Citation Nr: 1329457 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 08-20 525 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUE Entitlement to service connection for left ear hearing loss. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran had active service from January to June 1973 and from January 1974 to January 1977. This case comes to the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision by the RO in Waco, Texas. A personal hearing was held before the undersigned acting Veterans Law Judge at the RO (i.e., a Travel Board hearing) in September 2010. A transcript of this hearing is of record. In March and December 2012, the Board remanded this case to the RO for additional development. The case was subsequently returned to the Board. FINDINGS OF FACT 1. The Veteran has sufficient hearing loss in his left ear to be considered a ratable disability by VA standards. 2. The most probative (competent and credible) medical and other evidence of record indicates the Veteran's current left ear hearing loss disability is unrelated to his military service. CONCLUSION OF LAW The Veteran's current left ear hearing loss disability was not incurred or aggravated during his active military service, and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Duties to Notify and Assist VA has duties to notify and assist the Veteran in substantiating this claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Proper notice from VA must inform the Veteran of any information and medical or lay evidence not of record: (1) that is necessary to substantiate this claim; (2) that VA will obtain and assist him in obtaining; and (3) that he is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). These VCAA notice requirements apply to all five elements of a service-connection claim: (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), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a downstream disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id., at 486. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and readjudicating the claim - such as in a SOC or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In this case, an April 2007 letter was sent prior to the adjudication of this claim in the November 2007 decision on appeal. That letter informed the Veteran of the type of information and evidence required to substantiate this claim for service connection and apprised him of his and VA's respective responsibilities in obtaining this supporting evidence. He also was advised of the downstream disability rating and effective date elements of this claim in this letter. See Dingess/Hartman, supra. The claim was most recently readjudicated in an April 2013 supplemental statement of the case. So he has received all required VCAA notice concerning this claim. Moreover, he has not alleged any prejudicial error in the content or timing of the VCAA notice he received. As explained in Shinseki v. Sanders, 129 S. Ct. 1696 (2009), he, not VA, has this burden of proof of showing there is a VCAA notice error in timing or content and, moreover, that it is unduly prejudicial - meaning outcome determinative of his claim. Thus, absent this pleading or showing, the duty to notify has been satisfied. And as for the duty to assist, the RO obtained the Veteran's service treatment records (STRs) and VA treatment records. He also had VA compensation examinations in October 2007 and April 2012, and a March 2013 VA medical opinion concerning the determinative issue of whether any current hearing loss disability is related to his military service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C.A. § 5103A(d)(2); and 38 C.F.R. § 3.159(c)(4). The reports of these examinations, and the other evidence in the file, contain the findings needed to make this critical determination of causation and properly adjudicate this claim. So additional medical comment concerning this is not needed. 38 C.F.R. § 4.2. See also 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). Also see 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). Notably, the Board primarily remanded this case in March and December 2012 so the AMC might obtain VA medical records and arrange for another VA examination and medical opinion, which has been done. The Board is therefore satisfied there was compliance with these remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) and Dyment v. West, 13 Vet. App. 141, 146- 47 (1999). A Court or Board remand confers upon the appellant the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board concludes that all the available records and medical evidence have been obtained in order to make a determination as to this claim. 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 v. Principi, 16 Vet. App. 183 (2002). Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claim. At this time, the Board also notes that it is cognizant of the ruling in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. § 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The Board finds that this was done at the September 2010 Board hearing. Moreover, as discussed above, to the extent possible, VA has obtained the relevant evidence and information needed to adjudicate this appeal. Neither the appellant nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the June 2010 Board hearing. Analysis The Veteran contends that he incurred left ear hearing loss as a result of noise exposure in service. In his June 2008 substantive appeal (VA Form 9), he said that he was in an artillery unit and fired 55 millimeter howitzers on a constant basis, and that he stood on the right side of the artillery piece. The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the appellant's claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Sensorineural hearing loss (as an organic disease of the nervous system) is a chronic disease, per se, which 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; 38 C.F.R. §§ 3.307, 3.309(a). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the United States Court of Appeals for the Federal Circuit (Federal Circuit Court) held that a three-element test must be satisfied in order to establish entitlement to 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 so-called "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 F3d. 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 causes unrelated to service ("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. The Federal Circuit Court noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a Veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, 708 F3d. at 1336. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three- element test for entitlement to disability compensation"). Significantly, the Federal Circuit Court indicated that showing a continuity of symptomatology after service is a lesser evidentiary burden than the nexus requirement of the three-part test discussed above: "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" Id. at 1339. 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 Federal Circuit Court held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. at 1338-40. By regulation, sensorineural hearing loss is subject to service connection based upon 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. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, the tinnitus (ringing in the ears), etc.), (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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). See also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Turning to the evidence of record. For purposes of applying the laws administered by VA, impaired hearing only will be considered to be a ratable disability when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz (Hz) 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. That said, to establish entitlement to service connection, it is not required that a hearing loss disability by these standards of 38 C.F.R. § 3.385 be demonstrated during service, including at time of separation, although a hearing loss disability by these standards must be currently present, and service connection is possible if this current hearing loss disability can be adequately linked to service. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Service connection for hearing loss may be granted where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting regulatory requirements for hearing loss disability for VA compensation purposes (i.e., 38 C.F.R. § 3.385), and a medically sound basis upon which to attribute the post-service findings to the injury in service, as opposed to intercurrent causes. Hensley v. Brown, 5 Vet. App. 155 (1993). The results of the Veteran's October 2007 and April 2012 VA audiological examinations confirm he has sufficient hearing loss in each ear to be considered a ratable disability according to the requirements of 38 C.F.R. § 3.385. The question remaining is whether his current left ear hearing loss disability is related to 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."). See Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); and Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). The Veteran's DD Form 214 reflects that his primary military occupational specialty (MOS) was that of a wheeled vehicle mechanic. His secondary specialty was power gen. equipment op. mechanic. He had no foreign or sea service, and received no combat citations. STRs are entirely negative for complaints, diagnosis or treatment of hearing loss. On entrance medical examination in December 1973, audiometric testing revealed right ear decibel thresholds of 10, 5, 5, 5, and 15, and left ear decibel thresholds of 15, 10, 10, 15, and 20 at the respective frequencies of 500, 1000, 2000, 3000 and 4000 hertz. On separation medical examination in November 1976, the Veteran's ears were listed as normal, and audiometric testing revealed right ear decibel thresholds of 0, 5, 5, and 15, and left ear decibel thresholds of 5, 5, 5, and 15 at the respective frequencies of 500, 1000, 2000, and 4000 hertz. A December 1976 Rudmose tracing was attached to the separation examination report. In a November 1976 report of medical history, the Veteran denied a history of hearing loss, and denied ear, nose or throat trouble. A June 2007 VA outpatient audiology consultation reflects that the Veteran reported that he had hearing loss in his left ear since service. He stated that he had gradual decrease in hearing for both ears since military service, and gave a history of noise exposure from field artillery, and occupational noise exposure from oil-field work and as a truck driver. The examiner noted that his responses to pure tone testing were inconsistent with speech reception thresholds, and were significantly worse than the latter. These improved with repeated reinstruction, but were still inconsistent with speech testing, and were not reported due to poor reliability. The diagnostic assessment was "Unable to assess hearing abilities at this time due to poor reliability/inconsistent responses." On VA audiological examination in October 2007, the Veteran reported that his MOS in service was as a tracked vehicle mechanic, and he was assigned to a 155 millimeter howitzer battalion, and was cross training as a gunner. He also worked on the M-60 tank as a mechanic. He reported that his ears sometimes got stopped up and he could not hear well, which could last for more than a week. The examiner stated that he had significant non-military noise exposure, and worked as a forklift operator for 11 years and in quality assurance as an inspector. Audiometric testing revealed right ear decibel thresholds of 25, 20, 30, 50 and 60, and left ear decibel thresholds of 25, 20, 30, 50 and 60 at the respective frequencies of 500, 1000, 2000, 3,000 and 4000 hertz. Speech recognition scores using the Maryland CNC test were 96 percent in the right ear and 96 percent in the left ear. The examiner indicated that his hearing in both ears was within normal limits to 1000 hertz, there was a mild sensorineural hearing loss at 2000 hertz, and moderate sensorineural hearing loss at 3000 and 4000 hertz. The examiner stated that the claims file was reviewed. The examiner stated that upon review of the STRs, a December 1976 Rudmose tracing was well within normal limits for both ears, and this was part of his separation physical examination. He stated that based on the STRs it was his clinical opinion that a hearing loss was not caused by or the result of his military duties, and that it is commonly accepted in audiology that when a person is removed from a noisy environment, the hearing should not change. Some of the exceptions to this are the aging process, further noise exposure, medications, and illness. He concluded that it is commonly accepted that hearing loss will take place at the time of the noise exposure or soon afterwards, but not years later. At his September 2010 Board hearing, the Veteran stated that a VA doctor told him his hearing loss was related to service. He testified that he had hearing trouble in service but did not seek medical treatment. He reported noise exposure from artillery in service, and denied exposure to loud noises during his post-service work as a truck driver. On VA examination in April 2012, audiometric testing revealed right ear decibel thresholds of 30, 30, 35, 50 and 60, and left ear decibel thresholds of 25, 20, 30, 45 and 65 at the respective frequencies of 500, 1000, 2000, 3,000 and 4000 hertz. Speech recognition scores using the Maryland CNC test were 96 percent in the right ear and 96 percent in the left ear. The examiner diagnosed bilateral sensorineural hearing loss. The examiner reviewed VA medical records but did not review the claims file. The examiner noted that the Veteran reported military noise exposure from artillery, and said he worked as a truck driver after service. The examiner did not provide an opinion as to the etiology of the hearing loss. In a May 2012 addendum, the VA examiner again stated that the claims file was not reviewed, but nonetheless commented on the STRs. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale was that the November 1976 separation audiogram revealed hearing to be within normal limits bilaterally from 500 to 4000 hertz with no threshold shifts, and there were no complaints of hearing problems in the STRs. The Veteran reported a history of occupational noise exposure as a truck driver following military service. The examiner opined that the hearing loss present today is more likely caused by some combination of occupational/recreational noise exposure and family history than from his brief military service. She concluded that the hearing loss present today was less likely as not caused by military noise exposure. In a March 2013 VA addendum medical opinion, the same VA examiner stated that the claims file was reviewed, and commented on relevant medical records. She opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner included her rationale from the prior examination report, and added further comment. She stated that the Veteran had post- service noise exposure as a truck driver, oil field worker, forklift operator and inspector. His hearing at separation was within normal limits, as documented in the separation audiogram. She stated that an audiogram is the objective, definitive evidence of normal hearing, and that hearing loss due to noise exposure occurs at the time of exposure and has no delayed onset. She noted that in a 2006 study by the Institute of Medicine (IOM) entitled "Noise and Military Service - Implications for Hearing Loss and Tinnitus," the IOM concluded that based on current knowledge of cochlear physiology concluded there was no sufficient scientific basis for the existence of delayed onset hearing loss. She concluded that it was unlikely that the hearing loss present today was caused by military noise exposure while he served as a wheeled vehicle mechanic and had claimed additional duty of firing artillery. 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, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Board sees that the Veteran has made varying statements regarding his history of noise exposure throughout this appeal. A June 2007 VA outpatient treatment record reflects that the Veteran reported that he had gradual decrease in hearing for both ears since military service. He gave a history of noise exposure from field artillery, and occupational noise exposure from oil-field work and as a truck driver. On VA examination in October 2007, he reported noise exposure during service when he cross-trained as a gunner assigned to a howitzer battalion. He also reported noise exposure after service working as a forklift operator for 11 years and in quality assurance as an inspector. At his September 2010 Board hearing, he testified that he had noise exposure while firing artillery in service, and that after service he was a truck driver with no exposure to loud noises. On VA examination in April 2012, he reported military noise exposure from artillery, and said he worked as a truck driver after service. The Veteran's service treatment records (STRs), including his entrance and separation examinations, are unremarkable for complaints of noise-related injury to his ears or treatment or a diagnosis of hearing loss. In Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006), the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) recognized lay evidence as potentially competent to support the presence of the claimed disability, both during service and since, even where not corroborated by contemporaneous medical evidence such as actual treatment records (e.g., STRs, etc). In other words, the Board cannot determine lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence, although this may factor into the Board's decision of whether the evidence is ultimately probative. The Federal Circuit Court has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Board therefore may consider the absence of any indication of a relevant medical complaint until relatively long after service as one factor, though not the only or sole factor, in determining whether a disease or an injury in service resulted in chronic or persistent residual disability. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). See also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (cautioning that negative evidence, actual evidence weighing against a party, must not be equated with the absence of substantive evidence). In cases involving combat, VA is prohibited from drawing an inference from silence in the STRs. But in cases, as here, where this inference is not prohibited [i.e., non-combat scenarios], the Board may use silence in the STRs as contradictory evidence if the alleged injury, disease, or related symptoms ordinarily would have been recorded in the STRs. See Kahana v. Shinseki, 24 Vet App 428 (2011). See also Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (For non-combat Veterans providing non-medical related lay testimony regarding an event during service, Buchanan is distinguishable; the lack of documentation in service records must be weighed against the Veteran's statements.) In this circumstance, the Board must make two preliminary findings in order to rely on this inference (see Kahana): First, the Board must find that the STRs appear to be complete, at least in relevant part. If the STRs are not complete in relevant part, then silence in the STRs is merely the absence of evidence and not substantive negative evidence. Second, if the STRs are complete in relevant part, then the Board must find that injury, disease, or related symptoms ordinarily would have been recorded had they occurred. In making this determination, the Board may be required to consider the limits of its own competence on medical issues. Ultimately, the Board must consider all the evidence relevant to the claim, including the availability of medical records, the nature and course of the disease or disability, the amount of time that has elapsed since military service, and any other pertinent facts. Cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact-finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). This particular Veteran served during wartime, but the evidence (including his own statements) shows that he did not serve in combat. Accordingly, the acoustic trauma he claims to have sustained during his service did not occur in combat. Moreover, his STRs appear to be complete in relevant part, in turn meaning it is acceptable for the Board to have expectation of some complaint, treatment or diagnosis regarding his hearing acuity while in service, which, again there was not. So this is evidence tending to go against the notion that his hearing loss began in service. This does not preclude granting service connection, however, because even disorders initially diagnosed after service may be service connected if the evidence, including that pertinent to service, establishes the disorder was incurred in service. See 38 C.F.R. § 3.303(d) . In determining whether statements submitted or made by a Veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). See also Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self- interest, malingering, desire for monetary gain, and witness demeanor). Here, after reviewing all the relevant lay and medical evidence, the Board finds that the weight of this evidence (the most probative of it) indicates the Veteran has not experienced continuous hearing loss symptoms since service. His lay testimony concerning this, while competent, is not credible. The Board finds that his more recently-reported history of continued symptoms of hearing loss since service is inconsistent with the other lay and medical evidence of record. Indeed, while he now asserts this disorder began in service, in the more contemporaneous medical history he gave during his military separation examination, he did not report any history or complaints of symptoms of hearing loss. Moreover, the service separation examination report reflects that he was examined and that his hearing was found to be clinically normal. The unremarkable history of symptoms he recounted while in service, including at the time of his separation examination, is far more contemporaneous to the claimed injury during service in question, so is of more probative value than his more recent assertions to the contrary made long after the fact. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later); Struck v. Brown, 9 Vet. App. 145, 155-56 (1996) (Contemporaneous medical findings may be given more probative weight). The post-service medical evidence does not reflect any complaints or treatment related to hearing loss for 30 years following the conclusion of his service. And while it is true he need not have received continuous treatment for his hearing loss during those many intervening years after the conclusion of his service up to the present, only instead have experienced persistent or recurrent symptoms, the absence of any intervening complaints or findings related to this disability for so long after service is a factor weighing against continuity of symptomatology. 38 C.F.R. § 3.303(b) (2012). See also Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (ruling that a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service resulting in any chronic or persistent disability); Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where Veteran had failed to account for lengthy time period between service and initial symptoms of disability). The Veteran did not claim that hearing loss symptoms began in (or soon after) service until filing his current VA disability compensation claim in 2007. Such statements made for VA disability compensation purposes are of lesser probative value when in contradiction to histories he previously provided. See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). Throughout this appeal, the Veteran has consistently asserted that his hearing loss is related to service. He is certainly competent to say he began having difficulty hearing while in service since this is within the realm of lay experience. 38 C.F.R. § 3.159(a)(2). See also Jandreau, supra; Davidson, supra; Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). However, he has given inconsistent reports to different medical providers about whether or not he had noise exposure during his post-service employment. These inconsistencies in the record weigh against his credibility as to the assertion of continuity of symptomatology since service. See Madden v. Gober, 125 F.3d 1477, 1481 (Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with this claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, his previous history as reported to different examiners, and the absence of complaints or treatment for so many years after service. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms since service. Moreover, the VA examiner has disassociated any current hearing loss from service, after clinical examination and a review of his claims file and medical records. Considered together, the April 2012 medical report and May 2012 and March 2013 addenda are of high probative value because the examiner is qualified to comment on the etiology of this claimed disorder, examined the Veteran, reviewed his medical records, and considered the Veteran's reported history of acoustic trauma both during and after service. The examiner had the benefit of reviewing the Veteran's claims file and, thus, not only considered what is said to have occurred during service but also during the many years since. The March 2013 opinion is well reasoned, detailed, and consistent with the other evidence of record. Prejean v. West, 13 Vet. App. 444 (2000). But, even more importantly, this commenting VA examiner sufficiently discussed the underlying medical rationale of the opinion, which, rather than mere review of the claims file, is more so where the probative value of the opinion is derived. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Green v. Derwinski, 1 Vet. App. 121 (1991). Finally, the Board notes that there is no competent evidence of record linking the current left ear hearing loss to service, and no evidence of sensorineural hearing loss manifested to a compensable degree within the first post- service year. Although the Veteran testified that a VA doctor told him his hearing loss was related to service, the VA medical records do not verify this statement. Moreover, the connection between what a physician said and a layman's account of what the physician purportedly said, filtered as it was through a layman's sensibilities, simply is too attenuated and inherently unreliable to constitute competent medical evidence in support of a claim for service connection. See Robinette v. Brown, 8 Vet. App. 69, 77 (1995). Although the Veteran himself has asserted that his current hearing loss is related to noise exposure in service, he has not been shown to have the necessary training or expertise to competently provide a medical nexus opinion as to the etiology of his sensorineural hearing loss, which is not the type of condition that is readily amenable to probative lay comment regarding its appropriate diagnosis and etiology. The Board therefore finds that the most probative evidence is against the claim. And since, for the reasons and bases discussed, the preponderance of the evidence is against the claim, there is no reasonable doubt to resolve in the Veteran's favor, and his claim for service connection for left ear hearing loss must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for left ear hearing loss is denied. ____________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs