Citation Nr: 1754988 Decision Date: 11/30/17 Archive Date: 12/07/17 DOCKET NO. 11-25 832 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for diabetes mellitus. 2. Entitlement to service connection for a respiratory disorder, to include COPD, due to asbestos exposure. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for a heart disorder. 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for a right eye disability. 7. Entitlement to service connection for a right leg disability. 8. Entitlement to service connection for a bilateral foot disability. 9. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Erin J. Carroll, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy between November 1978 and November 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Regional Office (RO) of the Department of Veterans' Affairs (VA) in Montgomery, Alabama. In September 2016, the Board granted the petition to reopen the claim for service connection for a respiratory disorder and remanded this appeal for further development, to include providing the Veteran with VA examinations to evaluate his claimed disabilities. These examinations were conducted in December 2016. The issues of entitlement to service connection for bilateral hearing loss, a right eye disability, a right leg disability, a bilateral foot disability, and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran does not have a current diagnosis of diabetes mellitus. 2. The preponderance of the competent and credible evidence of record is against finding that the Veteran's respiratory disorder, including COPD, is a result or consequence of his military service - even when accepting that he may have been exposed to asbestos during his service. 3. The Veteran's current hypertension was not caused by a disease or injury during active duty, and did not manifest to a compensable degree within the Veteran's first post-service year. 4. The Veteran's current heart disorder was not caused by a disease or injury during active duty, and did not manifest to a compensable degree within the Veteran's first post-service year. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for diabetes mellitus have not been met. 38 U.S.C.A. §§ 1101, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. The Veteran's respiratory disorder, irrespective of its diagnosis, was not due to disease or injury incurred in or aggravated by the Veteran's service and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5121A (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.1010 (2017). 3. The criteria for service connection for hypertension are not met, and service-connection may not be so presumed. 38 U.S.C.A. §§ 1110, 1154(b) (West 2014); 38 C.F.R. §§ 3.303, 3.309 (2017). 4. The criteria for service connection for a heart disorder are not met, and service-connection may not be so presumed. 38 U.S.C.A. §§ 1110, 1154(b) (West 2014); 38 C.F.R. §§ 3.303, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran has not raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Entitlement to Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A nexus to service may be presumed when "a chronic disease is 'shown in service (or within the presumptive period under § 3.307).'" Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013). To be "shown in service," there must be "a reliable diagnosis of the chronic disease while in service.... [T]he disease identity must be established and the diagnosis not be subject to legitimate question." Id. In such cases, the claimant need not demonstrate nexus, "so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. Alternatively, continuity of symptomatology may be used in place of nexus "[i]f evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not 'shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,' i.e., 'when the fact of chronicity in service is not adequately supported.'" Walker, 708 F.3d at 1336; 38 C.F.R. § 3.303(b). 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 claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. Diabetes Mellitus Service treatment records and post-service treatment records are silent for any complaints, treatment, or diagnosis related to diabetes mellitus. In December 2016, the RO afforded the Veteran a VA examination. The examiner determined that there was no diagnosis of diabetes mellitus type I or type II, nor any reported medical treatment related to the diabetes. Notably, the Veteran denied a diagnosis of "borderline diabetes" five to six years earlier and he denied receiving any medication for diabetes. Laboratory results were not consistent with a diagnosis of diabetes. Ultimately, the examiner concluded that the Veteran did not have a current diagnosis of diabetes. Based upon a review of the record the evidence shows no current diagnosis of diabetes mellitus. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (service connection requires a current disability). A current disability is one shown at some time during the period beginning proximate to the date of claim. Romanowsky v. Shinseki, 26 Vet. App. 303 (2013). In this case, there is no evidence of a diagnosis of diabetes mellitus. Upon discharge, there was no documentation of any complaints, treatment, or diagnoses related to diabetes. Furthermore, the December 2016 VA examiner found that the Veteran did not have a current diagnosis of diabetes mellitus and laboratory testing conducted at that time was not indicative of a diagnosis of diabetes. The Veteran has not reported any pertinent symptomatology or treatment during the current appeal. In fact, he has denied any medical treatment or diagnosis related to diabetes. There is no evidence of any post-service treatment, there is no other evidence to show a current underlying disability, and there is no indication of any change since December 2016. As such, the preponderance of the evidence is against service connection for diabetes mellitus. Reasonable doubt does not arise, and the benefit-of-the-doubt doctrine does not apply; the Veteran's claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. B. Respiratory Disorder In this case, the Veteran claims service connection for a respiratory disorder, to include COPD, which he believes is related to asbestos exposure during service. In cases involving asbestos exposure, the claim must be analyzed under VA administrative protocols. Ennis v Brown, 4 Vet App 523 (1993), McGinty v. Brown, 4 Vet App 428 (1993). Although there is no specific statutory or regulatory guidance regarding claims for residuals of asbestos exposure, VA has several guidelines for compensation claims based on asbestos exposure M21 1,VBA Adjudication Procedure Manual M21 1, part IV, Subpart ii, Ch 2, Section C (August 7, 2015). In this regard, the M21-1 provides the following non-exclusive list of asbestos-related diseases/abnormalities: asbestosis, interstitial pulmonary fibrosis, tumors, pleural effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, lung cancer, bronchial cancer, cancer of the larynx, cancer of the pharynx, cancer of the urogenital system (except the prostate), and cancers of the gastrointestinal tract. See M21-1, part IV, Subpart ii, Chapter 2, Section C, 2 (b). The M21-1 also provides the following non-exclusive list of occupations that have higher incidents of asbestos exposure: mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, and manufacture and installation of roofing and flooring materials, asbestos cement sheet and pipe products, and military equipment. See M21-1, part IV, Subpart ii, Chapter 2, Section C, 2 (d). The M21-1 provides that a clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. Diagnostic indicators include dyspnea on exertion, end-respiratory rales over the lower lobes, compensatory emphysema, clubbing of the fingers at late stages, and pulmonary function impairment and cor pulmonale that can be demonstrated by instrumental methods. See M21-1, part IV, Subpart ii, Chapter 2, Section C, 2 (g). Additionally, the Board should consider whether military records demonstrate evidence of asbestos exposure during service, whether there was pre-service, post-service, occupational, or other asbestos exposure, and whether there is a relationship between asbestos exposure and the claimed disease. The Board finds that the Veteran's contentions regarding potential in-service exposure to asbestos are plausible. However, mere exposure to a potentially harmful agent is insufficient to be eligible for VA disability benefits. The question in a claim such as this is whether disabling harm ensued as a result of any such asbestos exposure. The medical evidence must show not only a currently diagnosed disability, but also a nexus that is, a causal connection, between this current disability and the exposure to asbestos in service. STRs are silent as to treatment or diagnosis for COPD or any other respiratory-related conditions. While the Veteran stated in June 2011 that he suffered a cold throughout his period of service and that he had respiratory problems, he did not report any issues on his medical history upon separation nor was it noted in the examination report at that time. Indeed, the Veteran specifically denied issues with his ears, nose, and throat, as well as his chest and lungs upon separation. There is no indication and the Veteran does not contend that he was diagnosed with or treated for COPD, or any other respiratory disorders during service. Additionally, he does not contend that his respiratory conditions manifested within one year of his separation from service. Instead, his claim of entitlement is focused on the development of these conditions as a result of his asbestos exposure during service. VA examination reports from May 2004 and December 2016 indicate that the Veteran has been diagnosed with COPD since 2000, and sleep apnea since 2016. The December 2016 VA examiner opined that the Veteran's COPD was not likely related to in-service smoking, as intermittent smoking does not result in tobacco dependence and there is no evidence of tobacco dependence during his active duty service. Additionally, she concluded that tobacco use is not a major risk factor for sleep apnea. Thus, while the record clearly reflects that the Veteran suffers from the claimed disorder, there is no competent medical evidence to demonstrate a link between the Veteran's respiratory conditions and his service through a theory of direct service connection. Accordingly, the Board finds that a preponderance of the evidence is against a finding that the Veteran's respiratory disorder, to include COPD, is related to service on a direct basis. The Board will next address the Veteran's contention that his respiratory disorder is related to in-service asbestos exposure As a preliminary matter, the Board notes that the Veteran's service personnel records reflect that he served in the Navy aboard the USS Norton Sound. In a June 2011 statement, he indicated that, at that time, the USS Norton Sound was the oldest ship in the Navy and that it went through extensive renovations with removal of some asbestos, but that he also lived with asbestos while aboard the ship. He stated that, a year after the first renovations, the ship went back to the Long Beach shipyard in California for further renovations, and that a year after that, there were more renovations in Pascagoula, Mississippi. Although the Veteran's DD Form 214 and service treatment records do not specifically demonstrate that he was exposed to asbestos as part of his duties, given his shipboard duties in the Navy, VA has conceded his exposure to asbestos while on active duty. In May 2004, the Veteran underwent a VA examination to evaluate his respiratory disorder. He reported a chronic cough that was occasionally productive, as well as progressive shortness of breath that had developed over the past several years. He stated that during service he was stationed on an old naval ship that was being renovated, which exposed him to dust. Most recently, in December 2016, the Veteran underwent another VA examination to evaluate his respiratory disorder. The examiner noted diagnoses of COPD and obstructive sleep apnea. He denied a history of asbestosis. The Veteran reported that he quit smoking six months prior to the examination, at which point he had been smoking a half of a pack of cigarettes per day. The examiner opined that the Veteran's COPD did not likely have its onset during service, based upon a lack of respiratory symptoms during service, the normal separation examination results, and the lack of a diagnosis of COPD until 2000. Additionally, the examiner concluded that the COPD was not likely related to asbestos exposure because there was no evidence of asbestosis-related changes based upon the examination and imaging results. The examiner further stated that medical evidence did not support asbestos exposure as being a major risk for the development of COPD or sleep apnea. The Board finds that service connection must be denied for a respiratory disorder, including COPD, as related to exposure to asbestos. The Board recognizes that, for disabilities involving a veteran's exposure to asbestos, even the passage of 18 years without manifestation of a disability may not be fatal to a claim of service connection. Nevertheless, service connection may not be granted unless there is some competent medical evidence indicating that the Veteran's disability is indeed causally linked to his exposure to asbestos. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, his or her knowledge and skill in analyzing the data, and his or her medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448- 9 (2000). In this case, as noted above, the December 2016 VA examiner's opinion determined that the Veteran's currently-diagnosed conditions are less likely than not caused by asbestos exposure. The Board finds this opinion to be highly probative to the matter at hand. The examiner in this case reviewed the claims folder in its entirety and conducted a full examination of the Veteran. Furthermore, she explained that the examination and its associated imaging studies failed to demonstrate that the Veteran had asbestos-related changes. Her conclusions were also based upon a lack of medical evidence to support asbestos exposure as a risk factor for COPD. The Board thus finds the December 2016 VA opinion to be highly probative on the issue of establishing a connection between in-service asbestos exposure and the Veteran's respiratory disorder. A persuasive probability of nexus has not been established in this case. The Board notes that the only positive etiology opinion of record comes from the Veteran himself, who believes there is a link between in-service asbestos exposure and his respiratory disorder. The Board recognizes that there are instances in which lay testimony can provide probative evidence in medical matters. A layperson may be competent to offer testimony on certain medical matters, such as describing symptoms observable to the naked eye, or even diagnosing simple disorders such as a dislocated shoulder. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). However, the question of whether the Veteran's respiratory disorder is related to in-service asbestos exposure is of such medical complexity as to require an opinion from a medical professional. In the absence of competent evidence of a nexus, service connection for a respiratory disorder, to include COPD, as due to asbestos exposure is not established. In short, the Board finds that there is no persuasive evidence that shows that the Veteran's respiratory disorder is related to his military service, to include on a direct basis or due to in-service asbestos exposure. Finally, the evidence does not show that the Veteran had a diagnosis of COPD manifested to a degree of 10 percent or more within the first post-service year. Thus, a presumption of service connection under 38 C.F.R. §§ 3.307 is not established. For these reasons, the preponderance of the evidence is against the claim and service connection for a respiratory disorder, to include COPD, is not warranted. As the preponderance of the evidence weighs against the claim, the benefit of the doubt rule is not for application. 38 U.S.C.A. § 5107 (b), 38 C.F.R. § 4.3. C. Hypertension In this case, the Veteran claims service connection for hypertension that he believes is related to service. With respect to the requirement for a current diagnosis, the December 2016 VA examination report noted a diagnosis of hypertension in 2000. Thus, the Board finds the requirement for a current disability is met. As it pertains to an in-service event or injury, the treatment notes are silent for any treatment for or symptoms of hypertension during service. The Veteran's blood pressure at the time of his separation examination in October 1982 was normal and did not note a diagnosis or symptoms consistent with hypertension. In fact, the evidence of record indicates that the Veteran was not diagnosed with hypertension until 2000, approximately 18 years after separation from service. Therefore, there is no evidence of an in-service event or injury for service-connection purposes. Furthermore, the evidence of record is against a finding that a nexus exists between the Veteran's military service and his hypertension. Initially, the Board notes that the October 1982 separation examination documented normal blood pressure readings, with no indication of hypertension at that time. In December 2016, the Veteran was afforded a VA examination to evaluate his hypertension. The examiner opined that it was less likely than not that the hypertension had its onset or was otherwise related to his active military service. She reasoned that the hypertension could be attributed to the Veteran's history of alcohol abuse. Additionally, she supported her conclusion based upon the normal separation examination results, which indicated that the Veteran was not experiencing hypertension at that time, as well as the 18 year gap between service and a diagnosis. Based on the pertinent evidence of record, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for hypertension. While the evidence of record shows that he has a current diagnosis of hypertension, the probative evidence of record demonstrates that the disability is unrelated to his service. The examiner noted the October 1982 separation examination, which indicated the Veteran's blood pressure was normal at that time. The VA examiner also indicated that the Veteran's hypertension could be attributed to his history of alcohol abuse. To the extent that the Veteran has offered his own opinion that his hypertension is due to service, the Board notes that although he is competent to report related symptoms and his medical history, he has not been shown to have the requisite medical expertise and training to diagnose and opine as to the origin of a complex medical condition such as a cardiovascular disability. See 38 C.F.R. § 3.159(a)(2); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The Board places great probative weight on the December 2016 VA opinion. This opinion was adequate because the examiner reviewed the entire medical history file, considered the Veteran's lay statements, and provided a conclusion based on an accurate factual basis with supporting rationale. The examiner clearly noted the diagnosis of hypertension, as well as the onset of 2000. She did not reject the symptoms or diagnosis, but rather did not recognize them as related to the Veteran's military service based on a review of the treatment records which fully support the conclusions. Additionally, she provided a supporting rationale which explained that the Veteran's history of alcohol abuse could have contributed to the development of his hypertension and that there was no evidence indicating that his blood pressure was abnormal upon separation, until 18 years later. Here, the opinion offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran has had ample opportunity to supplement the record with a medical opinion against the finding of the December 2016 VA examiner, but has not done so. The Board finds the VA examiner's opinion is the most competent and probative evidence of record addressing the question of whether his hypertension is related to service. The Board adds that the evidence is against a finding that chronic hypertension existed in service, or manifested within the Veteran's first post-service year. The Veteran's assertions of continuity of symptoms are outweighed by the fact that he had a "normal" clinical evaluation of his blood pressure upon separation from service in 1982. For the foregoing reasons, the Board must deny the claim for service connection for hypertension. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as no competent, probative evidence supports the Veteran's claim, that doctrine is not applicable. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, supra. D. Heart Disorder In this case, the Veteran claims service connection for a heart disorder that he believes is related to service. With respect to the requirement for a current diagnosis, the December 2016 VA examination report noted a diagnosis of congestive heart failure in 2007. Thus, the Board finds the requirement for a current disability is met. As it pertains to an in-service event or injury, the treatment notes are silent for any treatment for or symptoms of a heart condition during service. The Veteran's heart was noted to be normal at the time of his separation examination in October 1982, and there was no indication of a diagnosis or symptoms consistent with congestive heart failure. In fact, the evidence of record indicates that the Veteran was not diagnosed with congestive heart failure until 2007, approximately 25 years after separation from service. Therefore, there is no evidence of an in-service event or injury for service-connection purposes. Furthermore, the evidence of record is against a finding that a nexus exists between the Veteran's military service and his congestive heart failure. Initially, the Board notes that the October 1982 separation examination documented normal heart conditions, with no indication of congestive heart failure at that time. In December 2016, the Veteran was afforded a VA examination to evaluate his heart condition. The examiner opined that it was less likely than not that the congestive heart failure had its onset or was otherwise related to his active military service. She reasoned that the heart condition could be attributed to the Veteran's history of alcohol abuse and hypertension. Additionally, she supported her conclusion based upon the 25 year gap between service and a diagnosis of a heart condition, which indicated that the Veteran was not experiencing congestive heart failure at the time of separation. Based on the pertinent evidence of record, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a heart condition. While the evidence of record shows that he has a current diagnosis of congestive heart failure, the probative evidence of record demonstrates that the disability is unrelated to his service. The examiner indicated that the Veteran's heart condition could be attributed to his history of alcohol abuse or his diagnosis of hypertension. To the extent that the Veteran has offered his own opinion that his heart condition is due to service, the Board notes that although he is competent to report related symptoms and his medical history, he has not been shown to have the requisite medical expertise and training to diagnose and opine as to the origin of a complex medical condition such as a cardiovascular disability. See 38 C.F.R. § 3.159(a)(2); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The Board places great probative weight on the December 2016 VA opinion. This opinion was adequate because the examiner reviewed the entire medical history file, considered the Veteran's lay statements, and provided a conclusion based on an accurate factual basis with supporting rationale. The examiner clearly noted the diagnosis of congestive heart failure, as well as the onset of 2007. She did not reject the symptoms or diagnosis, but rather did not recognize them as related to the Veteran's military service based on a review of the treatment records which fully support the conclusions. Additionally, she provided a supporting rationale which explained that the Veteran's history of alcohol abuse and hypertension could have contributed to the development of his heart condition and that there was no evidence indicating that his heart was abnormal until 25 years after separation. Here, the opinion offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran has had ample opportunity to supplement the record with a medical opinion against the finding of the December 2016 VA examiner, but has not done so. The Board finds the VA examiner's opinion is the most competent and probative evidence of record addressing the question of whether his congestive heart failure is related to service. The Board adds that the evidence is against a finding that chronic congestive heart failure existed in service, or manifested within the Veteran's first post-service year. The Veteran's assertions of continuity of symptoms are outweighed by the fact that he had a "normal" clinical evaluation of his heart upon separation from service in 1982. For the foregoing reasons, the Board must deny the claim for service connection for a heart disorder. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as no competent, probative evidence supports the Veteran's claim, that doctrine is not applicable. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, supra. ORDER 1. Entitlement to service connection for diabetes mellitus is denied. 2. Entitlement to service connection for a respiratory disorder, to include COPD, is denied 3. Entitlement to service connection for hypertension is denied. 4. Entitlement to service connection for a heart disorder is denied. REMAND Bilateral Hearing Loss The Board's September 2016 remand directed the RO to provide the Veteran with a VA audiological examination. A VA medical opinion was rendered in December 2016, in which the examiner determined that the Veteran's hearing loss was less likely than not related to service. However, she based her rationale entirely on the Veteran's normal hearing acuity upon enlistment and separation from service, without explanation as to why silence in the record had clinical significance. See Dalton v. Nicholson, 21 Vet. App. 23 (examination found inadequate where examiner did not comment on the Veteran's report of in-service injury and, instead, relied on the absence of evidence in the service treatment records to provide a negative opinion). Thus, the Board finds that a remand for an addendum opinion that takes the Veteran's lay statements into account is necessary. Right Eye Disability In accordance with the Board's September 2016 remand directives, the RO obtained a VA medical opinion addressing the Veteran's right eye disability in December 2016. The examiner opined that the right eye disability was less likely than not related to service and stated that his current eye conditions were unrelated to service. However, the examiner failed to explain her reasoning as to why such diagnoses were unrelated to the Veteran's service. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Thus, a remand to obtain an addendum opinion with a sufficient supporting rationale is necessary prior to adjudication of this issue. Right Leg Disability Additionally, per the September 2016 remand, the RO obtained a nexus opinion pertaining the etiology of the Veteran's claimed right leg disability. The examiner opined that the Veteran's restless leg syndrome was less likely than not related to service. However, the rationale was based upon a normal lower extremity examination upon separation and consisted primarily of a restatement of facts related to the Veteran's diagnosis and reported symptomatology. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, on remand, the RO must seek an addendum opinion related to the Veteran's claim for a right leg disability. Bilateral Foot Disability Finally, the September 2016 remand instructed the RO to seek a nexus opinion related to the claim for a bilateral foot disability. Such an opinion was obtained in December 2016, in which the examiner initially concluded that the Veteran did not have a diagnosis related to a foot condition, but later stated that his reported symptoms were consistent with a diagnosis of plantar fasciitis. Thus, the opinion is inherently contradictory and an addendum opinion is necessary. See Barr, supra. TDIU The claim for a TDIU is dependent on whether the Veteran's service connected disabilities render him unable to secure or follow a substantially gainful occupation. As such, the claim is inextricably intertwined with the issue of whether service connection is warranted for bilateral hearing loss, a right eye disability, a right leg disability, and a bilateral foot disability. VA treatment records through February 2017 have been associated with the record. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify all VA and non-VA health care providers, other than those already associated with the claims file, and authorize VA to obtain non-VA records. Updated VA treatment records since February 2017 should also be obtained. 2. Return the claims file, to include a copy of this remand, to the December 2016 VA examiner, if available, for an addendum opinion addressing the relationship between the Veteran's military service and his hearing loss. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran's hearing loss is related to his in-service acoustic trauma. In providing any opinion, the examiner should consider the Veteran's lay statements, VA treatment records, and service treatment records. A rationale is requested for any opinion given. 3. Ask the December 2016 VA examiner, if available, for an addendum opinion addressing the relationship between the Veteran's military service and right eye disability. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner should then provide an opinion as to whether it is at least as likely as not that the Veteran's right eye disability had its onset in or was caused by his active military service. In providing any opinion, the examiner should consider the Veteran's reported symptomatology, VA treatment records, and service treatment records. A rationale is requested for any opinion given. 4. Ask the December 2016 VA examiner, if available, for an addendum opinion addressing the relationship between the Veteran's military service and his right leg disability. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner should then provide an opinion as to whether it is at least as likely as not that the Veteran's right leg disability had its onset in or was caused by his active military service. In providing any opinion, the examiner should consider the Veteran's reported symptomatology, VA treatment records and service treatment records. A rationale is requested for any opinion given. 5. Ask the December 2016 VA examiner, if available, for an addendum opinion addressing the relationship between the Veteran's military service and his bilateral foot disability. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner should identify any diagnoses related to the bilateral feet, including plantar fasciitis, and then provide an opinion as to whether it is at least as likely as not that any diagnosed bilateral foot disability had its onset in or was caused by the Veteran's active military service. In providing any opinion, the examiner should consider the Veteran's reported symptomatology, VA treatment records, and service treatment records. A rationale is requested for any opinion given. 6. When the development requested has been completed, all issues on appeal should be readjudicated, to include the Veteran's claim for TDIU. The Veteran 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 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). ______________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs