Citation Nr: 1327426 Decision Date: 08/27/13 Archive Date: 09/05/13 DOCKET NO. 07-05 203 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hearing loss. 3. Entitlement to service connection for tinnitus. 4. Entitlement to service connection for a bilateral foot disability. REPRESENTATION Appellant represented by: Mississippi Veterans Affairs Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Nadine W. Benjamin, Counsel INTRODUCTION The Veteran served on active duty from September 1976 to March 1982. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In September 2010, the Veteran appeared before the undersigned Acting Veterans Law Judge and gave testimony in support of his claim. A complete transcript is of record. In February 2011, the Board remanded this claim for additional development. The case has been returned to the Board and is ready for further review. The Board is satisfied that as to the issues decided below, there was substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The issues of entitlement to service connection for hearing loss and for tinnitus 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 1. An acquired psychiatric disability is not attributable to service. 2. PTSD has not been associated with a verified stressor. 3. The Veteran does not have a musculoskeletal bilateral foot disability; athlete's foot is not attributable to service. CONCLUSIONS OF LAW 1. An acquired psychiatric disability to include PTSD was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. A bilateral foot disability was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in January 2006 and was sent prior to the initial RO decision in this matter. The letter informed him of what evidence was required to substantiate the claim for an acquired psychiatric disorder and a bilateral foot disorder, and of his and VA's respective duties for obtaining evidence. As to the claim for PTSD, the Veteran was provided with a notice letter in February 2011. His claim was thereafter adjudicated in a supplemental statement of the case, thereby curing any timing deficiency. With respect to the Dingess requirements, in September 2006, the RO provided the Veteran with notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. 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). First, the RO has obtained the Veteran's service treatment records, VA outpatient treatment records and records from the Social Security Administration. Next, a medical opinion pertinent to the issue on appeal was obtained. The report of the examination, and the other evidence in the file, contains the findings needed to make a proper determination. Thus, another examination or additional medical comment concerning this issue is not needed. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). See also Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (VA's duty to assist includes providing an adequate examination when such an examination is indicated). Therefore, relevant evidence has been obtained in order to make an adequate determination as to these claims. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, 16 Vet. App. at 183. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). Service connection may also 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 service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr, 21 Vet. App. at 309. Service connection for certain chronic diseases may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year (three years for active tuberculous disease and Hansen's disease; seven years for multiple sclerosis) from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2012). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term "chronic disease" refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki 708 F.3d 1331 (Fed. Cir. 2013). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is 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 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. at 465. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. 38 C.F.R. § 3.159(a)(2); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. Davidson, 581 F.3d at 1316. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. Additionally, establishing service connection for PTSD generally requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., under the criteria of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptoms and the claimed in-service stressor. 38 C.F.R. § 3.304(f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). An Acquired Psychiatric Disorder other than PTSD With respect to the first element of Horn, the Board notes that there are current diagnoses of depression and anxiety. For example VA records show that in November 2009, depressive disorder was found; major depression was noted on screening in July 2007; in September 2009, depression was diagnosed; in December 2009, anxiety and depression were noted, and on VA examination in July 2009, anxiety disorder was diagnosed. Further, service treatment records show that the Veteran was treated during service in 1977 for adjustment reaction to adult life. Thus, the second element of Horn has been met. Therefore, in order for the Veteran to prevail, there must be competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. In July 2009, the Veteran was examined by VA. The claims file was reviewed. His history was noted. He indicated that he had a history of anger toward the military and the way he reported being treated. He reported current conflict with his brother and father and he reported having stress because he is unable to see his family in Germany. He reported having poor sleep and his mood was mostly down. He reported having symptoms since 1977. He reported having no alcohol or drug abuse history. He was examined and the examiner diagnosed anxiety disorder, not otherwise specified. The examiner concluded that anxiety disorder NOS is not due to or caused by military service. The examiner reported that the Veteran was treated in the military for adjustment reaction. The examiner noted that adjustment reaction by definition is time-limited and stress responsive. It was stated that the hospitalization in the military was the result of anger towards others including military personnel, violent dreams about killing and desire to hurt others. It was noted that the hospitalization was not for an anxiety diagnosis. The examiner stated that neither of the foregoing indicates a long term anxiety condition. It was noted that on examination currently, the Veteran again expresses his anger at the way he was treated in the military and connects his mental health troubles with that treatment. It was stated that accordingly, no nexus is established between the Veteran's anxiety disorder and military service. Having carefully reviewed the evidence of record, the Board finds that the preponderance of the evidence is against service connection for an acquired psychiatric disorder other than PTSD. Although the Veteran was seen in service for symptoms diagnosed as adjustment reaction to adult life, no psychiatric disorder is shown thereafter during service. In January 1982, the Veteran indicated that he did not wish to undergo a separation examination, and none was conducted. Post-service, in July 2007, VA records show a positive depression screen. VA records show treatment continuing into 2012 for depression and substance abuse. Thus the findings of depression or anxiety disorder are first shown many years after service discharge and have not been related to service. The Board accepts that the Veteran is competent to report his psychiatric symptoms and treatment. Layno, 6 Vet. App. at 469. However, the Veteran is not competent to attribute any currently shown psychiatric disorder to service, to include his treatment in service because in this case, that question is one of medical complexity. This determination is not susceptible to lay observation. See Jandreau, 492 F.3d at 1377; see also 38 C.F.R. § 3.159 (a)(1) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. Therefore, although the statements of the Veteran in support of his claim have been given full consideration by the Board, they are not considered competent medical evidence and do not serve to establish a medical nexus between the disorders and the Veteran's period of service. Therefore, the Board finds that the Veteran's statements as to the origin of an acquired psychiatric disorder have no probative value as the question of nexus in this specific case requires expertise as it is a complex medical question. The Board assigns greater probative value to the negative VA medical opinion dated in July 2009. The Board finds the VA psychiatric examination to be the most probative evidence as to nexus. Also, the Board notes that the July 2009 medical opinion was prepared by an expert medical professional after review of the claims files and examination of the Veteran. Further it stands uncontradicted in the record by any other competent opinion evidence. Accordingly, this aspect of the claim must be denied. There is no doubt to resolve as the preponderance of the evidence is against the claim. PTSD Service treatment records, VA treatment records, and report of VA psychiatric examination dated in July 2009 show no diagnosis of PTSD. The record shows that the Veteran was noted to have a positive PTSD screen in VA records dated in March 2009. However, the Board finds that service connection is not warranted for PTSD, as the evidence of record demonstrates that there is no verified stressor upon which a diagnosis of PTSD could be based. The Board notes that the Veteran was informed of the requirements for establishing service connection for PTSD. In response to a Board remand, he was sent a letter in February 2011 requesting he supply complete information regarding his alleged stressor of having a friend die in his arms as a result of bomb explosion in Munich. However, the Veteran has not provided VA with any information on this event. While VA has a duty to assist the Veteran in substantiating his claim, that duty is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (a veteran cannot passively wait for help from VA). His service records reflect no PTSD stressors. He has not provided VA with any additional information that would allow it to assist him in the verification of any in-service stressors. The Veteran has been accorded ample opportunity to furnish evidence in support of his claim and has not done so. See 38 U.S.C.A. § 5107(a) (noting it is a claimant's responsibility to support a claim for VA benefits). As no specific details were provided related to his claimed in-service stressors, VA is unable to attempt verification. Therefore, element (3) is not met with regard to this Veteran's claim for service connection. Without an in-service stressor that is supported by credible evidence a current diagnosis of PTSD, and medical evidence of a link between PTSD and the in-service stressor, a claim for service connection for PTSD cannot be granted. 38 C.F.R. § 3.304(f). Here, the Veteran has not assisted VA in the development of his claim. Even if VA obtained additional post-service evidence of diagnosis or nexus on his behalf, the claim still could not be granted due to lack of an adequate stressor. 38 C.F.R. § 3.304(f). The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55-57. The claim of service connection for PTSD must be denied. A Bilateral Foot Disability The Veteran claims that he has a bilateral foot disability that is related to his military service. The service treatment records show that in April 1978 the Veteran was seen for pain in his left foot after playing basketball; sprain left foot was diagnosed. In August 1979, he was seen for a sore right foot after twisting it in a hole playing football. Twisted foot was diagnosed. In December 1979, he was seen for a right foot injury, and sprain was diagnosed; x-rays were normal. In January 1982, the Veteran indicated that he did not wish to undergo a separation examination, and none was conducted. The Veteran underwent a VA examination in March 2011 pursuant to the Board's February 2011 remand. The claims file was reviewed. By way of history, the Veteran reported having frostbite on both feet in 1977 while stationed in Germany. His service treatment records were reviewed and the examiner noted that there was no treatment for frostbite and that the Veteran did have treatment for several sprains. It was noted that he had no diagnosis of frostbite while on active duty. The examiner stated that the examinations of the feet in service were entirely of self limited injury and there were absolutely no injuries described which could have been confused with a cold injury of any type. It was also noted that the Veteran has been seen since 2006 at VA and there is no complaint related to a frostbite injury. It was noted that in 2010 and 2011 he was noted to have athlete's foot and was prescribed an appropriate treatment. It was pointed out that there is absolutely no other indication that the Veteran had problems with his feet of any type. The Veteran currently complained of pain, weakness, stiffness and heat in the feet. Examination of the feet showed no evidence of painful motion, edema, instability, weakness or tenderness. Gait was normal. It was noted that he exhibited no wincing or any other aspect that the examination was painful except when asked if a particular portion of the examination was painful. There was a fungus infection noted on the skin between the toes. There was no evidence of hammer toe, high arch claw foot or other deformity. There was no flat feet and not hallux valgus. X-rays of the feet were normal. A fungus infection of the feet was diagnosed. It was noted that the Veteran had no complaints whatsoever of foot pain since he has been in the United States in 2007, and the only complaint was of foot fungus only diagnosed within the previous year. The examiner stated that the only finding of foot pain was arbitrary and the Veteran was not found to have foot pain consistently. It was opined that the foot pain, because of the previous factors explained, is not related to or caused by any of the transient episodes which the Veteran experienced while he was on active duty. It was stated that further, it his highly unlikely that the Veteran's athlete's foot has continued form the time that he was in the military. It was noted that there is no history of his complaining of having athlete's foot from 2007 until the previous year and if he had athlete's foot in the military it was apparently temporary and as relieved. The Board finds that as to the claim of service connection for a bilateral foot disability, the claim must be denied. In this regard, the Veteran was treated in service for bilateral musculoskeletal foot complaints. Thus as to any musculoskeletal disability of the foot, the second element of Horn has been established. However, the first element has not been found. That is, there is no finding of a current musculoskeletal disability of the feet. The March 2011 VA examiner determined that there was no such diagnosis and x-rays were negative. The United States Court of Appeals for Veterans Claims (Court) has indicated that in the absence of proof of a present disability, there can be no valid claim for service connection; an appellant's belief that he or she is entitled to some sort of benefit simply because he or she had a disease or injury while on active service is mistaken, as Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). There is also no competent evidence of a musculoskeletal disability of the feet at any point during the claim or appeal period. McClain v. Nicholson, 21 Vet. App. 319 (2007). Further while the Veteran has subjective complaints of pain, which are unconfirmed on objective examination, the Board would point out that pain alone is insufficient to prove a claim, as there must be evidence of an underlying disorder associated with the pain. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted); dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). The Veteran has also indicated on the most recent VA examination that he had foot problems due to frostbite in service. The service treatment records are negative for any frostbite complaints. Further the record contains no diagnosis of such complaints or residuals thereof. Thus, as noted above, in the absence of proof of a present disability, there can be no valid claim for service connection. It is noted that the Veteran has been diagnosed with athlete's foot on VA examination in March 2011. Thus, as to this condition, the first element of Horn has been met. However, the service records are negative for any skin disorder and a VA examiner has stated that the current finding of athlete's foot is not related to service. The record contains no competent medical evidence associating this disorder to service. Thus the disorder of athlete's feet is first shown many years after service discharge and has not been related to service. The Board accepts that the Veteran is competent to report his symptoms and treatment. Layno, 6 Vet. App. at 469. However, the Veteran is not competent to attribute any currently shown foot disability to service, to include his treatment in service because in this case, that question is one of medical complexity. This determination is not susceptible to lay observation. See Jandreau, 492 F.3d at 1377; see also 38 C.F.R. § 3.159 (a)(1) [competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions]. Therefore, although the statements of the Veteran in support of his claim have been given full consideration by the Board, they are not considered competent medical evidence and do not serve to establish a medical nexus between athlete's foot and the Veteran's period of service. Therefore, the Board finds that the Veteran's statements as to the origin of a bilateral foot disability have no probative value as the question of nexus in this specific case requires expertise as it is a complex medical question. The Board assigns greater probative value to the negative VA medical opinion dated in March 2011. The Board finds the VA examination to be the most probative evidence as to nexus. Also, the Board notes that the March 2011 medical opinion was prepared by an expert medical professional after review of the claims files and examination of the Veteran. Further it stands uncontradicted in the record by any other competent opinion evidence. Accordingly, this claim must be denied. There is no doubt to resolve as the preponderance of the evidence is against the claim. ORDER Service connection for an acquired psychiatric disorder, to include anxiety and PTSD, is denied. Service connection for a bilateral foot disability is denied. REMAND Tinnitus The Board notes that, while an April 2011 VA examiner found that the Veteran reported that he did not have tinnitus at the present time, the Veteran has been diagnosed with tinnitus during the appeal period. (See, e.g., VA ENT consult of April 2006, private record of May 2004, and VA addendum of March 2010). Further during the course of this appeal, he has indicated that he has tinnitus, and he is competent to attest to having the disorder. (See, e.g., May 2006 notice of disagreement, VA examination in July 2009, hearing testimony before the Board in September 2010, and VA outpatient record of September 2010). Under McClain, the current disability requirement for a service connection claim is satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim. 21 Vet. App. at 321. The Veteran filed his claim in December 2005. Therefore, the Board finds that the Veteran's claims file should be returned to the April 2011 examiner for an addendum opinion as to whether the Veteran's diagnoses of tinnitus and complaints of tinnitus are related to his military service which includes conceded exposure to loud noise during service. Hearing Loss In February 2011, the Board remanded this claim for additional development. The Board pointed out that the Veteran has contended that during service as a switchboard operator, he was exposed to loud ringing, static and other noise on a relatively constant basis and that a service treatment record, dated in June 1979, documents that the Veteran complained of experiencing a bilateral ear ache and that he was exposed to loud noise at his job. A VA July 2009 examination showed that the Veteran's hearing loss does not meet the criteria of 38 C.F.R. § 3.385. The Board noted, however, that a February 2006 VA audiologist diagnosed the Veteran with "mild and moderately-severe SNHL [sensorineural hearing loss] for both ears," and that the Veteran had speech discrimination results of 92 percent for the right ear and 76 percent for the left ear. In an April 2006 VA physician's report states that the Veteran had "left hearing loss and tinnitus," caused by "maximal conductive hearing loss on the left with normal hearing on the right." It was noted that medical records show that the Veteran was subsequently diagnosed with chronic otitis media that required adenotonsillectomy in 2006 and other treatment and that in an April 2007 otolaryngology outpatient note, the examiner noted that treatment had been relatively successful. The Board pointed out that the Veteran's chronic otitis media was not indicated at the time of the July 2009 VA examination and the hearing loss noted in February 2006 may not have been chronic. The Board observed that the medical evidence shows a diagnosis of hearing loss meeting the criteria of 38 C.F.R. § 3.385 in February 2006, and that this occurred during the pendency of the Veteran's claim. The Board stated that the July 2009 VA examination, although finding that the Veteran's hearing was then normal for purposes of VA compensation regulations, did not address the hearing loss that may have been caused by chronic otitis media. Moreover, it was noted that no VA examiner has addressed whether the in-service complaints of ear aches are related to any hearing condition currently manifested by the Veteran. On remand, the Veteran's VA claims folder was to be provided to a competent audiologist or other appropriate medical professional who shall provide an opinion based on the evidence of record whether it is at least as likely as not that the Veteran's hearing loss recorded in February and April 2006 was caused by chronic otitis media and, if so, whether it is at least as likely as not that the chronic otitis media condition was incurred during active duty service. A review of the file reveals that the Veteran was examined by VA in April 2011, and normal hearing was diagnosed; however, the requested opinion was not addressed by the April 2011 VA examiner. The Board mandated that the Veteran be evaluated under clearly specified conditions and the Board directed that specific questions be answered by the examiner regarding the disorder on appeal. Review of the file reveals that the mandates presented by the Board were not adequately followed or addressed. A remand of this claim is necessary to ensure compliance with the prior Board remand directives. See Stegall, 11 Vet. App. at 271. Accordingly, these issues are REMANDED for the following actions: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claims. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. 2. Then, the Veteran's claims file should be returned to the April 2011 examiner who conducted the hearing loss and tinnitus examination. If the April 2011 VA is unavailable, forward the claims file to an appropriate medical professional to offer the addendum opinion. An examination of the Veteran is not required unless deemed necessary by the medical professional selected to offer the opinion. The claims file, to include a copy of this remand, must be made available to and be reviewed by the examiner. The claims file and any pertinent evidence in Virtual VA must be reviewed by the examiner. The examiner is advised that the Board finds that the Veteran has been diagnosed with tinnitus and has competently indicated that he has tinnitus during the course of the appeal. Therefore, the examiner is requested to offer an opinion regarding the following: Following a review of the Veteran's claims file, and with consideration of the Veteran's statements as to observable symptoms, other lay statements of record, and a review of the Veteran's history of inservice and post service noise exposure, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's current tinnitus had its onset during, or is otherwise related to, his military service. The examiner must also provide an opinion based on the evidence of record as to whether it is at least as likely as not that the Veteran's hearing loss recorded in February and April 2006 was caused by chronic otitis media and, if so, whether it is at least as likely as not that the chronic otitis media condition was incurred during active duty service. If the reviewer is unable to provide the requested opinions without resort to mere speculation, the reviewer shall state the reasons why that is the case. 3. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the Veteran's claims remaining on appeal must be readjudicated. If any benefit sought on appeal remains denied, the Veteran and his representative must be furnished a supplemental statement of the case and be given the opportunity to respond thereto. The appeal must then be returned to the Board for appellate review. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court or additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ RYAN T. KESSEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs