Citation Nr: 1752583 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 14-07 947 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for a left shoulder disability. 3. Entitlement to service connection for a left elbow disability. 4. Entitlement to service connection for a cervical spine disability. 5. Entitlement to service connection for a lumbar spine disability. 6. Entitlement to an initial disability rating in excess of 10 percent for dermatitis. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Salazar, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1983 to November 1991 and February 2003 to February 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which granted the Veteran service connection for dermatitis (assigning a 10 percent disability rating, effective from June 27, 2011) and denied service connection for bilateral hearing loss, left shoulder, left elbow, cervical spine, and lumbar spine disabilities. Since then, jurisdiction has been transferred to the RO in Columbia, South Carolina. See, e.g., February 2017 VA Form 8. In a July 2012 rating decision, the RO granted service connection for dermatitis and assigned a 10 percent disability rating effective June 27, 2011. When, as here, a Veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In June 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A copy of the transcript is associated with the evidentiary record. Since the Agency of Original Jurisdiction (AOJ) issued the December 2016 supplemental statement of the case (SSOC), the Veteran has submitted additional evidence, along with waivers of consideration of this evidence by the AOJ. The issues of entitlement to service connection for cervical spine and left elbow disabilities are addressed in the REMAND portion of the decision below and REMANDED to the AOJ. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. The evidence of record, to include competent expert and non-expert evidence, is at least in equipoise as to whether the Veteran has a thoracolumbar spine disability, which began during active duty or is related to an incident in service. 2. The preponderance of the competent and credible evidence weighs against finding that the Veteran has bilateral hearing loss for VA compensation and pension purposes. 3. The preponderance of the competent and credible evidence weighs against finding that the Veteran has a left shoulder disability. 4. Throughout the appeal period, the Veteran's dermatitis has not been manifested by at least 20 percent of the entire body or at least 20 percent of exposed areas affected. His dermatitis also has not required systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of at least six weeks or more during the past 12-month period. CONCLUSIONS OF LAW 1. The criteria for service connection for a thoracolumbar spine disability have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 3. The criteria for service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 4. The criteria for an initial rating in excess of 10 percent for dermatitis have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.118, Diagnostic Code 7806 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in part at 38 U.S.C. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claim. As to the Veteran's thoracolumbar spine disability claim, the requirements of the VCAA have been met. In light of the fact that the Board allows the benefit sought, discussion of the notice and assistance requirements of the VCAA and a detailed explanation of how VA complied with the Act is unnecessary. 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. As to the bilateral hearing loss, dermatitis, and left shoulder claims, the duty to notify has been met. Neither the Veteran, nor his representative, has alleged prejudice with regard to notice. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[A]bsent extraordinary circumstances . . . it is appropriate for the Board and the [United States Court of Appeals for Veterans Claims] to address only those procedural arguments specifically raised by the veteran . . . ." Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). In light of the foregoing, nothing more is required. The duty to assist includes assisting the claimant in the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The RO associated the Veteran's VA and identified private treatment records with the claims file. No other relevant records have been identified and are outstanding. As such, the Board finds VA has satisfied its duty to assist with the procurement of relevant records. During the appeal period, the Veteran was afforded VA examinations to assess the current severity of his dermatitis in October 2011, January 2013, December 2013, and November 2016. Further, the Veteran was afforded VA examinations and concomitant addendum opinions to assess his hearing loss claim in August 2011, January 2012, and November 2016. In August 2011 and June 2014, the Veteran was afforded VA examinations to assess his left shoulder. The Board has carefully reviewed the VA examinations of record and finds that the examinations and opinions, along with the other evidence of record, are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The Veteran has not made VA aware of any additional evidence that must be obtained in order to fairly decide the appeal. He has been given ample opportunity to present evidence and argument in support of his claims. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of the issues has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2017). II. Service Connection A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C §§ 1110, 1131. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). Under 38 C.F.R. § 3.303(b), claims for chronic diseases enumerated in 38 C.F.R. § 3.309(a) benefit from a relaxed evidentiary standard. See Walker v. Shinseki, 708 F.3d 1331, 1339 (Fed. Cir. 2013). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show 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 a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms, such as joint pain for degenerative joint disease, does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The United States Court of Appeals for the Federal Circuit (Federal Circuit), however, has clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). While hearing loss is not a disease specifically enumerated as a chronic disease under 38 C.F.R. § 3.309(a), organic diseases of the nervous system are listed as a disability subject to presumptive service connection. Accordingly, service connection may be granted on a presumptive basis for sensorineural hearing loss if it is shown to be manifest to a degree of 10 percent or more within one year following the Veteran's separation from active military service. 38 C.F.R. §§ 3.307, 3.309(a). Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels) over a range of frequencies (in Hertz). See Hensley v. Brown, 5 Vet. App. 155, 158 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a 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 thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz 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. For service connection, in-service noise exposure need not be the only source of acoustic trauma; it must only be a contributing source. The absence of in-service evidence of hearing loss disability during a veteran's period of active duty is not fatal to a claim for service connection. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Competent evidence of a current hearing loss disability (i.e., one meeting the requirements of section 3.385, as noted above), and a medically sound basis for attributing such disability to service, may serve as a basis for a grant of service connection for hearing loss disability. See Hensley, 5 Vet. App. at 159. In the absence of proof of a present disability, there can be no valid claim. Degmetich v. Brown, 104 F.3d 1328, 1332 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement for service connection that a current disability be present is satisfied when a Veteran has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 322-23 (2007) (a service connection claim may be granted if a diagnosis of a chronic disability was made during the pendency of the appeal, even if the most recent medical evidence suggests that the disability resolved); see also Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013) (holding that when the record contains a recent diagnosis of disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). A. Hearing Loss The Veteran applied for entitlement to service connection for bilateral hearing loss in June 2011. He avers that exposure to noise as a pilot, to include improper ear protection, caused his current bilateral hearing loss. See August 2011 VA examination. The Veteran underwent two VA examinations to determine whether he had bilateral hearing loss for VA purposes. At the first examination, the Veteran did not register audiometric testing results exhibiting hearing loss for VA purposes. See August 2011 VA examination. Specifically, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 15 20 LEFT 10 10 20 15 15 Speech recognition scores "inconsistent...that make combined use of puretone threshold average and speech discrimination scores inappropriate." See August 2011 VA examination. In fact, the VA examiner perused the file and discussed multiple audiometric results while the Veteran was on active duty and at least a year thereafter. See Id. Specifically, the examiner determined that the Veteran's hearing was normal in both ears at entrance because his audiogram was normal upon contemporaneous testing. Id. Further, the Veteran's audiograms in November 2006, December 2007, December 2008, and December 2009 showed normal hearing in both ears. Further, the examiner did not find significant threshold shifts comparing the Veteran's July 1983 and December 2009 audiograms. As the examiner explained, "a 5 or 10 dB change is not significant because it may be due to equipment, testing, or examiner differences in the opinion of the examiner." Id. In November 2016, the Veteran again went through audiometric testing. The examiner could not test for hearing loss because "responses to pure tone stimuli were inconsistent and unreliable." Nevertheless, the November 2011 VA examination, combined with multiple audiometric results during and after service did not show that the Veteran suffered from bilateral hearing loss for VA purposes. The Veteran is competent to testify as to facts he personally observed or described; this includes recalling what he personally felt, saw, smelled, heard, or tasted. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to offer opinions on complex medical matters. Whether the Veteran has hearing loss for VA purposes cannot be determined by mere observation alone. This requires specialized training. The Board finds that determining the etiology of the Veteran's hearing symptoms is not within the realm of knowledge of a non-expert, and concludes that his opinion in this regard is not competent evidence and therefore not probative of whether he has hearing loss for VA purposes. Therefore, following a review of all available evidence, the record does not reflect a current diagnosis for bilateral hearing loss for VA purposes. To that end, the Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). As such, without a current disability, the Veteran lacks the evidence necessary to substantiate his claim for service connection. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, the Board denies the Veteran's claim for entitlement to service connection for bilateral hearing loss because the evidence of record is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). B. Left Shoulder The Veteran contends that he began to experience left shoulder pain which is documented in service. See October 2005 service treatment record. He asserts that this pain derived from the constant loading and unloading of bags and equipment as well as all his time spent flying. See July 2015 Veteran statement. The Veteran had two unremarkable left shoulder x-rays at VA examinations in both August 2011 and June 2014. Neither VA examiner diagnosed a left shoulder disability in the Veteran. While the Veteran has reported pain in the left shoulder, pain alone (without a diagnosed or identifiable underlying malady or condition) does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). The Veteran is competent to testify as to facts he personally observed or described; this includes recalling what he personally felt, saw, smelled, heard, or tasted. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to offer opinions on complex medical matters. Whether the Veteran has a left shoulder disability cannot be determined by mere observation alone. The Board finds that determining the etiology of the Veteran's left shoulder pain is not within the realm of knowledge of a non-expert, and concludes that his opinion in this regard is not competent evidence and therefore not probative of whether he has a current left shoulder disability. Therefore, following a review of all available evidence, the record does not reflect a current diagnosis for a left shoulder disability. To that end, the Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). As such, without a current disability, the Veteran lacks the evidence necessary to substantiate his claim for service connection. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, the Board denies the Veteran's claim for entitlement to service connection for a left shoulder disability because the evidence of record is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). C. Lumbar Spine The Veteran applied for entitlement to service connection for a thoracolumbar spine disability in June 2011. The first element under Shedden is met. The record is replete with documented degenerative changes in the Veteran's thoracolumbar spine. Importantly, a VA examiner determined that the Veteran had a magnetic resonance image (MRI) examination conducted in service that showed arthritis in the Veteran's thoracolumbar spine. See August 2011 VA examination. As such, the Veteran has a current thoracolumbar spine disability. The second element under Shedden is also met. As stated above, the Veteran had an MRI taken in service showing degenerative changes in his thoracolumbar spine. While in the military, the Veteran logged over 5,600 flying hours. See December 2009 Aeromedical Summary. The Veteran also complained of lower back pain as a result of cumulatively carrying bags into and out of planes. See June 2017 VA Board hearing. As such, the crux of this case hinges on whether the Veteran's thoracolumbar spine disability is attributable to service. Arthritis is an enumerated disease subject to presumptive service connection. In October 2005, the Veteran complained of lower back pain; an MRI confirmed arthritis. See October 2005 service treatment record. In October 2007, the Veteran sought treatment for his lower back pain; the treatment provider determined that the Veteran's subjective report was consistent with objective findings. See October 2007 service treatment record. A month later, a second MRI confirmed "multilevel [degenerative disc disease] and associated mild facet arthropathy." See November 2007 MRI. Further, the Veteran attended 12 physical therapy sessions to address his lower back pain between October 2008 and March 2009. See March 2009 service treatment record. Since then, a private treatment provider has stated that the Veteran has been receiving physical therapy for "just over 3 years on a weekly basis. [The Veteran] sought out [the treatment provider's] expertise for relief of musculo-skeletal [sic] treatment due to injuries sustained from his military flying career." See July 2017 JIFC medical treatment letter. In contrast, a VA examiner did not offer an opinion as to whether the Veteran's degenerative disc disease was attributable to service. See December 2013 VA examination. Therefore, at the very minimum, the evidence is in equipoise in showing that the Veteran's thoracolumbar spine disability is attributable to service. In resolving all reasonable doubt in the Veteran's favor, service connection is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. III. Initial Increased Rating Here, the Veteran has averred that his service-connected dermatitis warrants a higher initial disability rating. He filed his service connection claim in June 2011 and submitted new evidence before his July 2012 rating decision (which granted a 10 percent disability rating for dermatitis) became final. He ultimately submitted a notice of disagreement (NOD) on the appropriate form in September 2013 to a July 2013 rating decision continuing his 10 percent disability rating. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a "staged" rating are required. See Fenderson v. West, 12 Vet. App. 199, 125-26 (1999). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Under Diagnostic Code 7806, a noncompensable rating is warranted where less than 5 percent of the entire body or less than 5 percent of exposed areas are affected, and; no more than topical therapy was required during the past 12-month period. A 10 percent rating will be assigned where at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted where more than 40 percent of the entire body or more than 40 percent of the exposed areas are affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs were required during the past 12-month period. 38 C.F.R. § 4.118, Diagnostic Code 7806 (2017). In Johnson v. Shulkin, the Federal Circuit held that the operative terms of Diagnostic Code 7806 were "systemic therapy" and "topical therapy," but not the exemplary reference ("such as") to corticosteroids. 862 F.3d 1351, 1354 (Fed. Cir. 2017). In that case the Federal Circuit determined that "systemic therapy" means "treatment pertaining to or affecting the body as a whole," whereas topical therapy means "treatment pertaining to a particular surface area, as a topical antiinfective applied to a certain area of the skin and affecting only the area to which it is applied." Id. at 1355. The Veteran was afforded VA examinations in October 2011, January 2013, December 2013, and November 2016 to assess the current severity of his dermatitis. At his October 2011 VA examination, the Veteran reported itching, scaling, and flaking. See October 2011 VA examination. He also stated that he used medicated shampoo to treat his condition. The VA medical examiner determined that the Veteran's dermatitis covered between 5 to 20 percent of both his total and exposed skin. Id. These symptoms and conclusions continued at the Veteran's January 2013 VA examination. See January 2013 VA examination. Almost a year later, the Veteran reported getting dermatitis that was "relatively calm" and that he used "topical steroid" during active service that "helped." See December 2013 VA examination. There, he denied using any topical medication for his dermatitis since he left active service and reported that when his skin breaks out he got bumps on his chest and flaking skin on the scalp and around the nose. Id. However, the examiner determined that the total body area affected was less than 5 percent and no exposed areas were affected. Id. Almost three years later, the Veteran stated that his dermatitis worsened in the heat. See November 2016 VA examination. There, the examiner stated that the Veteran used a shampoo and his dermatitis covered less than 5 percent of both his total and exposed skin. Id. By way of background, in March 2005, the Veteran obtained a medical flight waiver for "intermittent use of topical steroids" to treat his dermatitis. See March 2005 Aeromedical Summary. However, in December 2009, the Veteran obtained an indefinite medical flight waiver for dermatitis "that has been quiescent, and he is not using anything at this time." See December 2009 Aeromedical Summary. Based on the evidence of record, the Board finds that the record does not show that the Veteran's dermatitis affected at least 20 percent, of the entire body or exposed area, and it did not require the use of intermittent systemic therapy required for a total duration of six weeks or more during a 12-month period. Significantly, the evidence does not show that the condition required intermittent systemic therapy or other immunosuppressive drug at any time during the appeal period. Johnson v. Shulkin, 862 F.3d 1351, 1354 (Fed. Cir. 2017). In assessing the severity of the disability under consideration, the Board has considered the Veteran's assertions regarding his symptoms, which he is certainly competent to provide. See, e.g., Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds that the Veteran's symptomatology, including his complaints of itching and flaking, is contemplated by the criteria under which his disability is currently rated. As such, his lay assertions do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. In sum, the preponderance of the evidence shows that the Veteran's dermatitis does not warrant an initial disability rating in excess of 10 percent at any time during the appeal period. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. ORDER Entitlement to service connection for a thoracolumbar spine disability is granted. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for a left shoulder disability is denied. Entitlement to an initial increased rating in excess of 10 percent for dermatitis is denied. REMAND The Board sincerely regrets the additional delay, but finds that further development is required prior to final adjudication of the Veteran's claims. After his June 2017 Board hearing, the Veteran's medical provider submitted a statement on his behalf. Specifically, the medical provider stated that he has treated the Veteran for over three years on a weekly basis for "relief of musculo-skeletal [sic] treatment due to injuries sustained from his military career." See July 2017 JIFC private medical statement. However, the letter stated that "after thoroughly reviewing [the Veteran's] past medical records, I began treating his chronic injuries and minimize his symptomology (see attached diagnostic reports for full details)." Id. He further described spinal adjustments to the cervical, thoracic, lumbar, and pelvic areas. On remand, the RO should undertake appropriate efforts to obtain all outstanding private treatment records. The Veteran received numerous meritorious service medals between his active duty periods and was last released from the Air Force Reserves in February 2010. See February 2010 Reserve Order. In fact, from March 2006 to December 2009, the Veteran amassed approximately 600 flying hours. See December 2009 Aeromedical Summary. Further, as to the left elbow claim, the Veteran complained about a gradual onset of left elbow pain "from using the left hand on the stick while flying the airplane during reserve duty." See June 2010 treatment record. Therefore, upon review of the record, it does not appeal that all periods of service have been verified. The Board notes that only service department records can establish if and when a person was serving on active duty, active duty for training (ACDUTRA) and/or inactive duty for training (INACDUTRA). See Cahall v. Brown, 7 Vet. App. 232, 237 (1994). Given the governing legal authority set forth above, a remand is necessary to clarify the Veteran's service dates and all periods of ACDUTRA or INACDUTRA. On remand, the Veteran's complete military personnel records must be obtained and associated with the claims file so that all service dates are accounted. Before adjudicating his claims, VA last afforded the Veteran examinations in December 2013 and January 2017 to assess his left elbow and cervical spine service connection claims. However, the Board finds that the VA examiner's opinions are inadequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The Veteran was last afforded a left elbow examination in January 2017. The VA examiner did not provide an opinion as to whether the Veteran's lateral epicondylitis of the left elbow was attributable to his job duties in service. Further, the Veteran was last afforded a VA examination in December 2013 to assess the etiology of his cervical spine disorder. The examiner did not consider the Veteran's statements concerning his over 5,600 flight hours and an incident where he slipped and fell on ice during service. See December 2013 VA examination. Thus on remand, the Veteran should be afforded addendum opinions as to his left elbow and cervical spine disabilities. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify any private testing and/or treatment, as well as any VA treatment, related to his cervical spine and left elbow disabilities since June 2011. Undertake appropriate development to obtain any outstanding treatment records, to include any treatment records from JIFC from January 2013 to present and VA treatment records from the Charleston VAMC from January 2017 to present. The AOJ must perform all necessary follow-up indicated. If the records are not available, or a negative response is received, the AOJ should make a formal finding of unavailability, advise the Veteran and his representative of the status of his records, and give the Veteran the opportunity to obtain the records on his own. 2. Verify the Veteran's service dates as a member of the Reserves. Determine whether that service included any periods of active duty training (ACDUTRA) or inactive duty training (INACDUTRA) and, to the extent feasible, ascertain the dates for each such period. Efforts should include a request of earnings records from the Defense Finance and Accounting Service (DFAS) that indicate the Veteran's duty status for active duty, ACDUTRA and INACDUTRA. If a negative response is received, make a formal finding of unavailability. 3. Obtain an addendum opinion from an appropriately qualified VA examiner to determine the nature and etiology of the Veteran's cervical spine and left elbow disability. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The addendum opinion must include a notation that this record review took place. It is up to the discretion of the examiner as to whether a new examination is necessary to provide an adequate opinion. After the record review and examination of the Veteran if deemed necessary by the examiner, the VA examiner is asked to respond to the following inquiries: A. Is it at least as likely as not that the Veteran's cervical spine disability was either incurred in, or is otherwise attributable to, the Veteran's active duty service or in the line of duty during periods of ACDUTRA/INACDUTRA? The medical professional must address the Veteran's degenerative disc disease shown on x-ray in August 2011 and discuss whether his time spent flying or carrying bags, to include his incident in August 2005, and a December 2008 incident when he experienced neck pain after slipping on ice, caused his cervical spine disability. In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the medical professional rejects the Veteran's reports, he or she must provide an explanation for such rejection. B. Is it at least as likely as not that the Veteran's left elbow disability, to include lateral epicondylitis, was either incurred in, or is otherwise attributable to, the Veteran's active duty service or in the line of duty during periods of ACDUTRA/INACDUTRA? The medical professional must address the Veteran's physical therapy treatment in June 2010 and his assertions that repeated use of his left elbow over his military career led to pain and a strain. In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the medical professional rejects the Veteran's reports, he or she must provide an explanation for such rejection. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. The examiner cannot improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 4. The AOJ should conduct any other development deemed appropriate, and ensure that the VA examination report and opinion complies with the Board's remand instructions. 5. After the above development has been completed, readjudicate the claims. If the benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC), and return the case to the Board. The Veteran and his representative have 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 claims 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. §§ 5109B, 7112 (2012). ______________________________________________ G. A. WASIK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs