Citation Nr: 1614715 Decision Date: 04/12/16 Archive Date: 04/26/16 DOCKET NO. 12-07 617 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to a compensable rating for bilateral hearing loss. ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from July 1984 to September 2005. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. REMAND The Board finds that additional development is necessary before a decision may be rendered in this case. First, efforts must be made to obtain records of VA and other Federal treatment not included in the record before the Board. The electronic claims file contains clinical records from the Naval Medical Center in San Diego, California, including records of audiological evaluations conducted in December 2009 and March 2012. However, these evaluation reports are not legible and there are no records from the Naval Medical Center dated after March 2012. The Veteran also stated in the February 2011 notice of disagreement that he was issued hearing aids by the VA San Diego Health Care System, but records from this facility are not included in the evidence of record. The Board also finds that a VA examination is necessary to determine the current severity of the service-connected hearing loss. The Veteran was provided a VA audiological examination in February 2010, but the results were deemed invalid due to poor agreement between the Veteran's reported pure tone thresholds and speech recognition scores. A valid VA examination was performed in October 2011, but the results of this examination appear inconsistent with the portions of the December 2009 and March 2012 Naval Medical Center audiograms the Board is able to interpret. Upon remand, a new VA examination must be conducted and the examiner should comment on any conflict between the VA examination results and the Naval Medical Center audiological evaluations. Accordingly, the case is remanded for the following action: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. When requesting records not in the custody of a Federal department or agency, such as private treatment records, the RO must make an initial request for the records and at least one follow-up request if the records are not received or a response that records do not exist is not received. Regardless of the Veteran's response, the RO must attempt to obtain a. The Veteran's complete records of audiological treatment from the VA San Diego Health Care System, to include any audiogram reports scanned into the facility's online system. b. The Veteran's complete audiological records from Naval Medical Center San Diego from December 2009 to the present, to include legibile copies of the December 2009 and March 2012 audiological evaluations. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 2. The Veteran must then be afforded an appropriate examination to determine the severity of his service-connected bilateral hearing loss. The electronic claims file must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies, to include an audiogram, must be accomplished. Specifically, the results of the audiological evaluation must state in numbers, the findings of puretone decibel loss at 1000, 2000, 3000, and 4000 Hertz, provide the puretone threshold average, and must also state the results of the word recognition test in percentages, using the Maryland CNC test. The objective findings and the Veteran's subjective complaints must be recorded in detail. The VA examiner must fully describe the functional effects of the Veteran's hearing loss, to include the effects of the Veteran's hearing loss on his occupation in the examination report. The examiner should address any discrepancy between the results of the VA examinations and the December 2009 and March 2012 Naval Medical Center San Diego audiological evaluations. If clearer copies of the Naval Medical Center evaluations are not received in response to development ordered above, the VA examiner must attempt to interpret the December 2009 and March 2012 Naval Medical Center audiological evaluation reports for the Board, if possible, to include the measured pure tone threshold averages and speech recognition scores. 3. After the development requested has been completed, the RO must review the examination report to ensure that it is in complete compliance with the directives of this Remand. If the reports are deficient in any manner, the RO must implement corrective procedures at once. 4. The RO must notify the Veteran that it is his responsibility to report for the examinations and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2015). In the event that the Veteran does not report for the aforementioned examination, documentation must be obtained which shows that notice scheduling the examinations was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 5. Once the above actions have been completed, and any other development as may be indicated by any response received as a consequence of the actions taken above, the claim on appeal must be adjudicated. If any benefit remains denied, a supplemental statement of the case must be provided to the Veteran. After he has had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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 your appeal. 38 C.F.R. § 20.1100(b) (2015).