Citation Nr: 1330093 Decision Date: 09/19/13 Archive Date: 09/25/13 DOCKET NO. 07-07 571 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a gastrointestinal disorder, to include colitis and rectal bleeding. 2. Entitlement to service connection for idiopathic thrombocytopenic purpura (ITP), to include as due to Agent Orange exposure. 3. Entitlement to service connection for recurrent infections, to include as due to Agent Orange exposure. 4. Entitlement to service connection for otalgia, to include as secondary to bilateral hearing loss and/or service-connected tinnitus. 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for a lumbar spine disorder. 7. Entitlement to service connection for a bilateral hip disorder. 8. Entitlement to service connection for a right hip scar. ATTORNEY FOR THE BOARD Rebecca Feinberg, Counsel INTRODUCTION The Veteran served on active military duty from April 1966 to February 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Houston, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA). The Board notes that the issue of entitlement to service connection for rectal bleeding has been recharacterized as a petition to reopen a claim for entitlement to service connection for a gastrointestinal disorder, to include rectal bleeding and colitis. The Veteran filed a claim for entitlement to service connection for rectal bleeding. A claim for service connection for a disability encompasses all relevant symptomatology, regardless of how that symptomatology is diagnosed. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009). This is because a claimant generally is not competent to diagnose his or her specific condition where such a diagnosis requires medical expertise; he is only competent to identify and explain the symptoms that he observes and experiences. Clemons, 23 Vet. App. at 4-5. Post-service discharge medical records contain complaints and diagnoses of rectal bleeding and colitis. Thus the issue is more properly characterized as a claim for a gastrointestinal disorder. Additionally, as more fully addressed in the remand section, the issue is a claim to reopen and not a service connection claim. The Veteran's claims were previously before the Board. In a February 2013 decision, the Board reopened the claims regarding bilateral hearing loss, a lumbar spine disorder, a bilateral hip disorder, and a right hip scar and remanded the matters for additional development. In addition, the claims of entitlement to service connection for recurrent infections, ITP, and otalgia, and the application to reopen the claim of entitlement to service connection for a gastrointestinal disorder were remanded for additional development. With regard to the claims decided herein, and as will be explained in more detail below, the remand directives, to the extent possible, were complied with, and the claims may be adjudicated by the Board at this time. Stegall v. West, 11 Vet. App. 268, 271 (1998). In a June 2013 written and signed statement, the Veteran indicated that he was withdrawing the representation he had previously assigned to Texas Veterans Commission and wished to represent himself. The Board recognizes this change. The issues of a petition to reopen a claim for entitlement to service connection for depressive disorder and whether there was clear and unmistakable error (CUE) in the June 1970 denial of service connection for a skin disorder and in an earlier denial of service connection for tinnitus were raised in a March 2008 submission, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. A review of the Veteran's virtual VA claims files reveals that they contain only evidence that is duplicative of that already contained in the claims file or irrelevant to the issues decided herein. The issues of whether new and material evidence has been received to reopen a claim of entitlement to service connection for a gastrointestinal disorder and the claim of entitlement to service connection for ITP 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. Recurrent infections did not manifest in service and are unrelated to service. 2. Otalgia did not manifest in service and is unrelated to service, nor is it related to a service-connected disability. 3. Bilateral hearing loss did not manifest in service, an organic disease of the nervous system did not manifest within the one-year presumptive period, and bilateral hearing loss is unrelated to service. 4. A lumbar spine disorder did not manifest in service, arthritis did not manifest within the one-year presumptive period, and a lumbar spine disorder is unrelated to service. 5. A bilateral hip disorder did not manifest in service and is unrelated to service. 6. A right hip scar did not manifest in service and is unrelated to service. CONCLUSIONS OF LAW 1. Recurrent infections were not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. Otalgia was not incurred in or aggravated by active military service nor is it proximately due to a service-connected disease or injury. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 3. Bilateral hearing loss was not incurred in or aggravated by service and an organic disease of the nervous system (including sensorineural hearing loss) may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 4. A lumbar spine disorder was not incurred in or aggravated by active military service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 5. A bilateral hip disorder was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 6. A right hip scar was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminarily, the Board notes that some of the Veteran's claims are unclear. In particular, it is not clear what kind of recurrent infections the Veteran claims. Additionally, his claims regarding the presence of CUE in several different RO decision are not well-defined. In August 2008, an RO employee contacted the Veteran to clarify some of these issues. In a report of contact, it was noted that the Veteran's response to the clarification requests were that his statements of record were already clear and that he did not understand why VA was requesting clarification. No further clarification or assistance was provided. The Board notes that "the duty to assist is not always a one-way street", but that it attempted to assess the scope of the claims and arguments by construing the statements of record in the light most favorable to the Veteran. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). VA's Duties to Notify and Assist With respect to the claims for entitlement to service connection for recurrent infections, bilateral hearing loss, a back disability, a bilateral hip disability, a right hip scar, and otalgia, 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). 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, 186-87 (2002). This notice must be provided prior to an initial RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). VCAA notice requirements 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication, such as where (1) the claimant demonstrates actual knowledge of the content of the required notice; (2) a reasonable person could be expected to understand from the notice what was needed; or (3) a benefit could not have been awarded as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. 396 (2009). Defective timing may be cured by a fully compliant notice letter followed by a readjudication of the claim. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, VA's duty to notify has been satisfied. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b). Regarding the claims for service connection, letters that provided the required notice were sent in February and August 2008, prior to the initial adjudication of the claims in a March 2009 rating decision. Accordingly, VA's duty to notify has been satisfied. VA's duty to assist the Veteran has also been satisfied. 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran's service treatment records (STRs), VA medical records, and identified private medical records were obtained and reviewed. The Veteran has been provided with VA examinations relevant to all claims decided herein. McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). Here, as will be discussed further below, the evidence of record shows that, with regard to bilateral hearing loss and otalgia, the VA examiners were not able to provide opinions because the Veteran did not cooperate with the examination. As was noted above, the duty to assist is not a one-way-street, and the Veteran must participate to the extent possible to obtain needed evidence. Wood v. Derwinski, 1 Vet. App. at 193. In this case, the Veteran failed to cooperate with the examiners. Therefore, while these examination reports do not contain the requested opinions, the Board finds that it is due to the unwillingness of the Veteran to participate, and additional development is not warranted. Regarding the claims of entitlement to service connection for recurrent infections, a back disability, a bilateral hip disability, and a right hip scar, the Board finds that the examinations were thorough and complete. The Veteran's history was solicited and considered, and the examiners reviewed the claims file and provided conclusions based upon the evidence of record. The examination reports are, therefore, adequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in determining the probative value of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). In August 2004, the RO made second attempts to obtain records from H.A. and S.K., two private providers that the Veteran indicated had treated him. No records were returned from either facility. In an August 2004 letter, the Veteran was informed that these attempts to obtain the records had been made, and the RO reminded him that it was his responsibility to make sure they became a part of the record. The Board finds that the RO made the necessary attempts to obtain these private records and complied with the provisions of 38 C.F.R. § 3.159(c)(1). As the Veteran was provided with VA examinations regarding all of the claims decided herein, the Board finds that the February 2013 remand directives have been complied with, to the extent possible, and the Board may proceed with this adjudication. Stegall v. West, 11 Vet. App. 268, 271 (1998). There is no indication in the record that additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. at 121-22. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 542-43 (2006), aff'd, Mayfield v. Nicholson, 499 F.3d 1317 (2007); see also Dingess/Hartman, 19 Vet. App. at 486. Claims for service connection The Veteran does not allege, and the evidence does not suggest, that he engaged with combat with the enemy during service. Therefore, the provisions of 38 U.S.C.A. § 1154(b) are not for application. Generally, service connection may be established for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In order to establish service connection, the following must be shown: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including other organic diseases of the nervous system (which includes sensorineural hearing loss) and arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. As an organic disease of the nervous system, which includes sensorineural hearing loss, and arthritis, are considered to be a chronic disease for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Lay testimony is competent to establish a diagnosis where the layperson is competent to identify the medical condition, is reporting a contemporaneous medical diagnosis, or describes symptoms that support a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Additionally, service connection may be granted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). The Veteran has not alleged, and his service records do not suggest, that he had any service in Vietnam. He has noted that he service in Okinawa, and his service records show that this was the case in 1969. Because he lacks the requisite service, the presumptive disability provisions do not apply. 38 C.F.R. § 3.307(a)(6)(iii). Nevertheless, in Combee v. Brown, the United States Court of Appeals for the Federal Circuit held that, when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994), reversing in part Combee v. Principi, 4 Vet. App. 78 (1993). In various written statements, the Veteran asserts that he was stationed in Okinawa and was exposed to jet and aircraft engine fuel emissions, aircraft lubricants, chemical dioxins and toxins, outgoing airborne transportation of chemical dioxins and toxins or herbicide agents in support of the Vietnam conflict. Recurrent Infections In his February 2008 claim, the Veteran appeared to assert that infections of the skin, ear, respiratory system, and throat were due to exposure to Agent Orange. He reiterated this in a September 2008 written statement as well as several others. Despite the RO seeking further clarification in August 2008, the Veteran refused to provide any. A December 1968 service record shows that the Veteran had an upper respiratory infection and tonsillitis. When he was examined in January 1970, all of the Veteran's systems, including the mouth, ears, skin, and respiratory were normal. He denied a history of chronic or frequent colds and sinusitis. He reported a history of chronic earaches. A February 1998 private report shows that the Veteran did not report a current or recent history of nasal congestion, "sinus," sore throat, cough, or skin rashes. An undated report of history, submitted subsequently, shows that the Veteran reported sore throats as a current problem. A July 2007 private outpatient record shows a diagnosis of acute sinusitis, and a February 2009 private record shows treatment for acute bronchitis and sinusitis. In April 2013, the Veteran underwent VA examination. A previous diagnosis of allergic rhinitis is noted to have been given in April 2013. Acute tonsillitis was also noted to have been treated in December 1968. There was also evidence of rhinitis and larynx or pharynx condition. With regard to infectious diseases, a diagnosis of boils was noted to have been present in November 2012 and February 2013. It had resolved. When asked what he was claiming recurrent infections for, the Veteran stated it was due to his getting the flu and recurrent boils. He had tonsillitis and upper respiratory infections that were resolved. The examiner noted that the flu was an acute infection and was resolved. The boils on the buttock area, which occurred 40 years after separation from service, recurred once and resolved with only residuals of hyperpigmented scars. The claim of recurrent infection is but a culmination of acute infections that the Veteran had that have since resolved. There was no diagnosis for recurrent infections because, at the moment, there were no symptoms and no current clinical objective evidence of diagnosable disease or pathology. The examiner concluded that the infections were less likely than not incurred in or caused by service. The Veteran stated that his claim was based on recurrent tonsillitis, upper respiratory infections, and annual flu infections. The examiner noted that, while there is evidence that the Veteran had enlarged tonsils in December 1968, it was not uncommon to have enlarged tonsils while sick. They are like any other lymph tissue that swelled with illness. Additional December 1968 service records document an illness consisting of the flu and tonsillitis that took several weeks to resolve. Subsequently, there was no further documentation of tonsillitis, tonsillar hypertrophy, upper respiratory infections, or the flu. Tonsillitis, upper respiratory infections and the flu are acute illnesses and do not show chronicity based on the records reviewed. It was not abnormal to have one to three respiratory illnesses in a year. The skin infection the Veteran was referring to was his eczema. The skin boils occurred more than forty years after separation from service and are not recurrent skin infections related to any event, illness, or injury from service. Therefore, it was less likely as not that any recurrent infections were caused or aggravated by service. The claims file reveals that the Veteran is already in receipt of service connection for tinea cruria/eczema of the hands, feet, and groin. Therefore, to the extent that the Veteran seeks service connection for recurrent infections that involve the skin, any findings of tinea cruria or eczema of the hands, feet, and groin are not at issue here. The April 2013 VA examination report is adequate and addresses all potential matters raised by the Veteran regarding this claim. Specifically, evidence of possible recurrent infections involving boils, tonsillitis, the flu, and upper respiratory infections are considered and discussed, as some of them had been present in service. However, in a well-reasoned and supported opinion, the VA examiner determined that boils were not related to service, in that they had occurred more than forty years after separation and also indicated that the other infections referenced by the Veteran were acute and resolved during service. The post-service infections are not related to service. While the examiner did not specifically indicate that the infections were not related to Agent Orange or any other chemical exposure, the entirety of the opinion shows that the infections claimed by the Veteran were acute and resolved prior to his separation. See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (noting that medical reports "must be read as a whole" in determinations of adequacy). They are not related to any post-service diagnoses. In addition, the Veteran did not lay out a factual foundation for concluding that he was exposed to Agent Orange or any other chemical. Nevertheless, as stated above, even assuming he had been exposed to a chemical, the examiner's opinion, which is more probative than the Veteran's, concludes that the Veteran's recurrent infections, to the extent that they even exist, are not due to service. A layperson may be competent in some instances to provide opinions regarding diagnosis and etiology. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the Board finds that, in this case, the opinion of the medical professional is more probative than that of the Veteran. The VA examiner has a history of medical knowledge, education, and experience that the Veteran is not shown to have. In addition, the opinion was supported by a well-reasoned rationale based upon a review of the record. The Veteran's lay statement is a bare opinion that contains no support or rationale for the conclusion. As such, the opinion provided by the VA examiner in April 2013 is more probative than the Veteran's assertions, and the evidence against this claim outweighs the evidence in its favor. Otalgia and Bilateral Hearing Loss Impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels (dB) or greater or where the auditory thresholds for at least three of these frequencies are 26 dB or greater or when speech recognition scores are less than 94 percent. 38 C.F.R. § 3.385 (2012). When examined upon entry into service in February 1966, the Veteran's ears were normal. Pure tone thresholds, in decibels, were as follows, with the ANSI units then in use in parentheses and the currently used ISO units next to them: HERTZ 500 1000 2000 3000 4000 RIGHT (-10) 5 (-5) 5 (-5) 5 N/A (-5) 0 LEFT (-5) 10 (-5) 5 (-5) 5 N/A (-5) 0 A March 1967 service record shows that the Veteran was noted to have external otitis. When examined for separation in January 1970, the Veteran's ears were normal, and pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 20 15 20 20 LEFT 20 10 5 15 25 At that time, the Veteran reported a history of frequent trouble hearing and chronic earaches. In May 1970, the Veteran filed his original claim, which did not include a claim regarding hearing loss or the ears. Another claim filed in July 1982 did not include a claim of entitlement to service connection for hearing loss or the ears. February and March 1998 private reports of current and recent medical history show that the Veteran did not report poor hearing, while he did report other symptoms, including ringing in the ears. An October 2003 private report shows that the Veteran complained that he was exposed to loud aircraft noises and began having difficulty with loss of hearing during service. Hearing loss, without examination, was noted in a review of symptoms. Hearing loss was noted as an assessment with a notation that the Veteran was exposed to aircraft noise on the tarmac for at least three years. The physician opined that hearing loss was directly related to service. In September 2004, the Veteran underwent VA examination. He stated that he was a welder and maintenance scheduler in service. He reported decreased hearing bilaterally since the 1970s. His history was negative for ear infections, ear surgery, severe head injury, and familial hearing loss. His noise history included exposure to aircraft and ground power units. After leaving service, he became a building maintenance administrator and reported that he was no longer noise exposed. Pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 20 25 30 LEFT 20 20 15 25 35 The Veteran exhibited mild high frequency sensorineural hearing loss at 4000Hz bilaterally. Intertest consistency was good for the right and left ears. The examiner opined that it was unlikely that the Veteran's hearing loss had its origins during active service. This was based on entry and exit physical examination hearing evaluations, where his hearing was normal at 500Hz through 4000Hz bilaterally. November and December 2007 private records show that the Veteran sought treatment for hearing loss and possible blister polyp of the left ear. Audiological evaluation results, which were reported on a graph, suggested hearing impairment at a level deemed to be a disability for VA purposes. However, the test reliability was noted to be "fair." It was noted that the Veteran was very inconsistent with his responses, even after numerous reinstruction instances. The impression was sensorineural hearing and otalgia. A September 2008 private report of an audiological evaluation shows that the Veteran demonstrated pure tone thresholds that appear to be disabling for VA purposes. However, the reliability of the test was noted to be "fair," and the examiner noted that the Veteran was very inconsistent with his pure tone responses, and multiple reinstruction was required. In an April 2013 written statement, a VA examiner indicated that the Veteran had been scheduled for a VA examination. No audiologic data was reported for the Veteran because he could not or would not provide valid and reliable hearing test results. He did not respond to spoken words. There was no response to pure tones, except for 250Hz in both ears, and those were at the limits of the audiometer. Contralateral acoustic reflex thresholds and ipsilateral acoustic reflexes were obtained that produced thresholds that were all better than the Veteran's voluntary air conduction thresholds. Such findings were indicative of a non-organic component to hearing status since acoustic reflex thresholds were a supra-threshold measurement. No opinion regarding hearing loss could be provided without resorting to mere speculation as a result of those audiometric findings. In April 2013, the Veteran presented for examination regarding ear conditions. A previous history of otitis media was noted in March 1967, May 2012, and December 2012. He described an explosion in service, after which his ears started hurting. He sought treatment for other disorders but his ear pain was not treated. The examiner noted that a review of the record showed no further in-service treatment for ear diseases or for forty years after separation. The Veteran also described recurrent ear infections in 2009 and 2012. The examiner indicated that otalgia (ear pain) was subjective, and there was no diagnosis, because the examination was not reliable due to the Veteran just saying that he could not feel anything. Then, his foot would jump due to his being ticklish. He stated that he was unable to feel when the examiner touched his face. The Veteran just said "no" to everything. His ear, nose, and throat examination was within normal limits except for one inflammation in one nostril, and there was no way to know how long it had been there. The ear examination was normal, with no complaints of pain when the ears were being checked. Based on the evidence of record, the Board finds that service connection for sensorineural hearing loss and otalgia must be denied, to include on a secondary basis. The record is inadequate for making a decision in either case. However, the Veteran failed to cooperate in either examination, causing both examiners to determine that opinions could not be provided. As stated above, the duty to assist is not a one-way-street, and the Veteran must actively participate, when necessary, to allow VA to obtain all of the required evidence in his case. Wood v. Derwinski, 1 Vet. App. at 193. Here, both examiners indicated that the Veteran did not cooperate during the necessary examinations. As such, adequate opinions regarding etiology could not be obtained for either disorder, and the record lacks the evidence that would be needed to grant this claim. As further explanation, the Board finds that the opinion provided by a private physician in October 2003 that hearing loss is due to noise exposure during service is not adequate because no rationale is provided and no audiological testing was shown to occur. In fact, there is no adequate and reliable test result of record that demonstrates that the Veteran's hearing loss meets the criteria necessary to be considered a disability for VA purposes. 38 C.F.R. § 3.385. The September 2004 VA examination report revealed puretone thresholds that were better than that needed to demonstrate disabling hearing. While the 2007 and 2008 private examinations suggest a hearing loss disability, both reports indicate that results were only fair and the Veteran did not follow instructions during testing. In addition, neither of the private records indicate that an examination consistent with that needed for VA purposes was conducted. There is no evidence that either private provider conducted the Maryland CNC Word Test. The only complete examination conducted that complies with the VA regulatory requirements, the VA examination completed in September 2004, demonstrates hearing that is not disabling for VA purposes. 38 C.F.R. § 4.85. Nevertheless, an adequate opinion with regard to etiology is not of record, and the Veteran's actions have stood in the way of VA obtaining such an opinion. Finally, while sensorineural hearing loss is a chronic disease for which presumptive service connection may be awarded, this chronic disease is not noted in service, and the Veteran has not asserted that it has existed since that time. He generally reported during one incident of treatment that his hearing loss began in the 1970s but did not provide more specificity, and he later failed to report a history of hearing loss (while reporting the presence of other symptomatology) in 1998. The separation examination does not contain a notation or diagnosis of sensorineural hearing loss. Therefore, service connection for sensorineural hearing loss, as an organic disease of the nervous system, cannot be granted under the provisions of 38 C.F.R. § 3.303(b). While a layperson may be competent in some instances to provide opinions regarding diagnosis and etiology, see Jandreau v. Nicholson, 492 F.3d at 1376-77, in this case, the Veteran is not competent to assert that he has hearing loss at a level that is considered disabling for VA purposes, as this can only be found on audiological evaluation conducted by a licensed audiologist that includes the Maryland CNC Word Test. 38 C.F.R. § 4.85; Davidson v. Shinseki, 581 F.3d at 1315-16 (Fed.Cir.2009). In addition, given the Veteran's noncompliance with examinations regarding both of these claims, the Board finds that any assertion that can be gleaned from his written statements is not credible and not reliable. As such, the most probative evidence of record preponderates against the claim. Lumbar Spine, Right Hip, Right Hip Scar October 1967 service hospitalization records show that the Veteran was involved in a motor vehicle accident and suffered lacerations of his scalp, face, and leg and contusions of his body and upper and lower extremities. When examined for separation in January 1970, all systems were normal. The Veteran reported at that time that he wore a back brace and had occasional back pain since 1966. He reported a history of back trouble. When the Veteran filed claims in May 1970 and August 1982, they did not include claims related to the back or lumbar spine. A June 1987 private treatment record indicates that the Veteran was involved in a motor vehicle accident in April. Since that time, he had low back discomfort. Recent x-rays were unremarkable. As an assessment, the physician indicated that he was concerned that the Veteran had persistent pain for two months and may have had a disc problem. When the Veteran was seen for follow-up in August 1987, physical therapy had helped him. The assessment was probable disc syndrome. In January 1997 and February 1998 private records, the Veteran did not report the current or recent presence of back pain while reporting the presence of other symptoms. An October 2003 private treatment record shows that the Veteran reported right hip and leg pain and grinding. He stated that he fell off a jack stand in 1969, injuring his hip and back. A review of symptoms included chronic sciatica and radiculopathy to the right hip and chronic low back pain. The assessment was low back pain with radiculopathy and right hip pain. The physician opined that all of the Veteran's skeletal symptoms and clinical findings were as a result of his back and hip injury sustained in 1969 in service. They were worsened by continued physical demands of his job while continuing service. In September 2004, the Veteran underwent VA examination. He reported that he fell off a jet stand in 1968, injuring his back and right hip and lacerating the tissue in the upper third of the posterolateral aspect of the right hip. The wound was sutured and healed without infection. The scar was tender to deep pressure. There were no other symptoms. The diagnosis was post operative laceration, upper third, posterolateral aspect, right thigh. From a functional standpoint, the scar caused very little discomfort of any kind. It did occur at the time of his other injury, when he fell off the jet engine stand injuring his back and right hip. Therefore, it was at least as likely as not secondary to the same injury that caused his back strain and right hip. In September 2004, the Veteran underwent VA examination for his back and hip. The examiner reviewed the service records. On examination, the Veteran reported that his back pain began in 1970. He states that he sought treatment periodically beginning in 1970. The first entry by the Veteran that references the low back is dated in August 2003. At that time, the Veteran informed his private doctor that hurt his right hip and low back from falling off a jack stand in 1969. The Veteran's case clearly showed evidence of a motor vehicle accident in 1987, at which time the Veteran complained of low back pain. He reported that his last treatment for the back was in 2004. Following examination, the diagnosis was spondylosis of the lumbar spine without lower extremity radiculopathy. There was no significant musculoskeletal pathology identified of the right hip without ankylosis. The examiner, after reviewing the claims file, indicated that the evidence pointed to multiple variable injuries and accidents after service contributing to the back and hip problems. This included his career as a maintenance worker, his motor vehicle accident, his diagnosis of ITP, and his chronic use of steroid medications. All of these variables pointed to post-service causes and reasons for the back and hip pathology to include his overweight body habitus. There was no nexus association of the Veteran's right hip and back condition to active service events or scars. The lack of medical treatment made it impossible to implicate military incurred injuries as the source of his current spine and hip problem. His spinal pathology could also be explained as a natural aging process. A March 2005 private treatment record shows that the Veteran reported pain and soreness in his right hip. The assessment was right sciatica. In April 2013, the Veteran underwent VA examination. He claimed he was in Vietnam jumping and repelling and fell off a stand and lacerated his right lateral hip. It was then sutured. He stated that he was seen twice and given light duty. The Veteran contended against the 1987 automobile accident and reported an accident in 1967. He claimed the accident was before he went to Vietnam. X-rays revealed lumbar spine degenerative changes. The Veteran stated that he first noticed his right hip problem in 1969. He saw a provider after separation. Both hips make noise on movement. X-rays revealed no abnormalities. There was a scar on the right lateral proximal thigh that was healed and not tender, elevated, or hallowed or with absence of muscle or fascial tissues. The examiner noted that the Veteran reported one motor vehicle accident in 1967, the reports of which revealed no right thigh or hip issues. His case file was also silent for lumbar spine, bilateral hips, and proximal right thigh scar. When the Veteran first sought service connection in 1970, he did not claim these disabilities. The first indication of a low back problem is in an August 2003 written statement. This is the first time the Veteran mentions any of these disabilities in a written statement to VA. The October 2003 private opinion was provided on the basis of the Veteran's stated history only. There was no nexus to active duty, because there was no document to suggest the nexus. The examiner questioned the Veteran thoroughly about the June 1987 automobile accident. The Veteran emphatically denied any such history. He distinctly opposes any history of a motor vehicle accident in 1987. The examiner opined that the Veteran was not being honest or could not remember, even though he seemed to be able to remember what happened from 1966 to 1970. The examiner concluded that it was not at least as likely as not that the Veteran had a lumbar spine problem on active duty, and there was more than ample evidence that this problem of the lumbar spine developed post-service in a motor vehicle accident in 1987. Based on the record, the Board finds that service connection for a back disorder, a hip disorder, and a right hip scar is not warranted. There are several opinions of record that consider whether any of these disorders is related to the Veteran's service. It is the responsibility of the Board to assess the credibility and weight to be given to evidence. Owens v. Brown, 7 Vet. App. 429, 433 (1995) (citing Wood v. Derwinski, 1 Vet. App. 190, 192 (1991)). The Board is permitted to favor one opinion over another provided that it gives an adequate statement of its reasons and bases for doing so. Simon v. Derwinski, 2 Vet. App. 621, 623 (1992). First, the Board finds that the October 2003 private physician's opinion has relatively little probative value. Specifically, no review of the claims file was conducted, which is important in this case because the history provided by the Veteran varies from the history shown in the claims file. While a review of the medical records is not necessary in every case, see Snuffer v. Gober, 10 Vet. App. 400, 404 (1997) (stating that "the Court has never decided that in every case, a medical examiner must review all prior medical records before issuing a medical opinion or diagnosis"), in this instance, the history provided by the Veteran to the private physician is incomplete. Specifically, there is no indication that the Veteran's private physician was aware of the June 1987 record showing that the Veteran was involved in a motor vehicle accident and injured his back. Furthermore, the Veteran's report in June 1987 that his back pain began after the accident in April 1987 as well as evidence that x-rays were unremarkable at that time is necessary information for a provider to give an informed and adequate opinion. That is not the case with the October 2003 opinion, and the Board affords it relatively little probative value. The remaining relevant opinions of record are those from the Veteran and the September 2004 and April 2013 VA examiners. While laypersons are sometimes competent to provide opinions regarding medical matters such as etiology and diagnosis, see Davidson v. Shinseki, 581 F.3d at 1315-16 (Fed.Cir.2009), the Board finds that the opinions provided by the VA examiners are more probative than the Veteran's lay assertions. The VA examiners are medical professionals who possess training, expertise, and experience that the Veteran is not shown to have. In addition, the Veteran's opinion does not contain a rationale that considers the post-service motor vehicle accident and back injury in 1987. In fact, the Veteran denied that this event ever occurred during the April 2013 VA examination, despite contemporaneous evidence documenting the injury that is contained in the claims file. This diminishes the probative value of his opinion even more, since it does not consider this post-service injury. Therefore, the September 2004 and April 2013 VA examination reports are the most probative evidence of record with regard to whether the Veteran has a back disorder, hip disorder, or right hip scar that is related to service, and the evidence against the Veteran's claim outweighs the evidence in its favor. Finally, while arthritis is a chronic disease for which presumptive service connection may be awarded, this chronic disease is not noted in service, and the Veteran has not asserted that it has existed since that time. In fact, x-rays conducted in June 1987, more than fifteen years after separation from service, show that the Veteran's back was unremarkable. Degenerative changes were not shown on x-ray until many years later. Therefore, service connection for degenerative changes of the lumbar spine, cannot be granted under the provisions of 38 C.F.R. § 3.303(b). Conclusion In reaching these decisions the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claims, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for recurrent infections, to include as due to Agent Orange exposure, is denied. Service connection for otalgia, to include as secondary to bilateral hearing loss and/or service-connected tinnitus, is denied. Service connection for bilateral hearing loss is denied. Service connection for a lumbar spine disorder is denied. Service connection for a bilateral hip disorder is denied. Service connection for a right hip scar is denied. REMAND In the February 2013 remand, the Board directed that the Veteran must be supplied with appropriate notice regarding his application to reopen the claim of entitlement to service connection for a gastrointestinal disorder, to include colitis and rectal bleeding. Such notice was not provided to the Veteran. As such, the claim must be remanded to comply with the Board's February 2013 directives and send the Veteran the proper notice. Stegall v. West, 11 Vet. App. 268, 271 (1998). Regarding the claim for service connection for ITP, as noted in the Board's February 2013 remand, this issue is intertwined with the claim for service connection for a gastrointestinal disorder and must also be remanded. Accordingly, the case is REMANDED for the following action: 1. Provide appropriate VCAA notice to the Veteran regarding his petition to reopen a claim for entitlement to service connection for a gastrointestinal disorder. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); Kent v. Nicholson, 20 Vet. App. 1, 9-10 (2006). 2. After completing the above action and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. These claims are as follows: entitlement to service connection for ITP and the petition to reopen a claim for entitlement to service connection for a gastrointestinal disorder. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' 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). ______________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs