Citation Nr: 1758366	
Decision Date: 12/15/17    Archive Date: 12/28/17

DOCKET NO.  13-03 278	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in St. Louis, Missouri


THE ISSUE

1.  Whether vacatur of an October 24, 2017, decision of the Board of Veterans' Appeals (Board), which denied service connection for bilateral hearing loss, to include as secondary to service-connected diabetes mellitus, is warranted. 

2.  Entitlement to service connection for bilateral hearing loss, to include as secondary to service-connected diabetes mellitus. 


REPRESENTATION

Veteran represented by:	Vietnam Veterans of America


WITNESS AT HEARING ON APPEAL

The Veteran


ATTORNEY FOR THE BOARD

C. Taylor, Associate Counsel


INTRODUCTION

The Veteran served on active duty from June 1966 to June 1970. 

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St, Louis, Missouri. 

The Veteran, through his representative, testified at a travel board hearing before the undersigned Veterans Law Judge in March 2015.  A transcript of the proceeding is of record. 

In July 2015, the Board denied service connection for bilateral hearing loss.  The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (Court).  In February 2016, the Court granted a Joint Motion for Remand, which vacated the Board's decision and provided the Veteran an opportunity to submit evidence in support of his claim.  The Board remanded the appeal to the Agency of Original Jurisdiction (AOJ) for further development in March 2016.  

In August 2017, the Veteran's representative, Vietnam Veterans of America, submitted an informal hearing presentation (IHP) that set forth the Veteran's contentions with regard to the service connection claim.  On October 24, 2017, the Board issued a decision denying service connection for bilateral hearing loss, to include as secondary to service-connected diabetes mellitus.  For the reasons discussed below, this decision must be vacated and the claim considered de novo by the Board.  In its review of the instant appeal, the Board observes the Veteran's contentions, as set forth in the August 2017 IPH, which are addressed in the decision below.

The Board reviewed the Veteran's electronic claims file which includes records in Virtual VA and Veterans Benefits Management System (VBMS) databases prior to rendering its decision. 


FINDINGS OF FACT

1.  In an October 24, 2017 decision, the Board denied service connection for bilateral hearing loss, to include as secondary to service-connected diabetes mellitus.

2.  The August 2017 IHP was not included in the Veteran's claim file in VBMS prior to issuance of the Board's October 24, 2017 decision. 

3.  The Veteran did not exhibit bilateral hearing loss within VA standards in service or within one year after discharge from service, and his current bilateral hearing loss disability otherwise is not shown to be related to any disease or injury of service origin.

4.  The Veteran's bilateral hearing loss disability is not otherwise shown to be proximately due to, or aggravated by, the Veteran's service-connected diabetes mellitus.


CONCLUSIONS OF LAW

1.  The criteria for vacatur of the October 24, 2017, Board decision denying service connection for bilateral hearing loss, to include as secondary to service-connected diabetes mellitus, are met.  38 U.S.C. § 7104 (2012); 38 C.R.F.           § 20.904 (2017). 

2.  The criteria for establishing entitlement to service connection for bilateral hearing loss, including on a secondary basis, have not been met.  38 U.S.C. §§ 1101, 1110, 1111, 1112, 1113, 1153, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.385 (2017).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

I. Vacatur 

The Board may vacate an appellate decision at any time upon request of the appellant or his or her representative, or on the Board's own motion, when an appellant has been denied due process of law or when benefits were allowed based on false or fraudulent evidence. 38 U.S.C. § 7104 (a) (2012); 38 C.F.R    .           § 20.904 (2017). 

Review of the Veteran's claims file revealed that an August 2017 IHP was not included in VBMS when the October 24, 2017, Board decision was issued.  The Board determines that consideration of the Veteran's service connection claim without review of the August 2017 IHP was a denial of due process.  Accordingly, the October 24, 2017, Board decision addressing the issue of service connection for bilateral hearing loss, to include as secondary to service-connected diabetes mellitus, is vacated.

II. Service Connection 

Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if preexisting such service, was aggravated thereby.  38 U.S.C. §§ 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017).

Generally to establish entitlement to service connection, a veteran must show evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the current disability and an in-service injury or disease.  All three elements must be proved. See generally Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

Alternatively, under 38 C.F.R. § 3.303 (b), service connection may be established for certain chronic diseases listed under 38 C.F.R. § 3.309 (a) by either (1) the existence of such a chronic disease noted during service, or during an applicable presumption period under 38 C.F.R. § 3.307, and present manifestations of that same chronic disease; or (2) where the condition noted during service is not in fact shown to be chronic or where the diagnosis of chronicity can be legitimately questioned, then a showing of continuity of symptomatology after discharge is required to support the claim of service connection.  38 C.F.R. § 3.303 (b) (2017); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including organic diseases of the nervous system, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service.  38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. 

Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury; or, any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310(a)-(b).

In order to prevail on the theory of secondary service connection, there must be evidence of (1) a current disability, (2) a service-connected disability, and (3) a nexus, or link, between the service-connected disability and the current disability.  See Wallin v. West, 11 Vet. App. 509, 512 (1998).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

Factual Background and Analysis

The Veteran contends that his bilateral hearing loss is a result of his military service.

The existence of a present disability is established through VA examination reports produced during the course of his appeal.  See VA Examination Reports, dated December 2010 and May 2011.  These reports contain a diagnosis of bilateral sensorineural hearing loss and establish that the Veteran has a bilateral hearing disability within VA standards.  38 C.F.R. § 3.385.

The record evidence, including the Veteran's DD Form 214, shows that his military occupational specialty (MOS) as an aircraft maintenance specialist required that he repair turbo prop aircrafts and C-130's, which indicates his exposure to loud noise during service.

The service treatment records (STRs) reveal that the Veteran had mild hearing loss in the left ear when he enlisted. 
VA has historically considered that, on November 1, 1967, Service Departments changed from using American Standards Association (ASA) standards to using International Standards Organization - American National Standards Institute (ISO-ANSI) for audiograms. In light of the above, and where necessary to facilitate data comparison for VA purposes in the decision below, including under 38 C.F.R. § 3.385, audiometric data originally recorded using ASA standards will be converted to ISO-ANSI standard by adding between 5 and 15 decibels to the recorded data as follows: 500 Hz- 15dB, 1000 Hz- 10 dB, 2000 Hz- 10dB, 3000 Hz- 10dB and 4000 Hz- 5dB.

The Veteran's May 1966 enlistment audiometry report reads in decibels, after conversion to ISO-ANSI standard, 




HERTZ



500
1000
2000
3000
4000
RIGHT
15
5
10
15
20
LEFT
35
25
25
25
30

The audiometry report indicates that the Veteran's hearing loss disability was not within VA standards upon enlistment. 38 C.F.R. § 3.385; see also McKinney v. McDonald, 28 Vet. App. 15 (2016) (holding that some degree of hearing loss would nonetheless be entitled to the presumption of soundness under 38 U.S.C.    § 1111 if the hearing loss did not meet VA's definition of a "disability" for hearing loss under 38 C.F.R. § 3.385).  
A veteran will be considered to have been of sound condition when examined and accepted for service, except as to disorders noted on entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service.  Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111 (2012); 38.C.F.R. § 3.304(b).  In this case, because the Veteran's left ear hearing loss disability was not within VA standards, the Veteran's left ear hearing loss is not considered a pre-existing defect.  Thus, the Veteran is presumed to have entered service in sound condition and the presumption of soundness attaches. 38 C.F.R.   § 3.385; see McKinney, supra. 

As such, the remaining inquiry is whether the evidence demonstrates that the Veteran's currently diagnosed bilateral sensorineural hearing loss is related to his military service.  Upon review of the record evidence, the Board determines that the record evidence is against a finding that the Veteran's bilateral sensorineural hearing loss is related to his military service. 


	(CONTINUED ON NEXT PAGE)



In December 2010, after separation from military service, the Veteran was diagnosed with bilateral sensorineural hearing loss of the combined type, which was within VA standards.  The audiometry results, in decibels, reads: 




HERTZ



500
1000
2000
3000
4000
RIGHT
15
15
35
55
65
LEFT
15
10
20
45
65

In May 2011 the Veteran was afforded a VA audiology examination.  The Veteran was diagnosed with normal to severe sensorineural hearing loss in the right ear and normal to moderately severe sensorineural hearing loss in the left ear.  The audiometry results, in decibels, reads:   




HERTZ



500
1000
2000
3000
4000
RIGHT
15
15
30
50
70
LEFT
15
       10
30
50
70

With regard to the etiology of the Veteran's bilateral hearing loss, the examiner opined that the Veteran's hearing loss in his right ear at the 6000 Hz frequency was caused by in-service noise exposure.  In July 2011, the RO requested an addendum medical opinion regarding the Veteran's right ear hearing loss as audiometric testing results at the 6000 Hz frequency is not used for VA rating purposes.

In the July 2011 addendum medical opinion, relying on the May 2011 audiometry test results, the examining clinician determined that the Veteran's hearing sensitivity did not decrease for either ear and that there did not appear to be a significant change in hearing sensitivity due to in-service noise exposure.  The examiner opined that the current loss of 50 dB at 3000 Hz and 70 dB at 4000 Hz in the Veteran's right ear is likely related to acoustic trauma after service, such as occupational/recreational noise exposure.  According to the examiner, had the Veteran's hearing loss been a result of, or due to in-service acoustic trauma, it would have been present on the audiometric test results at the time of separation.  The examiner referenced research studies that have shown that hazardous noise exposure has an immediate effect on hearing, and that it is usually temporary at first.  The resultant hearing loss does not have a delayed onset nor is it progressive or cumulative.  In the examiner's opinion, research showed that it usually takes many incidents of temporary noise-induced hearing loss and tinnitus before hearing loss becomes permanent.

At the March 2015 hearing, the Veteran, through his representative in a written statement, testified to the effect that that VA had conceded that his MOS exposed him to hazardous noise levels that were capable of causing permanent hearing damage.  The Veteran related that he had mild hearing loss in his left ear prior to service and that his military ear protection was inadequate.  The Board notes that the Veteran's left ear hearing loss at enlistment was not within VA standards.  The Veteran made reference to literature that attributed hearing loss to exposure to hazardous noise, after which, the ears can heal in response to the acoustic trauma then result in some hearing loss.  The Veteran testified to the effect that he had limited exposure to hazardous occupational noise exposure after service and denied exposure to any hazardous recreational noise exposure after service.

In June 2016, the Veteran submitted numerous medical articles in support of his service connection claim.  Some of the articles include, but are not limited to: "Hearing and Noise in Aviation," www.atlasaviation.com (02/05/15), which discussed the relationship between noise produced by aircraft equipment, the aerodynamic interaction between ambient air and the surface of the aircraft, and the hearing loss that pilots experience due to aviation related noise.  The author posited that -
[The aircraft related] sounds . . . over time, cause permanent hearing impairment.  However, it is also important to remember that individual exposure to noise is a common occurrence away from the aviation working environment - at home or work, on the road, and in public areas. 
		
The author of "Occupational Hearing Loss," www.nim.nih.gov (02/05/2015), asserted that, "over time, repeated exposure to loud noise . . . can cause hearing loss" and that "occupational hearing loss is caused by long term exposure to loud vibration or sound."  The author listed "jobs involving . . . machinery" as having a "high risk for hearing loss."  In an article that discussed hearing loss and tinnitus published by The Veterans Health Council, http://veteranshealth.org (02/05/15), the author asserted that "for military personnel, the wear and tear on [their] ears over time from noise such as . . . aircraft engines can contribute to hearing loss by damaging [the] inner ear (cochlea)."

In June 2016, the Veteran was afforded a VA examination for hearing loss and tinnitus.  The Veteran's bilateral sensorineural hearing loss was confirmed.  The examination report refers to the Veteran's previous employment in a factory and warehouse after separation.  The Veteran conceded post-service noise exposure and reported using ear protection.  The examiner opined that based upon the objective evidence of records reviewed, the enlistment audiogram revealed data of normal hearing through 4000 Hz and that the Veteran's hearing loss is not the result of, or was caused by, the Veteran's military service.  According to the examiner, six months after the Veteran's enlistment audiogram, the Veteran's November 1966 audiogram revealed normal hearing, bilaterally.  The discharge audiogram data revealed no significant change compared to the enlistment audiogram data and only one change compared to best thresholds that were found and documented on the November 1966 audiogram.

Upon review of the foregoing evidence, the Board determines that the preponderance of the evidence is against a finding of service connection for bilateral sensorineural hearing loss.  In so finding, the Board observes that the July 2011 VA examiner opined that using 1000 Hz, 2000 Hz, 3000 Hz, and 4000 Hz, there did not appear to be a significant change in the Veteran's hearing sensitivity due to any in-service noise exposure.  The Veteran's current loss of 50 dB at 3000 Hz and 70 dB at 4000 Hz in the Veteran's right ear is likely related to acoustic trauma after service, such as occupational/recreational noise exposure.  According to the July 2011 examiner, it appears the Veteran's hearing sensitivity did not decrease for either ear as a result of his military service.  The examiner opined that if the Veteran's hearing loss had been a result of, or due to in-service acoustic trauma, it would have been present on the audiometric test results at the time of separation.  The examiner referenced research studies that have shown that hazardous noise exposure has an immediate effect on hearing, and that it is usually temporary at first.  The resultant hearing loss does not have a delayed onset nor is it progressive or cumulative.  The research showed that it usually takes many incidents of temporary noise-induced hearing loss and tinnitus before hearing loss becomes permanent. 

The Board also observes that the June 2016 VA examiner ultimately determined that six months after the Veteran's enlistment audiogram, the Veteran's November 1966 audiogram revealed normal hearing bilaterally and that the threshold at 4000 Hz revealed hearing loss at enlistment which was a temporary threshold shift.  

In fact, the Veteran's left ear hearing loss noted at enlistment was not within VA standards.  38 C.F.R. § 3.385.  The Veteran's discharge audiogram did not reveal a significant change compared to his enlistment audiogram.  Notably, during the June 2016 interview, the Veteran reported previous employment in a factory and warehouse after separation and conceded post-service noise exposure; although he reported using ear protection. 

The record evidence indicates that the Veteran's bilateral sensorineural hearing loss is not related to, or was caused by the Veteran's service. Indeed, the clinical evidence suggests that the Veteran's bilateral hearing loss may be attributable to his conceded post-service noise exposure.  The clinical findings indicate that the Veteran's discharge audiogram data revealed no significant change compared to his enlistment audiogram data.  Most critically, the Veteran did not exhibit hearing loss for VA rating purposes upon separation from military service.

In support of its finding, the Board acknowledges that it is well established that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."  See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).  The Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991).  The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion.  Sklar v. Brown, 5 Vet. App. 140 (1993).  With regard to the nexus element of the Veteran's service connection claim for bilateral hearing loss, the Board affords significant probative value to the July 2011 and June 2016 VA medical opinions in that both opinions are based upon a review of the Veteran's complete claims file and provides adequate rationales for the medical conclusions reached in this appeal. 

The Board notes that the Veteran was diagnosed with bilateral sensorineural hearing loss of combined type in December 2010, more than 40 years after discharge from military service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability).  The record evidence does not indicate that the Veteran reported bilateral hearing loss within the one year presumptive period after separation from service.  The record evidence does not indicate that the Veteran complained of, or was treated for hearing loss in the 40 years since separating from military service and his December 2010 bilateral sensorineural hearing loss of combined type diagnosis. 

The Board recognizes the Veteran's belief that he is entitled to service connection for bilateral hearing loss.  Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the Veteran is not considered competent to provide an opinion that establishes a nexus/relationship between his diagnosed bilateral sensorineural hearing loss and his military service.  The Board highlights that competent statements are limited to that which the Veteran has actually observed and is within the realm of his personal knowledge; such knowledge comes to the Veteran through use of his senses-that which is heard, felt, seen, smelled or tasted. See Layno v. Brown, 6 Vet. App. 465 (1994).  It is within the Veteran's realm of personal knowledge whether he experienced symptoms related to the claimed disability.  It is not shown, however, that the Veteran possesses the medical expertise necessary to provide a probative opinion on a complex medical matter such as the etiology of his bilateral hearing loss and its relation to his military service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007).

The Veteran's March 2015 testimony regarding the nexus/relationship between his currently diagnosed bilateral sensorineural hearing loss and his military service is of limited probative value as the Veteran does not possess the specialized knowledge or medical expertise to competently opine on such a medically complex issue. 

Furthermore, the Board has also considered the articles that the Veteran submitted in support of his service connection claim. Medical treatise evidence can, in some circumstances, constitute competent medical evidence.  Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1).  However, the Court held that "if such [medical treatise] evidence is presented, it must demonstrate a connection between service incurrence and a present injury or condition." Supra at 513 (citing Libertine v. Brown, 9 Vet. App. 521 (1996).  While the articles address the potential relationship between hearing loss and aviation related occupations, they do not contain any information or analysis specific to the Veteran's case with regard to the nexus/relationship between the Veteran's diagnosed bilateral sensorineural hearing loss and his military service.  As such, the article evidence submitted by the Veteran is of limited probative value. 

Secondary Service Connection 

The Veteran contends that his bilateral hearing loss is proximately due to and/or was aggravated by his service-connected diabetes.  The Veteran is service-connected for diabetes, currently rated as 20 percent disabling.  Upon review of the record evidence, the Board finds that the evidence of record is against a finding that the Veteran's bilateral hearing loss is proximately due to and/or was aggravated by the Veteran's service-connected diabetes.

During the March 2015 hearing, the Veteran testified that he believed that his hearing loss was due to his service-connected diabetes.  The Veteran cited medical treatise evidence produced by the American Diabetes Association.

In April and June 2016, the Veteran submitted numerous medical articles documenting an association between diabetes and hearing loss in support of his claim for secondary service connection.  Some of the articles include, but are not limited to: "Diabetes and Hearing Loss," American Diabetes Association, www.diabetes.org (02/24/15) which posit that - 

A recent study found that hearing loss is twice as common in people with diabetes as it is in those who do not have diabetes. Of the 86 million adults in the U.S. who have prediabetes, the rate of hearing loss is 30 percent higher than those with normal blood glucose. Right now we don't know how diabetes is related to hearing loss. It's possible that the high blood glucose levels associated with diabetes cause damage to the small blood vessels in the inner ear, similar to the way in which diabetes can damage the eyes and the kidneys . . . Since it can happen slowly, the symptoms of hearing loss can often be hard to notice.

"Hearing Loss and Diabetes: The Connection," http://ezinearticles.com (02/05/15) - 

Diabetics are at a 30 percent higher risk of developing hearing loss than those who do not have diabetes. . . [T]hose with diabetes are much more prone to losing some of their hearing as a result of their diabetes diagnosis . . . Tiny blood vessels and nerves in the inner ear are responsible for allowing us to hear.  Just like other areas of the body, these delicate highways can become scarred and damaged irreparably from the high blood sugar levels associated with both Type 1 and Type 2 diabetes. 

"Diabetes and Hearing Loss," www.healthline.com (02/05/15) - "recent studies have confirmed that there is a link between diabetes and hearing loss.  In 2008, the National Institutes of Health (NIH) found that hearing loss is twice as common in people who have diabetes."

The Veteran was afforded a VA hearing loss and tinnitus examination in June 2016. The Veteran's bilateral sensorineural hearing loss was confirmed.  With regard to the etiology of the Veteran's hearing loss, the examiner opined that current research has drawn no firm conclusions about any association between diabetes and hearing problems and that experts suspect there may be a relationship.  The audiologist declared that diabetes mellitus was not his specialty and instructed the RO to refer the case to a specialist "that deal[t] strictly with diabetes and the side effects/adverse symptoms caused by and or complications of said disease."

In an October 2016 addendum opinion, the VA examiner determined that the Veteran's bilateral hearing loss is less likely than not proximately due to, or the result of, the Veteran's service-connected diabetes.  According to the examiner, although some research exists which is suggestive of a linkage between diabetes mellitus and hearing loss, to date there is no firm evidence linking diabetes to hearing loss, as the significant studies were based on meta-analysis which did not control for HDL-cholesterol, diabetes duration, systemic blood pressure, microalbuminuria, GHbA1C, triglyceride, and age.  The examiner ultimately concluded that all of the above mentioned conditions may affect the auditory function of diabetics.

In a December 2016 VA medical opinion, the examiner opined that it is less likely than not the Veteran's bilateral hearing loss is proximately due to or the result of his service-connected diabetes.  The examiner opined that hearing loss etiology includes age related hearing loss (most common cause), infection, Meniere disease, noise exposure, trauma, tumors, endocrine or systemic disorders (thyroid, diabetic and anemia), autoimmune hearing loss, antibiotic, chemotherapeutic and neurological disorders.  The examiner noted that the Veteran has a history of diabetes, hypertension, hyperlipidemia, advancing age, and exposure to loud noises as noted in the December 2010 audiology examination.  The Veteran's occupational noise exposure was also noted in the examination (warehouse, factory, and jet engines).  Clinical records dated September 2009 to April 2016 indicated that the Veteran's diabetes was in good control.  The most recent audiology examination, dated June 2016, noted that the Veteran's hearing loss is not similar in both ears and that the Veteran's audiometry test reveals that the right ear has greater hearing loss than due to the natural aging process.  Hearing loss was noted at age 18 and was greater in the left ear.  The examiner concluded that if diabetes were the cause of the Veteran's bilateral hearing loss, it would be seen equally in both ears.

In the December 2016 medical opinion summary, the examiner noted that hearing impairment was more prevalent among adults with diabetes in low or mid frequency hearing and that those persons with diabetes have a higher prevalence of hearing impairment.  The examiner also noted that: sensorineural hearing loss was more common in patients with diabetes than in the control nondiabetic patients and that the severity of hearing loss seemed to correlate with progression of the disease as reflected in serum creatinine.  The summary highlighted that this may have been due to microangiopathic disease in the inner ear.  The summary further noted that current meta-analysis suggests that the higher prevalence of hearing impairment in diabetic patients compared with nondiabetic patients was consistent regardless of age.  

Based on the foregoing record evidence, the Board finds that the Veteran's bilateral sensorineural hearing loss is not proximately due to and/or was not aggravated by his service-connected diabetes.  In so finding, the Board considered the June 2016 VA medical opinion in which the examiner noted that current research has drawn no firm conclusions about any association between diabetes and hearing problems.  In an October 2016 addendum opinion, the VA examiner reiterated the June 2016 examiner's assessment that to date there is no firm evidence linking diabetes to hearing loss.  The October 2016 VA examiner noted that the medical treatise evidence included studies based on meta-analysis which did not control for HDL-cholesterol, diabetes duration, systemic blood pressure, microalbuminuria, GHbA1C, triglyceride, and age.  The examiner ultimately concluded that the Veteran's bilateral hearing loss is less likely than not proximately due to or the result of the Veteran's service-connected diabetes.  According to the examiner, all of the above mentioned conditions i.e., HDL-cholesterol, diabetes duration, GHbA1C, and age may affect the auditory function of diabetics. 

The VA examiner opined in the December 2016 addendum opinion that it is less likely than not the Veteran's bilateral hearing loss is proximately due to or the result of his service-connected diabetes.  According to the examiner, hearing loss etiology includes age related hearing loss (most common cause), infection, noise exposure, trauma, and endocrine or systemic disorders (thyroid, diabetic and anemia), among other disorders.  The December 2016 examiner noted that the Veteran has a history of diabetes, hypertension, hyperlipidemia, advancing age, and exposure to loud noises.  Clinical evidence indicates that the Veteran's diabetes was in good control.  The June 2016 audiology examination report noted that the Veteran's hearing loss is asymmetrical in the left and right ears and that the Veteran's audiometry test revealed greater hearing loss in the right ear than due to the natural aging process.  According to the examiner, if diabetes were the cause of the Veteran's bilateral hearing loss, then symmetrical hearing loss would be found in both ears.

As such, the Board affords significant probative value to the October and December 2016 VA medical opinions.  Both opinions are based upon review of the Veteran's complete claims file and provide adequate rationales for the medical conclusions reached in this appeal.  The clinical evidence does not indicate a nexus/relationship between the Veteran's bilateral sensorineural hearing loss and his service-connected diabetes.  See Sklar, supra.  The October 2016 examiner noted that the Veteran's conditions, i.e., hypertension, hyperlipidemia, advancing age may affect his auditory functioning.  The December 2016 examiner did not attribute the Veteran's bilateral sensorineural hearing loss to the Veteran's service-connected diabetes based upon the Veteran's well controlled glucose levels throughout the preceding 7 years, specifically from September 2009 to April 2016.  Most critically, the December 2016 examiner determined that if diabetes were the cause of the Veteran's bilateral hearing loss, the Veteran's hearing loss would be seen equally in both ears as the June 2016 audiology examination indicated that the Veteran's hearing loss is not similar in both ears.

The Board recognizes the Veteran's belief that he is entitled to service connection for bilateral hearing loss as secondary to his service-connected diabetes.  However, the Veteran does not possess the specialized knowledge or medical expertise to provide a medical opinion that establishes a nexus/relationship between his diagnosed bilateral sensorineural hearing loss and service-connected diabetes.  See Kahana, supra.

With regard to the medical treatise evidence, while the articles address the potential relationship between hearing loss and diabetes, they do not contain any information or analysis specific to the Veteran's case with regard to the nexus/relationship between the Veteran's diagnosed bilateral sensorineural hearing loss and his service-connected diabetes.  Most notably, in the article entitled "Diabetes and Hearing Loss," the author admits that "[r]ight now we don't know how diabetes is related to hearing loss."  The October 2016 VA examiner noted that although some research exists, which is suggestive of a linkage between diabetes mellitus and hearing loss, to date there is no firm evidence linking diabetes to hearing loss.  Similarly, the December 2016 VA examiner noted that hearing impairment was more prevalent among adults with diabetes in low or mid frequency hearing and that people with diabetes have a higher prevalence of hearing impairment.  As such, the article evidence submitted by the Veteran is at variance with the clinical evidence of record and is "too general and inconclusive"; thus, it is of limited probative value. See Wallin, supra (citing Beausoleil v. Brown, 8 Vet. App. 459 (1996).  

For the foregoing reasons, the Board finds that service connection for bilateral hearing loss, to include as secondary to service-connected diabetes must be denied.  In reaching this conclusion, 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, supra. 



ORDER

Vacatur of the October 24, 2017, Board decision denying service connection for bilateral hearing loss, to include as secondary to service-connected diabetes, is granted. 

Service connection for bilateral hearing loss, to include as secondary to the service-connected diabetes mellitus, is denied. 




____________________________________________
DEBORAH W. SINGLETON
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs