Citation Nr: 1334448 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 09-01 999 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran served on active duty from October 1969 to May 1972. He appealed to the Board of Veterans' Appeals (Board) from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In January 2011 the Board remanded the claims to the RO via the Appeals Management Center (AMC) for further development and consideration - including especially to have him undergo a VA audiological examination for a medical nexus opinion concerning whether his bilateral hearing loss and tinnitus are related to his military service. He had the examination in February 2011 and, after considering the results and the examiner's opinion, the AMC issued a Supplemental Statement of the Case (SSOC) in March 2011 continuing to deny the claims and shortly thereafter returned them to the Board for further appellate consideration. The Board issued a decision in October 2011 also denying the claims, and the Veteran appealed to the U.S. Court of Appeals for Veterans Claims (Court/CAVC). In an August 2012 Order, the Court granted a Joint Motion vacating the Board's decision denying these claims and remanding them for further proceedings consistent with the terms of the Joint Motion. And to comply with the Court's Order, including the need for a supplemental medical nexus opinion, the Board again remanded the claims to the RO via the AMC in July 2013. The AMC obtained this addendum opinion in August 2013 and, after considering it and other additional evidence, issued an SSOC later in August 2013 continuing to deny the claims and returned them to the Board shortly thereafter. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDING OF FACT The most probative (competent and credible) evidence of record indicates the Veteran's bilateral hearing loss and tinnitus are unrelated to his military service, including to noise exposure during his service. CONCLUSIONS OF LAW 1. The Veteran's bilateral hearing loss was not incurred in or aggravated by his military service and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2013). 2. His tinnitus also was not incurred in or aggravated by his military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDING AND CONCLUSIONS I. The Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative of the information and medical or lay evidence that is (1) necessary to substantiate the claim; (2) that VA will obtain; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). A December 2007 letter explained the evidence necessary to substantiate the claims and the division of responsibility between VA and the Veteran in obtaining this necessary supporting evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The letter also explained how a "downstream" disability rating and effective date are determined once service connection is granted, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). As well, the letter was provided prior to the initial adjudication of the claims in April 2008, so in the preferred sequence according to Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran therefore has received all required notice concerning these claims. With regards to the duty to assist, the claims file contains his service treatment records (STRs), VA treatment records, private treatment records, the reports of his VA compensation examinations, and his and his representative's assertions regarding the viability of these claims. VA also has specifically complied with the Board's prior remands by obtaining a VA audiological examination, medical nexus opinion, and then even an August 2013 supplemental opinion addressing the deficiencies in the prior opinion that were noted in the August 2012 Joint Motion. The Veteran has reported undergoing a stapedectomy procedure in approximately 1982. However, despite having been specifically provided notice to submit or identify (for VA to obtain) any evidence that might be pertinent to his claims, he has not provided any such information to VA concerning the medical provider who performed that operation. He also has not submitted any records pertaining to that operation and has not requested that VA obtain any records pertaining to that operation. Additionally, he has reported earlier post-service hearing evaluations but has affirmatively indicated that records of those evaluations are no longer available. The duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Without him providing any information concerning the surgery (occurring more than 30 years ago) or informing VA that records pertaining to the surgery or to the earlier reported hearing evaluations might be available, the Board finds that the duty to assist does not necessitate making efforts to locate such records inasmuch as these efforts, without the benefit of this necessary information, would be futile. See 38 C.F.R. § 3.159(c) and (e). There is nothing in the file suggesting there is any other outstanding evidence still needing to be obtained that is obtainable. Therefore, the Board is satisfied that VA has provided all assistance required by the VCAA and that appellate review of these claims may proceed without prejudicing the Veteran. He has received all essential notice and assistance, has had a meaningful opportunity to participate effectively in the development and adjudication of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Under the circumstances presented, yet another remand of these claims to the RO via the AMC for still further VCAA development would be an essentially redundant exercise and only result in additional delay with no tangible benefit to him. It is difficult to discern what additional guidance VA could have provided him regarding what further evidence he should submit to substantiate these claims. See Livesay v. Principi, 15 Vet. App. 165, 178 (2001) (en banc) (observing that "the VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims."); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (both observing circumstances when a remand would not serve any useful or meaningful purpose and not result in any significant benefit to the Veteran). II. Analysis Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service in the line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). 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 distinguished from merely isolated findings or diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge from service is required to support the claim. 38 C.F.R. § 3.303(b). But to establish entitlement to service connection based on continuity of symptomatology, the claimant must have one of the "chronic" diseases specifically enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). While sensorineural hearing loss has been recognized by VA as such a chronic disease (see VA Manual M21-1MR III.iv.4.B.12.a), tinnitus is not included among these enumerated diseases. 38 C.F.R. § 3.309(a). Thus, it is not subject to service connection based upon continuity of symptomatology since service under 38 C.F.R. § 3.303(b). Service connection nonetheless 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). Establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a relationship or correlation between the disease or injury in service and the currently claimed disability - which is the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). As specifically concerning claims of entitlement to service connection for hearing loss, the threshold for normal hearing is from 0 to 20 decibels; higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993) (citing Current Medical Diagnosis & Treatment, Stephen A. Schroeder, et. al. eds., at 110-11 (1988)). But before service connection may be granted for hearing loss, it must be of a particular level of severity. For purposes of applying the laws administered by VA, impaired hearing only will be considered a ratable disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory threshold for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In deciding these claims, the Board must determine the probative value of all of the evidence submitted, so of both the lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine whether the evidence also is "credible", or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board additionally must determine whether the evidence also is credible). Only if the evidence is both competent and credible does it ultimately have probative value. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). The third and final step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, a medical opinion was not required to prove nexus between service-connected mental disorder and drowning which caused Veteran's death). In certain instances, lay evidence has been found competent with regards to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). On the other hand, laypersons equally have been found not competent in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). See also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (indicating lay evidence must demonstrate some competence and affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). In ultimately rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons or bases 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). To this end, the Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit Court, citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id., at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court similarly has declared that, in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). The standard of proof to be applied in decisions on claims for Veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Turning now to the relevant facts of this particular case at hand. There is no disputing the Veteran has bilateral (i.e., right and left ear) hearing loss and tinnitus. A VA audiological evaluation performed in April 2008 revealed a 60-decibel loss at the 4000 Hz level for both ears. The Veteran also submitted several private treatment records from Dr. S. and Dr. C.L, both dated in May 1992, and another from J.D., MS CCC-A, in July 2008, noting the Veteran's complaints of hearing loss. Finally, during a February 2011 VA audiological evaluation, the audiologist who had performed the April 2008 VA examination reaffirmed diagnoses of profound sensorineural hearing loss in the right ear, severe sensorineural mixed hearing loss in the left ear, and tinnitus. The Veteran's DD Form 214 shows he was a radio operator-maintainer. This specialty has been identified as an occupation where there was a moderate probability of noise exposure. See Duty Military Occupational Specialty (MOS) Noise Spreadsheets, Veterans Benefits Administration Fast Letter 10-35 (Dep't of Veterans Affairs, September 2, 2010). Additionally, the Veteran has reported specific incidents of noise exposure in service, including being in close proximity to a loud explosion caused by a planted charge during the "Night Fire" segment of basic training; training as a Radio Relay/Carrier Operator, including long periods of time monitoring a "receive signal tone" of the clearest and loudest extent; ten days of walking guard duty at an airstrip; perimeter guard duties in a bunker in Vietnam located in close proximity to a Thai artillery battery with frequent fire so loud that it felt that the ground shook with every blast; and nearly two years of radio carrier operator duties consisting of hours of radio system maintenance requiring tuning transmitter/receivers to a high pitched tone, similar to the one hears due to tinnitus. Notably, the February 2011 VA examiner, along with other practitioners of record, conceded the Veteran had noise exposure in service. The Board is similarly finding that the Veteran experienced such noise exposure. So resolution of his claims turns on whether the current hearing loss and tinnitus are related or attributable to his noise exposure in service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). See, too, 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 STRs make no reference to any hearing loss or tinnitus, either in the way of a relevant subjective complaint or objective clinical finding such as a pertinent diagnosis. An audiological evaluation performed during his pre-induction examination in August 1969 noted a zero-decibel loss at all Hz levels in his right ear. Testing of his left ear revealed a 15-decibel loss at the 500 and 1000 Hz levels and a zero-decibel loss at the 2000 and 4000 Hz levels. Another audiological evaluation later performed during his separation examination in February 1972 revealed a zero-decibel loss at all Hz levels for both ears. There also is no mention of tinnitus in this report, or at any other time during his service. So his STRs do not show any manifestation of hearing loss or tinnitus during his service and do not provide evidence tending to show a relationship between his noise exposure in service, even accepting that it occurred, and these current conditions. The record also does not contain any documentation of a diagnosis of sensorineural hearing loss within one year of his discharge from service in May 1972, so meaning by May 1973. Hence, he also is not entitled to any presumption regarding in-service incurrence of this condition. See 38 U.S.C.A. §§ 1101, 1112, 1113; 38C.F.R. §§ 3.307, 3.309(a). In fact, the actual medical evidence of record indicates that after his separation from service, he was not seen for hearing problems by medical personnel until May 1992, by Dr. S., for progressive hearing loss on the right side. (The Veteran did affirmatively report the earlier stapedectomy in approximately 1982 and also asserted earlier post-service findings of hearing loss, though these latter reports are not considered credible, as explained below ). During that May 1992 consultation, the Veteran reported that he had just known for a long time that his right ear did not work as well as his left. He also reported that tinnitus was present. Audiometric evaluation showed a large conductive component and mixed hearing loss, right ear. The left ear was essentially normal. Dr. S.'s diagnostic impression was, "Otosclerosis versus ossicular chain discontinuity. Given lack of closure and normal tympanograms, [I] strongly suspect discontinuity." Also in May 1992, the Veteran was treated by C.L., D.O., for difficulty hearing, the chief complaint being, "I can't hear." The Veteran reported that he had first noticed decreased hearing twenty-five years earlier "per test while in the United States Army" and that he "(had) gradually had decreased hearing capability since that time." He did not report tinnitus or exposure to any explosions. His noted medical history included a surgically corrected deviated septum fourteen years earlier, as well as numerous nose factures. He also had experienced a couple of near syncopal episodes in the last five to ten years, the etiology of which had never been determined. There are no additional treatment records, VA or private, until his April 2008 VA compensation examination. The April 2008 audiologist noted the Veteran's history of noise exposure in service while working as a relay radio operator in Vietnam (i.e., a constant tone from his headset). He denied exposure to combat artillery. He denied post-military noise exposure, indicating that he had worked as a grain inspector since military service. Recreational noise exposure was denied. He reported a history of constant bilateral tinnitus since basic training in the military following an explosion. Following audiological evaluation, the VA audiologist diagnosed sensorineural hearing loss bilaterally and mixed hearing loss. The audiologist concluded that "bilateral hearing loss and tinnitus is (sic) less likely as not (less than 50/50 probability) caused by or a result of acoustic trauma during military service." The audiologist provided the following rationale: "The audiometric configuration seen today is not consistent with noise[-]induced hearing loss. There is no evidence of acoustic trauma during military service as he had normal thresholds at entrance and separation. Tinnitus was not documented in the service medical record." Following that April 2008 examination, the Veteran also submitted an opinion from private audiologist, J.D., in support of his claims. In a July 2008 report, J.D. noted that the Veteran reported being in close proximity to an explosion during basic training, resulting in constant tinnitus ever since and a temporary threshold shift. He also reported exposure to artillery fire while on guard duty. This commenting audiologist noted the Veteran had reported no other noise exposure since his discharge from active duty. Puretone threshold testing revealed a mild to severe-profound sensorineural hearing loss, bilaterally, beginning at 3000 Hz. The left ear also showed a moderate notch in hearing at 1000 Hz. The audiologist stated that, although the Veteran's audiograms during service showed normal hearing, "it is documented in the histopathology literature that outer hair cell damage in the cochlea occurs prior to an individual ever showing a threshold shift on an audiogram, therefore it is more likely than not that [the Veteran's] hearing loss and tinnitus is [sic] related to his military noise exposure and it may have worsened as a civilian." In February 2011, the Veteran had another VA audiological evaluation by the audiologist who had performed the April 2008 evaluation. This VA examiner acknowledged that the Veteran was likely exposed to high-risk noise levels during his service. The Veteran reported working for General Motors on the assembly line post-service without being required to wear hearing protection, working as a grain inspector and working pouring concrete without exposure to jackhammer noise. As for recreational noise exposure, he reported doing some hunting as a child and working on cars occasionally. Additionally, he reported that his father had hearing loss and that he had had the stapedectomy in the right ear in 1982. He reported constant bilateral tinnitus that he said had started during his basic training in the military after a "charge" went off. The VA examiner diagnosed hearing within normal limits through 2000 Hertz, sloping to a profound sensorineural hearing loss in the right ear and normal sloping to severe sensorineural mixed hearing loss in the left ear. The examiner noted the February 1972 separation examination's normal auditory threshold readings with no significant threshold shift during military service. The examiner explained that literature indicates that the detrimental effects of noise on hearing were seen immediately and did not manifest at a later date. Thus, the examiner concluded that, as hearing loss was ruled out at the time of separation, the Veteran's hearing loss was not caused by acoustic trauma during his military service. Also, the examiner commented that J.D. had not had the claims file available when formulating her opinion or, otherwise, she would have seen that the Veteran had had normal hearing at time of separation from service. Additionally, the VA examiner commented that the Veteran had reported the stapendectomy in 1982 and that Dr. S had documented that the Veteran possibly had otosclerosis or discontinuity in 1992. The VA examiner indicated that the results of her February 2011 examination were commensurate with Dr. S's findings in 1992 that the mixed component of the Veteran's "left ear" hearing loss is a result of middle ear pathology and not noise exposure. The VA examiner also stated there was no audiological basis or support for the Veteran's tinnitus claim. In April 2011 correspondence, the Veteran indicated that it was his contention that he did not have a hearing test at time of separation from service. He indicated that he was processed out one morning, running from the personnel department to the finance department, etc., and simply signed whatever he was told to sign. He reported that the first time his hearing loss was "documented" was August 1972, three months after separation from service and prior to employment at General Motors Corporation. He also reported that the hearing loss was again "documented" when he visited an Army doctor in Fort Leavenworth, Kansas, and again in 1978 during a physical with the Bendix Corporation. Unfortunately, G.M. and Bendix since had informed him that they did not keep records past 10 years and the Army at Fort Leavenworth had informed him that a fire had destroyed the records in question. Additionally, he noted that the auto mechanic work he had performed since service was not done on vehicles that were running at the time and that he had never used air tools. So he did not believe this additional activity since his service could account for his hearing loss and tinnitus. The subsequent August 2012 Joint motion pointed out that the February 2011 VA examiner had provided little if any explanation for why she agreed with Dr S's opinion, stating only that the results of her hearing testing were commensurate with Dr S's findings. Additionally the VA examiner's explanation for her disagreement with J.D's July 2008 private medical opinion was not supported by the record, as the VA examiner had stated that J.D. did not have the claims file or, otherwise, she would have seen that the Veteran had normal hearing at separation. But in her July 2008 opinion J.D. stated that she specifically had reviewed copies of the enlistment audiogram and separation audio examination and that these audiograms had indicated normal hearing. Thus, the parties found that the VA examination report was inadequate. Moreover the parties found that the Board incorrectly had determined that the Veteran's statements concerning his hearing loss and tinnitus dating back to injuries in service were not credible because the Board had based this determination simply on the conflict between these assertions and findings of the February 2011 VA examiner. In an October 2012 letter, J.D. indicated the Veteran was seen for a review of the February 2011 VA audiological evaluation. She reiterated that the Veteran had reportedly been in close proximity to an explosion during service, suffering a temporary threshold shift, and experiencing constant tinnitus ever since. She also noted that he was exposed to a high-pitched tone for hours on end during service while performing his duties as a relay radio operator and was exposed to some artillery fire while on guard duty. Additionally, it was noted that he reported having no other noise exposure since his discharge from the military without the use of mandatory hearing protection. J.D. found that, although the Veteran's audiograms during active duty indicated normal hearing, there was a positive threshold shift (hearing got better) between entrance and separation examinations, which lead her to believe that one or both of the examinations were invalid. It was her opinion that the separation examination was invalid, as the Veteran had claimed that he did not have this examination and all thresholds were reported as 0 dB, which was a very rare happening. J.D. also noted that the VA hearing examination in 2011 only reported hearing threshold levels out to 4000 Hz and that a 2005 Institute of Medicine (IOM) report indicated that, in order to document the characteristic notch associated with noise-induced hearing loss during service, testing should include measurements at and above 6000 Hz. J.D. indicated that it was still her opinion that the Veteran's high frequency hearing loss was more likely than not related to his military noise exposure. She noted that her opinion was based on case history and the time of onset of tinnitus. Because of this difference of opinion regarding the etiologies of the Veteran's bilateral hearing loss and tinnitus, and the noted deficiencies in the report of the February 2011 VA compensation examination and opinion, the Board again remanded these claims in July 2013 for supplemental comment. In an August 2013 supplemental medical opinion, the February 2011 VA examiner again acknowledged that the Veteran likely had high-risk noise exposure during his military service. However, the VA examiner indicated the Veteran did not suffer hearing loss during his military service according to VA standards. That was an apparent reference to the threshold minimum requirements of 38 C.F.R. § 3.385 for determining whether a Veteran has a ratable hearing loss disability. But 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 or even during the one-year presumptive grace period after service allowing for sensorineural hearing loss, as an organic disease of the nervous system, to initially manifest to a compensable degree (meaning to at least 10-percent disabling), 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, 5 Vet. App. at 159. Here, though, this VA compensation examiner then goes on to note that the Veteran had normal auditory thresholds at separation; that a standard threshold shift did not occur beyond normal progression and "test retest variability for either ear when comparing entrance and separation evaluations." The examiner also noted that the Institute of Medicine (IOM) (2005) concluded that, based on current knowledge of cochlear physiology, there is no scientific evidence to support delayed-onset of hearing loss secondary to military noise exposure. Hearing loss should occur at the time of the exposure. The IOM had indicated that there was not sufficient evidence from longitudinal studies to determine whether permanent noise-induced hearing loss could develop years after military noise exposure. Rather, the available anatomical and physiologic evidence suggested that delayed post exposure noise-induced hearing loss was not likely. Thus, the examiner concluded that, if hearing was normal on discharge, if there was no permanent significant threshold shift greater than normal progression, and "if test retest variability during military service" was present, then there was no basis to conclude that a current hearing loss is causally related to military service, including noise exposure therein. Accordingly, in this instance there was no nexus between any current hearing loss and military service. In addition, this VA examiner determined the Veteran's current audiometric configuration was not consistent with noise-induced hearing loss. The etiology of the right ear hearing loss had been determined by Dr. S to be a middle ear condition (i.e., either otosclerosis or discontinuity), and not noise exposure. Noise exposure typically affected both ears simultaneously and did not cause unilateral mixed hearing loss. The examiner also pointed out that Dr. S had found the left ear to be "essentially normal" in 1992. Additionally, she pointed out that the Veteran's father also had hearing loss, and that otosclerosis is known to have a genetic component. Thus, considering all of the evidence, this VA examiner agreed with Dr. S's stated etiology for the Veteran's hearing loss. She found that the audiometric configuration was consistent with middle ear pathology and not noise exposure and she indicated that she did not know whether J.D. had had this information when she had formulated her opinion. This VA examiner added that, while IOM (2005) recommended military audiograms include 6000-8000 Hz measurements in the future, failure to have auditory thresholds recorded at these frequencies during service did not invalidate the IOM's findings. The examiner noted that VA criteria for service connection for hearing loss had not changed to include hearing thresholds from 6000-8000 Hz. Also, J.D. had cited no scientific or research basis to conclude that the IOM report (with its conclusion concerning the lack of evidence for delayed-onset hearing loss) was invalid. Additionally, while the Veteran had correlated his tinnitus onset to an explosion in basic training, the examiner found there was no evidence to support this occurrence of acoustic trauma during his military service. The VA examiner observed that at no time during service did the Veteran report tinnitus and there was no presence of hearing loss during service to support his claim that tinnitus was present. Further, the examiner noted that the Veteran did not correlate tinnitus onset to his combat noise exposure for special consideration, which the examiner would have considered. Thus, considering all the evidence the examiner could not be 50% or more certain the tinnitus had resulted from military noise exposure. The Board finds that the VA examiner's August 2013 supplemental opinion is based on a more complete and accurate understanding of the Veteran's audiological history than that of the private audiologist. While there is no indication that J.D. was aware that the Veteran's father also had hearing loss, thus suggesting a potential hereditary component to the disability, this is clearly noted in the VA examiner's report. Also, while the Veteran reported to J.D. in July 2008, and also during the April 2008 VA examination, that he had not had any post-service noise exposure, in February 2011 the VA examiner specifically noted the Veteran had reported working for General Motors since service on the assembly line no less without being required to wear hearing protection, indicating at least some post-service noise exposure. (See, e.g., The Environmental Engineers Handbook, ed. Bela G. Liptak, David H.F. Liu, CRC Press, 1999, Section 6.2, Table 6.21, indicating that automobile assembly line noise can be as high as 125 decibels). The Board credits this latter report of medical history by the Veteran over the earlier ones indicating a lack of any post-service noise exposure because it was made against his interest in obtaining service-connected compensation. See, e.g., Caluza v. Brown, 7 Vet. App. 498, 511 (1995) ("The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character."). Indeed, courts have recognized how medical history recounted in the course of medical evaluation and treatment is especially probative (trustworthy) because the declarant has inherent incentive to give the most accurate history to in turn receive the best or most appropriate medical care. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). When, as here, there is an inconsistently reported history - sometimes claiming not to have had any additional noise exposure as a civilian and other times acknowledging this to have occurred, including at the civilian job - this tends to undermine the probative value of this history, particularly to the extent the Veteran recounted it to an examiner or evaluating clinician who then, in turn, relied on this history as true and correct in formulating the basis of his or her opinion when, in actuality, it is not. 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). A medical opinion is only as good and credible as the history on which it was predicated. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). And while the Board cannot summarily reject a favorable opinion merely because it was based, whether partly or entirely, on a history as supplied by the Veteran, this is permissible when this reported history has not been deemed credible. A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the Veteran). The Board, then, may conversely reject a medical opinion that was based on an inaccurate factual premise. Reonal, 5 Vet. App. at 461. As the Court explained in Coburn v. Nicholson, 19 Vet. App. 427 (2006), reliance on a Veteran's statements renders a medical report not credible if the Board rejects the statements of the Veteran as lacking credibility. The Board also finds that the August 2013 VA examiner's opinion contains a more convincing rationale. Generally, the degree of probative value that may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the Veteran's claims file, although review of the file is not determinative of the opinion's probative value. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually had examined the Veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). So as the Court made clear in Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008), the probative value of a medical opinion comes from when there is factually accurate, fully articulated, and sound reasoning for the conclusion, not just from mere review of the claims file). See also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[a] medical opinion...must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Here, the VA compensation examiner based her conclusion predominantly on the evidence showing normal hearing at separation, along with the finding of still normal hearing in the left ear some 20 years later in 1992. And even though right ear hearing loss was evident in 1992, it was determined to have been the result of otosclerosis versus ossicular chain discontinuity, rather than noise-induced, so not from the noise exposure and consequent injury, i.e., acoustic trauma, the Veteran had experienced during his military service. (The Board sees the VA examiner appeared to mix up the left and right ear in her February 2011 report, but this error was corrected in her February 2013 supplemental opinion). She then reasoned that, based on the finding of the IOM that there is no scientific evidence to support delayed-onset of hearing loss secondary to military noise exposure, there was no basis to find that the Veteran's current hearing loss had resulted from military noise exposure. That August 2013 addendum opinion did not rely in any way on whether or not J.D. had access to the claims file, as the examiner simply noted that she did not know exactly what information J.D. had access to when formulating her opinion. (And the VA examiner's August 2013 opinion is not dependent on the extent of J.D.s review of the record but on the examiner's own analysis of the record, coupled with her examination findings). The private audiologist did also support her opinions with specific rationales, indicating in her initial opinion that, although the Veteran's audiograms during service showed normal hearing, "it is documented in the histopathology literature that outer hair cell damage in the cochlea occurs prior to an individual ever showing a threshold shift on an audiogram, it was therefore more likely than not that [the Veteran's] hearing loss and tinnitus is [sic] related to his military noise exposure. She also in her subsequent opinion questioned the very validity of the Veteran's separation examination findings, seeing as though the report of that evaluation list across-the-board zeros, so a rare occurrence indeed. These rationales do not appear entirely consistent, however. In the initial July 2008 opinion, J.D. appeared to accept the audiological findings on both entrance and separation, as she did not comment on any "positive threshold shift" but simply concluded that a negative threshold shift deemed to have been experienced by the Veteran had likely not yet showed up on his audiogram at the time of separation, despite there being cochlear damage. Then, in the subsequent October 2012 opinion, she opined that the separation examination was invalid. While this latter finding could simply reflect an evolution of her viewpoint, the Board also notes that she did not specify how long after the occurrence of outer hair cell damage in the cochlea that one would expect to see a threshold shift. Additionally, she did not discuss nor appear to be aware of the 1992 findings of Dr. S, indicating normal left ear hearing and right ear hearing resulting from otosclerosis versus ossicular chain discontinuity. Additionally, as alluded to above, in formulating her opinion, she assumed that the Veteran had not had any post-service noise exposure when, in fact, he has acknowledged working on a G.M. automobile assembly line since service, in turn subjecting him to noise without hearing protection. The Board is cognizant of J.D.s notation that the 2005 IOM report recommended that hearing testing should include measurements at and above 6000 Hz in order to help document noise-induced hearing loss. However, as noted by the VA examiner, the lack of these findings in the Veteran's case does not form a basis for rejecting the IOM's conclusions (adhered to by the VA examiner and accepted by the Board in this case) that there is no scientific evidence to support delayed-onset hearing loss secondary to military noise exposure. If such findings concerning the higher frequency thresholds had been made at separation or at another point during service, they could have been analyzed, in conjunction with the IOM's findings, to determine whether non-delayed onset hearing loss was present during service. However, given that there are no such findings, it is necessary to weigh the evidence based on the information available. The Board is also cognizant of J.D.s opinion that the Veteran's separation examination results are invalid. However, the Board notes this opinion was not credited by the VA examiner (who indicated that the difference in hearing threshold findings at entrance and separation resulted from retest variability); that the separation examination results were also initially credited by J.D.; that there is no specific information in the record that the separation examination findings were not accurately arrived upon; and that J.D. simply found that the findings of 0 dB at all hearing thresholds shown on the separation examination report would be very rare (as opposed to impossible). Also, J.D. opined that the separation audiological evaluation was invalid at least in part because the Veteran reported he never had received such an evaluation. In this regard, the Veteran has specifically explained that he was processed out of service in one morning and definitely did not receive any such evaluation on that out processing day. However, the STRs show that his separation examination with hearing evaluation took place on February 3, 1972, and that at the time of separation (some 3 months later, on May 5, 1972), he completed a Statement of Medical Condition indicating that to the best of his knowledge his medical condition had not changed since the February 3, 1972 examination. Thus, the Board does credit his report of not receiving any evaluation of possible hearing impairment near the time of his service separation; instead, the record indicates he did indeed receive such an examination three months prior to separation rather than on the day of separation. Consequently, at least part of J.D.s basis for finding the separation examination invalid (i.e., that the Veteran reported not having a separation examination) is simply not credible. For all of these reasons, the Board finds that the weight of the evidence is in favor of a finding that the February 3, 1972 separation examination is valid versus invalid. Overall, then, given the VA examiner's more accurate understanding of the Veteran's medical history and the more convincing rationale for her conclusions, the Board attaches more probative weight to her opinion than to the opinion of J.D. Thus, as there are no other medical opinions of record supporting a relationship between noise exposure in service and current hearing loss, the weight of the medical evidence is against a finding that such a relationship exists. Additionally, to the extent the Veteran is arguing that his hearing loss is related to noise exposure during service through a mechanism other than continuity of symptomatology, as a layperson, without any demonstrated specific knowledge concerning the etiology of hearing loss, his opinion is entitled to minimal probative value. See Jandreau, 492 F. 3d 1372 (Fed. Cir. 2007). The Board has considered his report, made as early as 1992, that he has experienced hearing loss ever since service, along with his more recent report that his hearing loss was first "documented" just three months after the conclusion of his service. Although he is competent to make such a declaration, the Board notes that when reporting his medical history to C.L. in 1992 the Veteran indicated that he had first noticed decreased hearing twenty-five years earlier "per test while in the United States Army." However, as noted, the two hearing tests conducted during service show hearing within normal limits and no findings or complaints of hearing loss are noted in the STRs. This also tends to run afoul of the notion that he did not have a hearing test in anticipation of separating from service. Thus, the evidence on the whole indicates that his report of hearing loss noted on testing in service was erroneous. Also, beginning in 2008, he specifically reported a temporary threshold shift (i.e., temporary loss of hearing), along with the onset of tinnitus, in conjunction with an explosion in basic training (and did not report hearing loss found on testing during service). However, no such report by him of an explosion in service resulting in tinnitus and temporary hearing loss is documented in the private medical evidence from 1992. It stands to reason that, if he was able to recall in April 2008 and thereafter that he had experienced temporary hearing loss, along with tinnitus, due to an explosion in basic training, he would have similarly been able to recall this information 16 years earlier in 1992. The explosion appears to be an event that would be at least as memorable as the hearing test that he did apparently recall, albeit erroneously. The Board also presumes that, if he did report the explosion in 1992, this information would have been recorded as a significant event within his broader history of hearing loss. Additionally, his April 2011 report that his hearing loss was first documented three months after service in August 1972 is also inconsistent with his 1992 report of having been first found to have hearing loss during testing in service. Accordingly, given these patent inconsistencies, along with the specific finding of entirely normal hearing in February 1972 and his May 1972 signed statement that his health condition had not changed since February 1972, the Board does not find credible his assertion that he noticed, or was found to have, hearing loss in service or soon thereafter, and that his hearing progressively worsened after that point. (The Board is not making a finding that this lack of credibility is due to any negative motive on the Veteran's part; it may simply constitute misrecollections due to the passage of long periods of time). See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (The Board must make an express credibility finding regarding lay evidence.). In sum, because the weight of the evidence is against the presence of a relationship between noise exposure in service and current hearing loss, and because the Veteran's report of experiencing hearing loss since service is not credible, a nexus between noise exposure in service and current hearing loss is not established. Thus, the preponderance of the evidence is against this claim and it must be denied. See Watson, 4 Vet. App. 309, 314 (1993); Alemany, 9 Vet. App. 518 (1996). Regarding tinnitus, at the outset, the Board notes that the Veteran has reported that the disorder began after being in close proximity to an explosion during his military service. However, given that his report of hearing loss beginning in service is not credible, the credibility of his report of the onset of tinnitus is called into question since it purportedly is the result of the same cause or source as the hearing loss. Additionally, while he did report in 1992 that his hearing loss dated back to service, there is no indication he made any similar report at that time regarding his tinnitus, with the record only reflecting that he reported then currently having the disorder. Once again, the Board presumes that, if he was able to recall in April 2008 and thereafter that his tinnitus specifically began after an explosion in basic training, along with recalling experiencing a temporary hearing loss at that time, he should have been able to recall at least generally that the tinnitus began during service when reporting the history of the disorder during the 1992 medical visit. Yet, he made no such report concerning his tinnitus. Overall, given his inconsistency in reporting the tinnitus; given that the STRs contain no indication of any tinnitus during service; and given his already established lack of credibility concerning the report of the onset of hearing loss during service, the Board does not find credible the report of the onset of tinnitus during service. Instead, the Board finds that the record indicates that tinnitus first becoming manifest sometime around 1992. As the onset of tinnitus is not shown until many years after service, the Board is left to consider whether it is otherwise related to service. 38 C.F.R. § 3.303(d). Although J.D. has related the current tinnitus to service, her opinion is based on the tinnitus first becoming manifest during service. Thus, the Board can afford this opinion only minimal probative value. To the contrary, the VA examiner's opinion is based on the tinnitus not having its onset until after service. Thus, this opinion is more consistent with the evidence of record and entitled to significantly more probative weight. Additionally, to the extent the Veteran is arguing that his tinnitus is related to noise exposure during service through a mechanism other than continuity of symptomatology, as a layperson, without any demonstrated specified knowledge concerning the etiology of tinnitus, his opinion is entitled to minimal probative value. See Jandreau, 492 F. 3d 1372 (Fed. Cir. 2007). Accordingly, the weight of the evidence is against a finding that his current tinnitus is otherwise related to noise exposure in service. 38 C.F.R. § 3.303(d). In sum, because the Veteran's report of experiencing tinnitus since service is not credible and the weight of the evidence is against the presence of a relationship between noise exposure in service and current tinnitus, a nexus between noise exposure in service and the current tinnitus is not established. See Watson, 4 Vet. App. 309, 314 (1993). The preponderance of the evidence is against this claim and it must be denied. Alemany, 9 Vet. App. 518 (1996). ORDER The claim of entitlement to service connection for bilateral hearing loss is denied. The claim of entitlement to service connection for tinnitus also is denied. ____________________________________________ Keith W. Allen Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs