military service occurred as described by the Veteran. Ongoing VA audiological treatment records, if any, should also be obtained for review. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran, and request that he identify any records pertaining to his claims remanded herein. He should specifically be requested to provide information as to whether he recalls undergoing audiological evaluations in connected with his service in the Air National Guard or Air Force Reserves. If so, or if he is unsure, development efforts must be undertaken to secure any such records from all appropriate records repositories. If any records identified by the Veteran cannot be obtained, he should be so informed and it should be documented in the claims folder. 2. Obtain any ongoing VA audiological treatment records pertaining to the Veteran from Grand Junction, Colorado VAMC dating since November 2012. All efforts to obtain VA records should be fully documented, and the VA facility must provide a negative response if records are not available. 3. After all relevant records identified are obtained, refer the claims file to the audiologist who conducted the September 2012 VA audiology examination, or, if she is unavailable, to another audiologist qualified to render as opinion as to the etiology of the Veteran's current bilateral hearing loss disability. The claims file, to include any relevant documents in Virtual VA, the December 2008 VA examination report documenting the Veteran's report that he experienced temporary shifts in his hearing acuity during active military service, and his March and May 2009 reports that private audiological examination within 1 year of his separation from active military service was indicative of some degree of impaired hearing, should be reviewed by the examiner and the examination report should contain notation to this effect. The examiner should note that the absence of in-service evidence of a hearing disability during service is not always fatal to a claim for service connection. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for a hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury during active service. See Hensley v. Brown, Vet. App. 155, 159 (1993). The examiner should acknowledge that the Veteran's reported noise exposure during service and his report that he noticed shifts in his hearing acuity during service are presumed in light of his verified combat service and his military occupational specialty as a aircraft mechanic, which has a high probability of in-service noise exposure. As to the Veteran's current bilateral hearing loss disability, following a review of this REMAND and a complete review of the claims file, the examiner should render an opinion as to whether it is at least as likely as not (i.e. a 50 percent probability or better) that the Veteran's current bilateral hearing loss disability had onset during military service or is otherwise related to his active military service, to include significant military acoustic trauma therein coupled with temporary changes in hearing acuity during service. The examiner should acknowledge and discuss the significance, if any, of the reported shift in hearing acuity during service and indicate why it may or may not serve as the basis of a delayed onset hearing loss disability. The audiological report must explicitly state that the examiner reviewed the entirety of the Veteran's claims file before rendering an opinion. The opinion provider should cite to the medical and competent lay evidence of record, including the Veteran's contentions as to in-service noise exposure with temporary changes in hearing acuity during active service, and explain the rationale for all opinions given. If the examiner opines that any question presented cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 4. After the development requested has been completed, review the opinion to ensure that it is in complete compliance with the directives of this REMAND. If the report is deficient in any manner, the RO/AMC must implement corrective procedures at once. 5. Thereafter, readjudicate the issue of entitlement to service connection for a bilateral hearing loss disability in light of all pertinent evidence and legal authority. If the benefit sought on appeal is not granted, issue a supplemental statement of the case and afford the Veteran and his representative an opportunity to respond. Thereafter, the case should be returned to the Board, if in order. 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). 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). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs