Citation Nr: 1417221 Decision Date: 04/17/14 Archive Date: 05/02/14 DOCKET NO. 11-08 316 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Cheyenne, Wyoming THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to an initial, compensable rating for bilateral hearing loss. 3. Entitlement to an increased rating in excess of 10 percent for residuals of an injury to the left forearm and elbow with tendonitis. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from July 1968 to March 1970. This appeal to the Board of Veterans' Appeals (Board) arose from two April 2010 rating decisions in which the RO granted service connection for bilateral hearing loss and assigned an initial noncompensable rating, effective January 13, 2010;, denied service connection for tinnitus;, and, in a separate decision, denied a claim for a rating in excess of 10 percent for residuals of an injury to the left forearm and elbow with tendonitis. In April 2010, the Veteran filed a notice of disagreement (NOD) with the assigned rating for bilateral hearing loss and with the denial of service connection for tinnitus and for a rating in excess of 10 percent for residuals of an injury to the left forearm with tendonitis. A statement of the case (SOC) was issued in February 2011, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in March 2011. Because the appeal involves disagreement with the initial rating assigned following the award of service connection for bilateral hearing loss, the Board has characterized this matter in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). In January 2012, the Veteran testified during a Board video-conference hearing before the undersigned Veterans Law Judge; a transcript of that hearing is of record. The Veterans Benefits Management System and the Virtual VA paperless claims processing system do not contain additional evidence relevant to this appeal. The Board's decision addressing the claim for service connection for tinnitus is set forth below. The claims for an initial, compensable rating for bilateral hearing loss and for a rating in excess of 10 percent for residuals of an injury to the left forearm and elbow with tendonitis are addressed in the remand following the order; those matters are being remanded to the RO, via the Appeals Management Center (AMC) in Washington, DC. VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim herein decided have been accomplished. 2. Although the Veteran has alleged experiencing significant in-service shipboard noise exposure (which appears to be consistent with the circumstances of his service), there is no credible evidence of tinnitus in service or for many years thereafter, and the only competent, probative to address the question of whether there exists a medical nexus between alleged in-service noise exposure and the Veteran's tinnitus is adverse to the claim. CONCLUSION OF LAW The criteria for service connection for tinnitus are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2013)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim, as well as the evidence that VA will attempt to obtain and which evidence he is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (here, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. A January 2010 pre-rating letter provided notice to the Veteran of what was needed to substantiate a claim for service connection, as well as provided general information concerning VA's assignment of ratings and effective date. The notices also explained the Veteran's and VA respective responsibilities to obtain relevant evidence. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter on appeal. and that no additional RO action to further develop the record in connection with this claim, prior to appellate consideration, is required. Pertinent medical evidence associated with the claims file consists of service, VA and private treatment records, and the report of March 2010 VA examination. The Board finds that the examination is adequate because it included a review of the history, a physical and audiology examination, a review of relevant clinical testing, and an appropriate diagnosis with an opinion and rationale. Records of the award of disability benefits by the Social Security Administration (SSA) were obtained but are not relevant to the issue of service connection for tinnitus. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Additionally, in January 2012, the Veteran was provided an opportunity to set forth his contentions during a hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing to fulfill two duties: (1) to fully explain the issues and (2) to suggest the submission of evidence that may have been overlooked. Here, during the January 2012 hearing, the undersigned noted the issues on appeal. Also, information was solicited regarding the Veteran's experiences in service, his tinnitus, and its functional impact on his daily life and employment. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's claims. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and the hearing is legally sufficient. In summary, the duties imposed by the VCAA have been considered and satisfied. The Veteran has been notified and made aware of the evidence needed to substantiate the claim decided herein, the avenues through which he might obtain relevant evidence, and the Veteran's and VA's respective responsibilities obtaining relevant evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with this claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of any the matter herein decided, at this juncture. See Mayfield, v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis The Veteran served as a U.S Navy seaman with duty aboard an ammunition supply ship including while providing underway supply support for fleet operations in Southeast Asia. In a January 2010 claim, March 2010 VA examination, and during the January 2012 hearing, the Veteran contended that he has tinnitus caused by exposure to high noise levels aboard ship from deck gunfire, small arms fire, and metal maintenance tools. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). In general, direct service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) an etiological 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). The determination as to whether the required elements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Certain chronic diseases shall be presumed to have been incurred in service if manifested to a compensable degree within a prescribed period post service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). The presumption is available for organic diseases of the nervous system. With a chronic disease shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit recently clarified that the provisions of 38 C.F.R. § 3.303(b) pertaining to the award of service connection on the basis of continuity of symptomatology (in lieu of medical opinion) are limited to chronic diseases as defined in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Although tinnitus is not a chronic disease listed ln 38 C.F.R. § 3.309(a), given the nature of the disorder (as discussed below), the Board will consider the Veteran's assertions as to onset and continuity of symptoms of ringing in the ears in adjudicating this claim. After a full review of the record, including the medical evidence and statements made by and on behalf of the Veteran, the Board finds that the claim for service connection for tinnitus must be denied. Service treatment, post-service VA outpatient treatment, and private outpatient treatment records are silent for any symptoms, diagnoses, or treatment for organic ear disorders or impairment of hearing acuity. In March 2010, a VA audiologist noted a review of the claims file and the Veteran's reports of exposure to noise in service. The Veteran also reported noise exposure after service as a welder and recreational exposure in hunting and the use of power tools. The Veteran reported that he had experienced tinnitus for the past twenty years and that the disorder was distracting and interfered with sleep and watching television. Audiometric testing showed mild to moderate sensorineural hearing loss, and the audiologist found that the deficit was at least as likely as not related to military noise exposure. Regarding tinnitus, the audiologist found that tinnitus was less likely as not related to military noise exposure and opined, that the "ate of onset is not associated with military service." During the January 2012 Board hearing, the Veteran testified that symptoms of tinnitus started one year after military service and became more severe while working in his civilian occupation as a welder on an Air Force installation. At the outset, the Board notes that the Veteran is competent to report matters within his personal knowledge, to include shipboard noise during service. See, e.g., Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (noting that lay evidence is competent with regard to facts perceived through the use of the five senses). Here, such account is considered credible, as appears to be consistent with the nature and circumstances of his duties as shown in service personnel records. The Board further notes that the tinnitus (or, ringing in the ears) is the type of disability the Veteran is competent to establish on the basis of his own lay assertions. See also Charles v. Principi, 16 Vet. App. 370, 374 (2002) . As such, the remaining inquiry in this case is whether there is competent, credible, and probative evidence establishing a medical nexus between current tinnitus and the Veteran's service. Here, however, there is no objective or other credible evidence documenting tinnitus during or service, or for many years thereafter. Moreover, the only competent, probative opinion to address the etiology of the Veteran's indicates that tinnitus was not caused or aggravated by military noise exposure or any other aspect of active service. Although the audiologist's explanation was brief, her opinion clearly indicates that the onset of tinnitus is at the time of the high noise exposure and that it is not indicated in this Veteran's case. Significantly, neither the Veteran nor his representative has presented or identified an contrary, competent opinion-i.e., one that, in fact, supports a relationship between tinnitus and service. Moreover, the Veteran's reports as to the time of onset of tinnitus have been inconsistent. He reported to the audiologist that the onset was twenty years prior to the examination-which would be in 1990 and during a time when he was working as a welder in an industrial environment. During the hearing, testified that the onset was one year after service which would be in 1971, many years earlier. The Board finds more credible the report of an onset in 1990 made in conjunction with medical examination as opposed to oral assertions as to a much earlier, in-service onset made in connection with his claim for VA benefits. See White v. Illinois, 502 U.S. 346, 355-56 (1991) (statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25(1991) (a pecuniary interest may affect the credibility of a claimant's testimony). Furthermore, to whatever extent statements by the Veteran and/or his representative have been offered for the purpose of establishing that there exists a medical nexus between current tinnitus and in-service noise exposure, such evidence provides no basis for allowance of the claim. The matters of the medical etiology of the disability at issue is within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). Although laypersons are competent to provide opinions on some medical issues (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), the specific matter of the etiology of the disability under consideration is a complex medical matter that falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007) (providing that lay persons are not competent to diagnose cancer). As neither the Veteran nor his representative is shown to be other than a layperson without appropriate training and expertise, neither is competent to render a probative (persuasive) opinion on such a medical matter . See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998)). Hence, the lay assertions in this regard have no probative value. For all the foregoing reasons, the Board finds that the claim for service connection for tinnitus must be denied. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) ; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for tinnitus is denied. REMAND The Board's review of the claims file reveals that further RO action on the claims remaining on appeal is warranted. Regarding the claim for an initial compensable rating for bilateral hearing loss, the most recent examination was in March 2010. During the Board hearing, the Veteran testified that his sensed hearing acuity had become degraded because he had to raise the volume of his television and sit closer to people in conversation. When a veteran claims that his condition is worse than when originally rated, and when the available evidence is too old for an evaluation of the claimant's current condition, VA's duty to assist includes providing him with a new examination. Olson v. Principi, 3 Vet. App. 480, 482 (1992); Weggenmann v. Brown, 5 Vet. App. 281 (1993). To ensure that the record reflects the current severity of the Veteran's hearing loss and in light of the Veteran's contentions of increased and additional symptomatology, the Board finds that a more contemporaneous examination, with findings responsive to the applicable rating criteria, is needed to properly evaluate the service-connected bilateral hearing loss. Regarding the claim for a rating in excess of 10 percent for residuals of an injury to the left forearm and elbow with tendonitis, the Veteran contended that the residuals of his injury in service now limit his ability to grasp and lift objects greater than five pounds and are responsible for the loss of his job as a welder. The Veteran is left-handed. While underway on the ammunition ship in July 1969, the Veteran's left arm was caught between a heavy hatch and the hatch dogs. X-rays obtained ten days later were normal. A physician noted limitation of motion and reduction of grip strength at that time but no other vascular or neurological symptoms. The physician diagnosed hematoma and edema of the left elbow. In a follow-up in November 1969, an examiner diagnosed tendonitis. The Veteran received an honorable discharge in March 1970 because of a reduction in force and not for medical reasons. During the Board hearing, the Veteran testified that the only injury he ever sustained to his left arm was on his ship during active service. However, in a January 2000 letter to the Federal Office of Workers' Compensation Programs, a private physician noted that the Veteran reinjured his left arm during a fall by grasping a pipe, and reinjured his left elbow again in a lifting accident in October 1997. Private and VA medical records show symptoms such as pain and limitation of motion and imaging studies showing calcific tendinitis degenerative joint disease. However, there are also symptoms of loss of sensation in the fingers and loss of grip strength. The Veteran underwent several electro diagnostic studies. A study in March 1992 was "borderline," but a study in July 1993 was normal. In October 1997, a study obtained after the lifting accident was evaluated as abnormal and suggestive of mild carpal tunnel syndrome. However, a study in January 2001 was normal. A VA physician in January 2001 declined to diagnose carpal tunnel syndrome or ulnar neuropathy. In May 2001, the RO denied service connection for carpal tunnel syndrome in part based on the conclusions of this examiner. Although the private medical examiners diagnosed neurological disorders including carpal tunnel syndrome and ulnar neuropathy, they found that all residuals arose from the injury in service without acknowledging the other intervening accidents. In October 2010, a VA nurse practitioner noted a summary of the treatment and examination history. The nurse did not comment on carpal tunnel syndrome, referring to the RO's denial of service connection in 2001. The nurse found that ulnar neuropathy manifested many years after service and was not a residual of the injury in service but rather a result of repetitive use of the arm. Given the above, the Board finds that, with respect to the claim for an increased rating for left forearm/elbow disability, a significant but unresolved issue is whether any neurological impairment (other than carpal tunnel syndrome) is residual to in-service injury, or due to injury sustained in the two post-service accidents and/or from a long history of use of the dominant forearm and elbow in his occupation as a pipefitter and welder. Although, as indicated above, a VA nurse practitioner attempted to resolve these questions, as indicated, it does not appear that all pertinent records were then associated with the claims file. Therefore, the Board finds that further VA examination, by an appropriate physician, and medical opinion-based on full consideration of all evidence and assertions-are also needed to resolve this claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran is hereby notified that failure to report for any scheduled examination(s), without good cause, may well result in denial of the claim(s)-in particular, the claim for increased rating for left forearm/elbow disability. See 38 C.F.R. § 3.655(a),(b) (2013). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. If the Veteran fails to report to any scheduled examination(s), the RO should obtain and associate with the claims file (a) copy(ies) of the notice(s) of the date and time of the examination(s) sent to him by the pertinent VA medical facility. Prior to arranging for the Veteran to undergo further examinations, to ensure that all due process requirements are met, and the record is complete, the RO should undertake appropriate action to obtain and associate with the claims file all outstanding, pertinent records. The January 2000 letter by a private physician suggests that the Veteran applied for a Federal Workers' Compensation claim. VA is required to make reasonable efforts to help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). Further, during the Board hearing, the Veteran testified that he has been receiving on-going VA outpatient medical care and has requested VA vocational rehabilitation training. VA has constructive notice of VA and other Federal generated documents that could reasonably be expected to be part of the record, and that such documents are thus constructively part of the record before the Secretary and the Board, even where they are not actually before the adjudicating body. Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the RO must request copies of medical and adjudicative records from the U.S. Department of Labor, Office of Workers' Compensation Programs associated with a claim for benefits between 1997 and 2001 for injuries at F.B. Warren Air Force Base. The RO must also obtain VA medical records pertaining to the Veteran dated since April 2010. The RO should also give the Veteran another opportunity to provide information and/or evidence pertinent to the claims remaining on appeal, explaining that he has a full one-year period for response. See 38 U.S.C.A. § 5103(b)(1) (West 2002); but see also 38 U.S.C.A. § 5103(b)(3) (West Supp. 2013) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period. In the letter, the RO should specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private records. Thereafter, the RO should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159 (2013). The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2013). However, identification of specific actions requested on remand does not relieve the RO of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the RO should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claims remaining on appeal. The RO's adjudication of each claim should include consideration of whether "staged rating of the disability (assignment of different ratings for distinct periods of time, based on the facts found) is appropriate, as well as whether a higher rating is warranted on an extra-schedular basis under 38 C.F.R. § 3.321(b)(1). All evidence added to the record since the RO's last adjudication must be considered. Accordingly, these matters are hereby REMANDED for the following action: 1. Request copies of medical and adjudicative records from the U.S. Department of Labor, Office of Workers' Compensation Programs associated with a claim for benefits between 1997 and 2001 for injuries at F.B. Warren Air Force Base. Follow the procedures set forth in 38 C.F.R. § 3.159(c) as regards requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Obtain pertinent records of VA evaluation and/or treatment of the Veteran, dated since April 2010. Follow the procedures set forth in 38 C.F.R. § 3.159(c) as regards requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 3. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization, to obtain any additional evidence pertinent to the claims for an initial compensable rating for bilateral hearing loss and for an increased rating in excess of 10 percent for residuals of an injury to the left forearm and elbow with tendonitis. Specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private medical records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 4. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran and his representative of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 5. After all records and/or responses from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo VA audiology examination, by an appropriate medical professional, at a VA medical facility. The contents of the entire claims file (paper and electronic), to include a complete copy of this REMAND, must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented medical history and assertions. All appropriate test and studies-in particular, audiometry and speech discrimination testing-should be accomplished.. The examiner should provide numeric interpretation of any hearing tests conducted. The examiner should also set forth numeric values for each of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz ; and then provide the average pure tone threshold for these four frequencies. The reported numeric values and speech recognition scores (Maryland CNC test) must be in conformity with the requirements of 38 C.F.R. § 4.85. The examiner should fully describe the functional effects of the Veteran's hearing loss on his ability to work and his daily life. All testing results, along with complete rationale for the conclusions reached, must be provided. 6. After all records and/or responses from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo VA orthopedic/ neurological examination of his left lower arm by an appropriate physician,. The contents of the entire claims file (paper and electronic), to include a complete copy of this REMAND, must be made available to the physician designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented medical history and assertions. All necessary tests and studies including imaging studies and electro diagnostic tests, if necessary, should be accomplished and all clinical findings should be reported in detail. Request that the physician clearly identify all impairment of the left arm, to include any dysfunction such as limited or painful motion and loss of sensation, grip strength, reflexes, and/or or other motor function. Then, with respect to each such identified neurological impairment other than carpal tunnel syndrome,, the physician should indicate whether such impairment is at least as likely as not (i.e., a greater than 50 percent probability) residual to in-service injury, or whether impairment of the wrists and hands is more likely due to the two post-service accidents and/or from a long history of use of the dominant forearm and elbow in his occupation as a pipefitter and welder. In rendering the requested opinion, the examiner should consider and discuss all pertinent in- and post-service medical evidence and lay assertions. All examination findings, along with complete rationale for the conclusions reached, along with complete rationale for the conclusions reached, must be provided. 7. If the Veteran fails to report to any scheduled examination(s), the RO must obtain and associate with the claims file (a) copy(ies) of any notice(s) of the date and time of the examination(s) sent to him by the pertinent VA medical facility. 8. To help avoid future remand, ensure that all requested actions have been accomplished to the extent possible in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268 (1998). 9. After accomplishing all requested action, as well as any additional action deemed warranted by the VCAA, adjudicate the remaining claims for an initial, compensable rating for bilateral hearing loss and for an increased rating in excess of 10 percent for residuals of a left forearm and elbow injury with tendonitis. If the Veteran fails to report to the examination scheduled in connection with the left forearm/elbow disability, in adjudicating the claim for increased rating, apply the provisions of 38 C.F.R. § 3.655(b), as appropriate. Otherwise, adjudicate each claim in light of all pertinent evidence (to particularly include all that added to the record since the last adjudication of the claim) and legal authority. 10. If any benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate supplemental SOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication, and it is not the Board's intent to imply whether the benefits requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND 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. 2013). _________________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of the appeal. 38 C.F.R. § 20.1100(b) (2013). Department of Veterans Affairs