Citation Nr: 1752527 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 14-05 982 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for back disability. 2. Entitlement to service connection for neck disability. 3. Entitlement to service connection, to include on a secondary basis, for an acquired psychological disorder, to include PTSD, major depressive disorder (MDD), generalized anxiety disorder (GAD), and bipolar disorder. 4. Entitlement to an initial compensable rating prior to March 8, 2016, for bilateral hearing loss, and in excess of 40 percent disabling thereafter. 5. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: John-Paul Gustad, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Lamb, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1978 to March 1983. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of the Seattle, Washington, Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that in July 2014, the Veteran requested a copy of his claims file. The record reflects that the VA Records Management Center provided the requested documents in July 2016. During the pendency of the appeal, a March 2016 rating decision granted an increased rating for bilateral hearing loss of 40 percent, effective March 8, 2016 As this rating is not the maximum allowable, that issue remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). In August 2016, the Veteran submitted a statement requesting that his attorney be removed as his representative. However, in October 2016, the Veteran filed a request to reinstate his attorney, which included an authorization to disclose personal information to a third party. Additionally, the Board notes that the attorney represented the Veteran during his Board videoconference hearing in November 2016. Accordingly, the Board will continue to recognize the above mentioned attorney as his representative. In November 2016, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. The Board notes that in a November 2016 Brief, the Veteran's attorney asserted several issues before the Board, including PTSD, chronic mental condition, back condition, neck condition, bilateral shoulder condition, migraines, bilateral hearing loss, abdominal condition, TDIU and service-connected pension. The Board notes that the Veteran had previously claimed service connection for bilateral shoulder condition, migraines and an abdominal condition, and that those claims were denied in a September 2009 rating decision. In addition, the September 2009 rating decision denied a claim for non-service-connected pension because the Veteran had no war time service. These issues were listed in the December 2013 statement of the case (SOC), and the Veteran filed a timely VA Form 9, Substantive Appeal, in February 2014. However, the VA Form 9 indicated that the service connection issues for back and neck disability, PTSD and an increased rating for bilateral hearing loss were the only issues being appealed. Therefore, as the Veteran did not appeal the issues of service connection for bilateral shoulder condition, migraines, abdominal condition and entitlement to non-service-connected pension, the September 2009 rating decision is final as to those issues. See 38 U.S.C.A. § 7105(a) (West 2014); 38 C.F.R. §§ 3.104(a), 20.302(a), 20.1103 (2016). If the Veteran wishes to file a claim to reopen his previously denied claims, he is free to do so. With regard to a claim for a TDIU, the Board notes that since the September 2009 rating decision, an October 2016 private psychological evaluation found the Veteran totally disabled and unemployable due to his acquired psychological disorder. In addition, during a November 2016 Board videoconference hearing, the Veteran testified that the Social Security Administration (SSA) found him totally disabled and based that determination largely on orthopedic issues, but also relied on his psychological disorders. As such, a claim for a TDIU has been raised by the record and is part of the current appeal. See Rice v. Shinseki, 22 Vet. App. 447 (2009). With regard to the Veteran's service connection claim for PTSD, the Board has recharacterized the issue as a claim for entitlement to service connection for an acquired psychological disorder, to include PTSD, MDD, GAD, and bipolar disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Lastly, the issues of entitlement to service connection for bilateral upper and lower extremity radiculopathy, to include on a secondary basis, have been raised by the record. Additionally, the Board notes that during the November 2016 videoconference hearing, the Veteran's attorney asserted an earlier effective date for the Veteran's award of service connection for bilateral hearing loss. Thus as the issues of service connection for bilateral upper and lower extremity radiculopathy and an earlier effective date for the grant of service connection for bilateral hearing loss have been raised by the record but have not yet been adjudicated by the Agency of Original Jurisdiction (AOJ), the Board does not have jurisdiction over those issues. Accordingly, those claims are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2016). The issue of entitlement to service connection for an acquired psychological disorder and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. In providing the benefit of the doubt to the Veteran, the evidence establishes that the Veteran's back disability is attributable to service. 2. In providing the benefit of the doubt to the Veteran, the evidence establishes that the Veteran's neck disability is attributable to service. 3. Prior to March 8, 2016, the Veteran manifested no worse than level I hearing in the right ear, and no worse than level I hearing in the left ear; he has manifested no worse than 100 percent speech discrimination bilaterally. 4. As of March 8, 2016, the Veteran manifested no worse than level VII hearing in the right ear, and no worse than level VIII hearing in the left ear; he has manifested no worse than 56 percent speech discrimination in the right ear, and no worse than 52 percent speech discrimination in the left ear. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for back disability are met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2016). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for neck disability are met. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2016). 3. The criteria for a compensable disability rating, prior to March 8, 2016, for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.10, 4.85, 4.86, Diagnostic Code (DC) 6100 (2016). 4. The criteria for a disability rating in excess of 40 percent, as of March 8, 2016, for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.7, 4.10, 4.85, 4.86, DC 6100 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist VA provided the Veteran with 38 U.S.C.A. § 5103(a)-compliant notices in October 2008, and May, June and July 2009. The record also shows that VA has fulfilled its obligation to assist the Veteran in developing the claims, including with respect to VA examinations of the Veteran. Neither the Veteran nor his representative has identified any deficiency in VA's notice or assistance duties. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1131 (West 2014); 38 C.F.R. § 3.303 (2016). In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be presumed for certain chronic diseases which develop to a compensable degree within one year after discharge from service, even though there is no evidence of the disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1137 (West 2014); 38 C.F.R. 3.307, 3.309(a) (2016). Lay evidence presented by a Veteran concerning continuity of symptoms after service may not be deemed to lack credibility solely because of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (2006). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Back and Neck Disabilities The Board notes that the facts surrounding the Veteran's service connection claims for back and neck disabilities are similar and those claims will be addressed concurrently. The Veteran asserts entitlement to service connection for a back and neck disability. Specifically, the Veteran asserts that his current back and neck disability is related to his military occupational specialty (MOS) as a parachute rigger, including due to parachuting jumps and landings. The Board notes that the Veteran's DD214 shows his specialty was parachute rigger, and that he was the recipient of the parachutist badge. 1. Factual Background Initially, the Board notes that the Veteran's service treatment records (STRs) are silent as to any treatment or complaints of a back or neck disability. The Board does note a May 1981 STR showing the Veteran complained of left sided neck pain related to a diagnosed left para-tonsillar swelling. The claims file includes private chiropractic records dating from December 1991 to February 2009. The records show that the Veteran was initially seen following a work related back injury. The Veteran reported feeling back pain when he bent and twisted his back while picking up sheets of plywood. The Veteran filed an industrial injury claim which was granted in March 1992. A December 2006 chiropractic record also noted cervical pain in addition to lumbar and thoracic spine pain. In July 2008, the Veteran filed a claim for service connection for back disability. In an accompanying statement, the Veteran asserted that he sustained injuries following a hard landing during a helicopter jump in cold weather. The Veteran stated that the jump involved a hard landing that "jolted, compressed, and really shocked my spine from the tailbone to my skull." In addition, the Veteran stated that he could not move following his landing. Following the jump, the Veteran asserted that he went on a run and that the pain was terrible and excruciating with each step. A July 2008 X-ray study revealed mild degenerative endplate changes involving the mid and lower thoracic spine. A July 2008 X-ray study was also performed in response to symptoms of bilateral upper extremity radicular pain. The July 2008 X-ray study revealed significant narrowing of the C5-C6 and C6-C7 disc spaces. The C5-C6 block appeared relatively immobile and the cervical lordosis began above that level. Additionally, there was narrowing of the C5-C6 neural foramina bilaterally caused by uncovertebral hypertrophy, and also narrowing of the C6-C7 neural foramina, worse on the right than the left. An MRI study of the back and neck was recommended. An August 2008 MRI study of the back revealed minor endplate changes of the thoracic spine, a small focal central disc protrusion at T5-T6 without cord impingement, and a small left paracentral disc protrusion at L4-L5 narrowing the left lateral recess. Another August 2008 review of the MRI study noted moderate to severe degenerative joint disease (DDD) at L4-L5 with a diffuse bulge of the disc annulus, and mild to moderate lateral recess stenosis on the left. In addition, the thoracic spine revealed moderately severe DDD at multiple discs, with midline protrusion of the disc annulus at T5 and T6. An August 2008 MRI study of the neck revealed DDD at C4-C7 with foraminal narrowing worse at C5-C6 and C6-C7. Another August 2008 review of the MRI study noted moderately severe DDD and posterior bulge at C5-C6, and moderate to severe DDD and mild to moderate foraminal stenosis on the right at C6-C7. A September 2008 VA medical record noted chronic low back pain since the Veteran's time in the military. The physician noted that the chronic lower back pain was without a radicular component. Another September 2008 VA medical record noted the Veteran had experienced some chronic neck and low back pain dating back to his military service as a paratrooper. The Veteran also complained of bilateral upper extremity pain and numbness. The Veteran was diagnosed with chronic neck pain with recent worsening of upper extremity pain and paresthesia related to degenerative spondylosis and foraminal stenosis at C5-C6 and C6-C7. The Veteran underwent a C5-C6 and C6-C7 anterior discectomy and fusion with lordosis allograft blocks and 34 mm Vectra plate procedure in November 2008. Following the procedure, the Veteran reported total relief of radicular symptoms. A December 2008 physical therapy record shows the Veteran reported progressively worsening neural symptoms, included upper extremity muscle spasms, weakness and pain. In a February 2009 letter, the Veteran's spouse stated that the Veteran aggravated a pre-existing back disability during a work related injury in December 1991. She further stated that the Veteran suffered from continued back pain since service. An April 2013 VA medical record shows the Veteran reported worsening sciatic pain from his mid-back down both legs to his bilateral knee. A June 2013 VA medical record noted painful dysesthesias of the distal thighs and lateral knees with unclear etiology. The physician did find that the symptoms were consistent with radiculopathy. A June 2013 radiological study revealed multiple levels of spondylosis and articulating facets of arthrosis at L4-L5 and L5-S1. In a May 2014 letter, the Veteran's treating orthopedic and spine surgeon noted a diagnosis for cervical and lumbar spondylosis associated with myelopathy and radiculopathy. Based on a medical evaluation of the Veteran and a review of the imaging studies, the physician opined that it was "likely, on a more-probable-than-not basis, [the Veteran's] conditions as they relate to the cervical spine and the lumbar spine are related to his activities while in the military." The service related activities included parachuting and being involved in crash-landings. In addition, the physician opined that a one-time episode such as the December 1991 back injury, would not typically lead to the cascade of current medical problems. The Veteran underwent two VA examinations in August 2015, one for his back disability and one for his neck disability. With regard to the Veteran's back disability, he was diagnosed with status post lumbar discectomy with scar and IVDS associated with lower peripheral neuropathy (sciatica). The Veteran recently underwent a back discectomy earlier that month. The examiner additionally diagnosed the Veteran with mild radiculopathy resulting in mild paresthesia and/or dysesthesias involving the L4/L5/S1/S2/S3 bilateral nerve roots. The Veteran's IVDS was found not to require bed rest prescribed by a physician in the past 12 months. With regard to the Veteran's neck disability, he was diagnosed with status post cervical fusion with scar. No radiculopathy was found. The Veteran reported the onset of his symptoms in 1978 following a parachuting injury, and that he aggravated his neck and back through continued parachuting. The examiner opined that both the back and neck disabilities were "less likely than not (less than 50 percent or greater probability) incurred in or caused by the claimed in-service injury, event or illness." The examiner based the medical opinion on a lack of medical records containing clinical notes of a neck or back condition, or treatment for a neck or back condition during service. The examiner further noted that the first indication of a neck or back disability occurred in 2008, 25 years following service, which suggested that the conditions were the result of events or injuries independent of military service. An August 2016 medical record shows associated symptoms involving the bilateral upper and lower extremities including weakness, numbness, tingling and swelling. The physician noted evidence of C7 radiculopathy. The Veteran was diagnosed with lumbar and cervical myelopathy with August 2016 listed as the date of onset. 2. Legal Analysis After a review of the claims file, the Board finds that entitlement to a back and neck disability is warranted. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2016). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110 (West 2014); Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that interpretation of section 1110 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the present case, there is sufficient evidence the Veteran meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Specifically, the Veteran has been diagnosed with DDD of the back and neck as confirmed by radiological studies, and spondylosis as diagnosed by a private examiner. Thus, the Veteran clearly has current diagnoses and the remaining question is whether his back and neck disability is related to service. As noted above, the Veteran asserts that his back and neck disability resulted from his MOS as a parachute rigger, including due to parachuting jumps and landings. A May 2014 letter from his treating orthopedic and spine surgeon opined that it was "likely, on a more-probable-than-not basis" that the back and neck condition was related to his activities during service; specifically parachuting and being involved in crash-landings. Therefore, the record contains a medical nexus opinion linking the Veteran's current back and neck disability to his MOS during service. The Board notes that there is a conflicting medical opinion of record. The August 2015 examiner found that it was "less likely than not (less than 50 percent or greater probability)" that the back and neck disability was caused by service. In support of his negative nexus opinion, the examiner noted a lack of in-service treatment and a lack of medical evidence showing treatment until 25 years following service. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The credibility and weight to be attached to these opinions is within the province of the Board. Id. In this case, the Board finds the May 2014 letter from his treating orthopedist to be of more probative value than the August 2015 VA medical opinion. In this regard, the Board notes that the August 2015 VA examiner did not address the Veteran's MOS as a parachutist in providing his negative nexus opinion; a claim substantiated by the Veteran's DD214. At the very least, the evidence is at least in relative equipoise with regard to a causal connection between the claimed in-service incident(s) and the current disabilities. Accordingly, based on the foregoing, and providing the Veteran the benefit-of-the-doubt, the Board finds the May 2014 nexus opinion the most probative evidence of record. As such, the Board finds that the remaining Shedden inquiry has been satisfied and the claims are granted. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2016); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Increased Initial Ratings Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2016). The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2016). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2016). When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2016). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2016); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2016). Bilateral Hearing Loss The criteria for rating hearing impairment requires the consideration of the results of examinations using controlled speech discrimination tests (Maryland CNC) with the results of puretone audiometry tests. The results are charted on Table VI and Table VII, as set forth in the Rating Schedule. In order to establish entitlement to a higher rating for hearing loss it must be shown that certain minimum levels of the combination of the percentage of speech discrimination loss and average puretone decibel loss are met. 38 C.F.R. § 4.85 (2016). Hearing tests will be conducted without hearing aids. When the puretone threshold at 1000, 2000, 3000, and 4000 Hertz are each 55 decibels or more, or when the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, those exceptional patterns of hearing require different methods of rating. 38 C.F.R. § 4.86 (2016). The Veteran was granted service connection for hearing loss and assigned a noncompensable rating with an effective date of July 24, 2008, the date he filed his claim. In a March 2016 rating decision, the RO increased the disability rating to 40 percent disabling effective March 8, 2016; the date of the most recent VA examination. During the appeal period, the Veteran's claims file includes audiological examination conducted between May 2009 and March 2016. The May 2009 VA audiological examination noted the following puretone thresholds in decibels: HERTZ 1000 2000 3000 4000 RIGHT 45 35 40 45 LEFT 35 35 35 50 The average puretone threshold in the right ear was 41.25 decibels and 38.75 decibels in the left ear. Word recognition scores were 100 percent bilaterally. On VA audiological examination in December 2013, puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 30 35 30 45 LEFT 30 40 35 45 The average puretone threshold in the right ear was 35 decibels and 37.5 decibels in the left ear. The examiner noted speech recognition scores of 100 percent bilaterally. The examination utilized NU-6 rather than Maryland CNC. Another VA audiology assessment conducted in July 2015 noted the following puretone thresholds in decibels: HERTZ 1000 2000 3000 4000 RIGHT 45 35 30 50 LEFT 40 40 50 55 The average puretone threshold in the right ear was 40 decibels and 46.25 decibels in the left ear. Speech recognition scores were 96 percent in the right ear and 100 percent in the left ear. As with the December 2013 audiology assessment, the examination utilized NU-6 instead of Maryland CNC. The Veteran underwent another VA examination in March 2016. The May 2009 audiological VA examination noted the following puretone thresholds in decibels: HERTZ 1000 2000 3000 4000 RIGHT 50 55 60 75 LEFT 65 65 70 75 The average puretone threshold in the right ear was 60 decibels and 68.75 decibels in the left ear. Speech recognition scores were 56 percent for the right ear, and 52 percent for the left ear. Turning to the results of the May 2009 VA audiological examination, the findings correlate to a designation of level I in the right ear, and level I in the left ear. Those results provide for a non-compensable rating under DC 6100. With regard to both the December 2013 and July 2015 VA audiological examinations, both used NU-6 instead of Maryland CNC; thus, those examination results are not valid for rating purposes. In any event, even if one were to consider the results, both examination findings correlate to designations of level I in the right ear and level I in the left ear. Those results provide for a non-compensable rating under DC 6100. Lastly, turning to the results of the March 2016 VA examination, the findings correlate to a designation of level VII in the right ear, and level VIII in the left ear. Those results provide for a 40 percent evaluation under DC 6100. The Board emphasizes that disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). To the extent the Veteran may argue or suggest that the clinical data supports an increased disability rating or that the rating criteria should not be employed, he is not competent to make that assertion. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In sum, the examinations document that, prior to March 8, 2016, the bilateral hearing loss was, at most, subject to a non-compensable disability rating. Additionally, the March 8, 2016 VA examination documents that the bilateral hearing loss was, at most, subject to a 40 percent disability rating. Consequently, the preponderance of the evidence is against a compensable rating prior to March 8, 2016, in excess of 40 percent thereafter. The claim is denied. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board notes that the Veteran currently has a claim for a TDIU that remains on appeal. That claim is addressed in the Remand section below. ORDER Entitlement to service connection for back disability is granted. Entitlement to service connection for neck disability is granted. Entitlement to an initial compensable rating, prior to March 8, 2016, for bilateral hearing loss is denied. Entitlement to a rating in excess of 40 percent disabling, as of March 8, 2016, for bilateral hearing loss is denied. REMAND With regard to the remaining issues on appeal, the Board finds that further development is necessary. 1. Acquired Psychological Disorder The Veteran asserts entitlement to service connection for an acquired psychological disorder. The Veteran asserts that he has PTSD as a result of his MOS as a parachute rigger and due to an incident involving a hard landing. The Veteran also cites being passed over for promotion as another stressor related to his PTSD. The record also includes psychological assessments noting the Veteran reported being abused by his father as a child and witnessing and acting as the first responder to his brother's fatal tractor accident. Initially, the Board notes that the Veteran's STRs are silent for any treatment or diagnosis of an acquired psychological disorder. This includes a July 1978 enlistment examination and May 1982 separation examination, both of which noted normal psychiatric evaluations, and both of which show the Veteran denied any depression or excessive worry, or nervous trouble of any sort. A February 2008 VA psychological assessment shows the Veteran reported feeling guilty about the death of his younger brother who died in a tractor accident. The physician noted the Veteran's mood as anxious and irritated, and affect congruent with mood. The Veteran's thought content was described as black and white with a very harsh conscience that he applied to himself and others. The physician also noted some hypersensitivity to criticism that "may seem like paranoia." His insight and judgement were found adequate but distorted due to his thought content. The Veteran was diagnosed with bipolar disorder with a potentially associated sleep disorder. A GAF score of 60 was assigned. In July 2008, the Veteran filed a claim for PTSD. In an accompanying statement, the Veteran asserted that his PTSD was caused by environmental exposures, including exposure to equipment, cargo and parachutes that came from Vietnam, and jumping into drop zones on old artillery ranges. In addition, the Veteran asserted that his PTSD resulted from the stress of a bad jump and the pain from the resulting injury(ies). An August 2008 VA medical record noted the Veteran appeared to have a significant anxiety reaction to increased pain. In an October 2008 statement, the Veteran asserted that his PTSD was caused by not being deprogrammed prior to leaving service. He further stated that he was taught to always be on alert and on guard, and that he was alert and on guard all the time due to service during the cold war. He further stated that there was no specific incident besides bad jumps and being continuously on alert. A February 2009 VA psychiatry record noted the Veteran reported being abused by his father as a child and the psychiatrist attributed some of his anxiety to that abuse. The Veteran also reported that his anxiety increased during active duty service due to very stressful experiences. His mood was reported as irritable which increased with pain symptoms. The psychiatrist noted the Veteran seemed to meet the criteria for GAD with some PTSD symptoms which likely came from both his childhood abuse and experiences during service. Depressive symptoms were also noted as being related to chronic pain. In an April 2009 statement, the Veteran reiterated his previous assertion that his PTSD was caused by parachute jumps and being on alert at all times. The Veteran additionally asserted that his PTSD was caused by getting passed over for promotions which built an environment of distrust. In addition, the Veteran asserted that his psychological disorder was caused by being disciplined for incidents caused by his Sergeant who then blamed his unit. The Veteran also stated that his primary care physician told him his psychological issues were high anxiety, stress and depression which were related to military service. The Veteran underwent a February 2012 psychological evaluation. During the evaluation, the Veteran reported being physically abused by his father and being the first responder to his younger brother's fatal tractor accident. The Veteran also reported witnessing his father physically abuse his mother. The Veteran reported nightmares and intrusive thoughts from things that happened and "off the wall" things. He was found "avoidant." The Veteran was diagnosed with PTSD, MDD and assigned a GAF score of 64. The Veteran underwent another psychological evaluation in October 2016. The examiner conducted an evaluation to determine if there was a connection between an existing diagnosis for PTSD and military service. The Veteran reported trauma due to being physically abused by his father and being the first responder to his brother's fatal tractor accident. The Veteran was diagnosed with PTSD, recurrent severe MDD, and GAD. The psychiatrist stated that it appeared the Veteran's background and emotional pattern would lead to the development of PTSD. Additionally, the psychiatrist found that the Veteran did not appear to have the resources to respond effectively to traumatic events from the distant past. The psychiatrist further found that the Veteran had considerable trauma before he went into the military, and that he suppressed the trauma prior to his enlistment so that he appeared asymptomatic. During service, the psychiatrist noted that every injury, fear, pain, indignation and humiliation "likely accumulated and ultimately aggravated the intensity of his PTSD." Overall, the psychiatrist found a complex web of trauma that was not solely caused by military service, but, in his opinion, was more probable than not that the PTSD was aggravated by military service. As noted in the Introduction section above, the Veteran's claim of entitlement to service connection for PTSD is the type of claim that cannot be limited only to a particular diagnosis, but must be considered a claim for any mental disability that may be reasonably encompassed. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In addition, the October 2016 psychological evaluation raises a separate theory of entitlement to service connection; namely, that the Veteran's diagnosed PTSD pre-existed service and was aggravated by military service. The Board notes that a veteran is presumed to have been in sound condition when examined, accepted, and enrolled for service except as to defects, infirmities, or disorders noted at the time of examination, acceptance, enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2014); 38 C.F.R. § 3.304 (2016). The Veteran's medical records clearly show a current diagnosis for PTSD, MDD and GAD. This includes an October 2016 psychological nexus opinion. However, the Board finds the October 2016 nexus opinion inadequate as it is speculative in nature. This is especially true considering the clear and unmistakable evidentiary standard necessary for the recently claimed pre-existing condition. This includes findings that "it appears" the Veteran had the background and emotional pattern that would lead to the development of PTSD, that the Veteran "did not appear" to have the resources to respond effectively to traumatic events from the distant past, and that every injury, fear, pain, indignation and humiliation "likely" accumulated and ultimately aggravated the intensity of his PTSD. Speculative language does not create an adequate nexus for the purposes of establishing service connection, as it does little more than suggest a possibility of a relationship. See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Utendahl v. Derwinski, 1 Vet. App. 530, 531 (1991); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993). Further, the evidentiary standard for whether a condition existed prior to service is "clear and unmistakable," which is a formidable evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be "undebatable." Therefore, the Board finds that the opinion did not adequately address the question of whether the Veteran's acquired psychiatric disorder "clearly and unmistakably" pre-existed service. Additionally, given the favorable disposition of the service connection claims for back and neck disabilities, and medical evidence suggesting the Veteran's acquired psychological disorder, including GAD, is secondary to pain associated with the now service-connected disabilities (including on an aggravation basis), the Board finds that a medical opinion addressing that theory of entitlement to service connection is necessary to properly adjudicate the issue on appeal. VA's duty to assist a claimant includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d)(1) (West 2014); 38 C.F.R. § 3.159(c)(4) (2016). The medical examination provided must be thorough and contemporaneous and consider prior medical examination and treatment. Green v. Derwinski, 1 Vet. App. 121 (1991). VA must provide a medical examination when there is evidence of (1) a current disability, (2) an in-service event, injury, or disease, (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for VA to make a decision. McClendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A (d)(2) (West 2014); 38 C.F.R. § 3.159 (c)(4)(i) (2016). The third prong, which requires evidence that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McClendon, 20 Vet. App. at 83. Thus, the Board concludes that a VA examination is necessary to address these outstanding questions of etiology of the Veteran's acquired psychological disorder. 38 C.F.R. § 3.159(c)(4) (2016) (a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim); see Charles v. Principi, 16 Vet. App. 270 (2002); see also Colvin v. Derwinski, 1 Vet. App. 191 (1999) (the Board is prohibited from exercising its own independent judgment to resolve medical questions). The Board also notes that the record contains a December 2015 letter from SSA advising the Veteran of his monthly supplemental security income payment. However, the record does not include a copy of any other SSA record, including copies of medical records or a disability determination. Therefore, the Board finds that those records should be obtained and associated with the claims file. Where VA has actual notice of the existence of records held by SSA that appear relevant to a pending claim, VA has a duty to assist by requesting those records from SSA. Murincsak v. Derwinski, 2 Vet. App. 363 (1992). Accordingly, attempts to obtain and associate with the claims file any outstanding SSA records should be made. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010); see also Baker v. West, 11 Vet. App. 163, 169 (1998). In addition, the Veteran has claimed entitlement to a TDIU that is inextricable intertwined with the service connection claim that is currently on appeal. Thus, that issue is remanded. Accordingly, the case is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. Identify and obtain any outstanding SSA records that are not already associated with the record. If these records are unavailable, a written statement to this effect must also be incorporated into the claims file. 3. Then, schedule the Veteran for a VA examination with a psychiatrist or a psychologist. The examiner must determine whether the Veteran currently suffers from an acquired psychiatric disorder, to include PTSD, MDD, GAD and bipolar disorder. The examiner must review the claims file. The examiner should set forth all examination findings and a complete rationale for any opinion expressed should be provided. All necessary special studies or tests, to include psychological testing and evaluation, should be accomplished. The examiner should provide the following information: (a) Provide a full multiaxial diagnosis. Specifically state whether each criterion for a diagnosis of PTSD is met. Otherwise, provide a diagnosis for any acquired psychiatric disorder. (b) If a diagnosis of PTSD is appropriate, identify each stressor event upon which the diagnosis is based. (c) With respect to any psychiatric disorder found upon examination or identified during a review of the claims folder, the examiner should provide an opinion as to whether the diagnosed psychological disorder clearly and unmistakably preexisted the Veteran's active duty service? (d) If so, was any diagnosed psychological disorder clearly and unmistakably not aggravated by active service? (e) If any diagnosed psychological disorder of record is not clearly and unmistakably found to have preexisted service, or if a preexisting disorder is found to clearly and unmistakably NOT have been aggravated by service, then is it at least as likely as not (50 percent or greater probability) that any diagnosed psychological disorder is etiologically related to a period of active service? (f) With respect to any psychiatric disorder found upon examination or identified during a review of the claims folder, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that each such psychiatric disability was caused or aggravated by the Veteran's service-connected disabilities, to include back and neck disability. If a negative medical opinion is provided, the examiner should address conflicting medical evidence of record, including the October 2016 psychological evaluation and the medical records noting a possible relationship between the Veteran's back and neck disability and his GAD. A comprehensive rationale must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why the opinion cannot be made without resorting to speculation. 4. Then, readjudicate the claims on appeal, including the Veteran's claim for TDIU. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow an appropriate time for response. Then, return the claim to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Thomas H. O'Shay Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs