Citation Nr: 18143923 Decision Date: 10/22/18 Archive Date: 10/22/18 DOCKET NO. 15-26 273 DATE: October 22, 2018 ORDER Entitlement to service connection for right knee disability is denied. Entitlement to service connection for left knee disability is denied. Entitlement to service connection for left ankle disability is denied. Entitlement to service connection for right ankle disability is denied. REMANDED Entitlement to service connection for right hand/wrist disability is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for seizure disorder, to include epilepsy, is remanded. Entitlement to service connection for cognitive disorder is remanded. Entitlement to service connection for psychiatric disorder, to include depression, anxiety and PTSD, is remanded. FINDINGS OF FACT 1. The Veteran’s current left and right knee disabilities are not shown to have become manifest in service and are not shown to be related to service. 2. The Veteran’s current right ankle disability and any left ankle disability are not shown to have become manifest in service and are not shown to be related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right knee disability have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.307. 3.309. 2. The criteria for entitlement to service connection for left knee disability have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.307. 3.309. 3. The criteria for entitlement to service connection for right ankle disability have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.307. 3.309. 4. The criteria for entitlement to service connection for left ankle disability have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.307. 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1972 to July 1974. This matter is on appeal before the Board of Veterans Appeals (Board) from a January 2013 decision of a Department of Veterans Affairs (VA) Regional Office (RO). In August 2016, a Board hearing was held before the undersigned; a transcript of the hearing is of record. At the hearing, the Veteran submitted additional evidence along with a waiver of initial agency of original jurisdiction (AOJ) consideration of this evidence. This evidence included copies of selected service treatment records. These records had already been associated with the claims file prior to the March 2015 statement of the case, the latest readjudication of the claims on appeal, and were specifically noted by the RO as having been considered in conjunction with the issuance of the SOC. It was agreed at the hearing that the record would be kept open for 60 days to allow the Veteran time to submit further evidence. Thereafter, the Veteran submitted further private medical and lay evidence. It does not appear that this evidence was accompanied by a waiver of initial AOJ consideration. However, the Veteran is presumed to have waived AOJ consideration of this evidence as his VA Form 9 was filed in July 2015. See 38 U.S.C. § 7105(e). Service Connection The Veteran has claimed service connection for bilateral knee and bilateral ankle disabilities. He alleges that he injured his knees and ankles during a car accident in service, that working in a machine shop during service, and the rigors of Marine service also aggravated his injuries. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a claimed disorder, there must be: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). Certain listed, chronic disabilities, including arthritis are presumed to have been incurred in service if they become manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The standard of proof to be applied in decisions on claims for Veterans’ benefits is set forth in 38 U.S.C. § 5107 (2012). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Service connection for right and left knee disability. The evidence shows that the Veteran does have bilateral knee disabilities. In this regard, at a May 2013 VA examination, functional loss of both knees was noted and in a subsequent September 2014 addendum, it was noted that X-rays had also shown that the Veteran has current mild degenerative arthritis of both knees. A copy of the Veteran’s entrance examination does not appear to be of record. Thus, in the absence of any record of knee problems being noted upon the Veteran’s entry into service, his knees are presumed to have been sound upon entry. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Regarding alleged right or left knee injury during service, the service treatment records show that on January 24, 1973, the Veteran was seen for complaints of right knee pain while running. It was noted that he had had a history of a knee operation that involved cartilage removal. The Veteran was again seen for complaints of right knee pain on February 8, 1973. At that time, a physical examination showed that the knee was stable with full range of motion and no edema. Also, on February 24, 1973, the Veteran was seen for complaints of pain in the left leg for the past two weeks. On examination, there was tenderness and some edema of the left tibia-fibula. An X-ray of the left tibia-fibula was normal. Additionally, on February 27, 1973, the Veteran was again seen for complaints of right knee pain. Physical examination showed no swelling or edema and free movement. The diagnostic impression was muscular strain. Also, the Veteran was seen again the following day for tenderness in the right lower leg. At that time, physical examination showed point tenderness and no edema or ecchymosis. At an April 1973 periodic physical examination, the Veteran’s lower extremities were found to be within normal limits. In an April 1973 report of medical history, the Veteran reported that his health was fine except for a stiff neck. He also indicated that he had had a history of “trick or locked knee.” It was noted that he had had a surgical operation prior to service involving cartilage in the right knee. On January 19, 1974, the Veteran was seen by medical personnel after experiencing an auto accident. There were no noted physical injuries and no noted external signs of trauma. The Veteran did complain of a headache. At a follow-up visit, two days later, the Veteran again complained of a headache, along with gastrointestinal symptoms and was noted to have a soft tissue contusion of the head and post-concussion headache. At the Veteran’s July 1974 separation examination, it was noted that his right knee would periodically lock since his operation prior to service. On his July 1974 report of medical history at separation, the Veteran reported that he was in good health and did not report having any current knee problems. In sum, the medical evidence indicates that the Veteran’s right knee bothered him periodically during service and that he experienced at least one instance of left tibular/fibular difficulty but does not tend to indicate that either knee was causing him problems at the time of separation from service. Post-service, there is no medical evidence of record showing any right or left knee pathology until May 2013, when the Veteran underwent the VA examination. At that examination, the examiner found that the Veteran had functional loss in the right knee in the form of less movement than normal, incoordination, pain on movement, deformity, atrophy of disuse and disturbance of locomotion, and functional loss in the left knee in the form of less movement than normal and pain on movement. Also, as noted above, the VA examiner specifically found that the Veteran had bilateral degenerative arthritis of both knees after X-rays were performed in September 2014. Additionally, at the May 2013 VA examination, the examiner noted that the Veteran had a right meniscectomy (i.e. the surgery on the cartilage prior to service) but did not have any current residual signs or symptoms due to the meniscectomy and did not currently have any meniscal condition. Moreover, the Veteran reported that in the ensuing decades after service, he had been in multiple vehicle accidents and had broken many bones. He indicated that the worst injury involved his right leg being completely shattered and repaired with much hardware. The examiner noted that because of these accidents and the medical repair, the Veteran’s entire right leg was rotated outward and his gait was altered. Thus, while current arthritis of both knees is currently shown, it was not shown during service or within the first post-service year so as to warrant presumptive service connection. Regarding a potential nexus between the knee problems the Veteran experienced in service and his current knee disability, the VA examiner found in May 2013 that it was less likely than not that the Veteran’s current right or left knee disability was incurred in or caused by an in-service injury, event or illness. The examiner reasoned that the Veteran reported multiple vehicular accidents over the years following active duty, indicating smashing multiple vehicles and at least one motorcycle. The worst accident had shattered the bones of much of the right leg resulting in implantation of copious surgical hardware. In turn, this had caused the entire right leg to be rotated outward from hip to ankle and for the Veteran’s knee motion to be painful and limited. The examiner concluded that the Veteran’s post-service injuries were much more serious than his strain/sprain episodes during military service. Consequently, it was the examiner’s professional opinion that the Veteran’s bilateral knee conditions were less likely than not incurred in or caused by military service. Additionally, in a September 2014 addendum, the examiner specifically addressed the potential etiology of the Veteran’s mild degenerative arthritis. The examiner noted that the etiology of osteoarthritis is complex and includes age, trauma, genetics, repetitive use, muscle weakness, gait imbalance and prior surgery. The examiner indicated that the Veteran had had right knee surgery prior to entering military service and then a significant injury to his knee after leaving the service. There was no evidence in the service records of significant injury to the knees; no indication that he developed arthritis during service and no evidence that he developed knee osteoarthritis in the first few decades after leaving the service. The examiner concluded that the current mild osteoarthritis of the knees was most likely secondary to aging, right knee surgery prior to entering the service, and subsequent aging and post-service injuries. As noted above, the Veteran has asserted that his auto accident during service caused injury to both knees. In this regard, at the August 2016 Board hearing, he indicated that during the accident, his knees smashed into the dashboard. As a result, he was unable to walk for about 6 weeks after the accident. However, this account is inconsistent with the information contained in the service treatment records and the medical history the Veteran relayed to the examiner at the May 2013 VA examination. Once again, the service treatment records document treatment in January 1974 following the auto accident but specifically show that there were no noted physical injuries and no noted external signs of trauma. Also, at the May 2013 VA examination, the Veteran specifically reported that he injured his legs/knees in post-service motor vehicle accidents and did not report any such injury occurring during his in-service motor vehicle accident. Given that this specific report to the VA examiner is consistent with the information contained in the service treatment records and given that the Veteran’s subsequent hearing testimony is inconsistent with this information, the Board credits the report of the lower extremity/knee injuries occurring after service and finds not credible the report of lower extremity injuries occurring during the auto accident in service. Thus, the Board credits the medical history relied upon by the VA examiner to determine that the Veteran’s current knee disability was less likely than not incurred in or caused by service. Notably, the medical evidence of record contains no medical opinion evidence contrary to the VA examiner’s opinions (i.e. an opinion tending to indicate that the Veteran’s current right or left knee disability was incurred in or caused by military service). Also, although the Veteran asserts that his current right and left knee disabilities were incurred in or caused by service, as a layperson without any demonstrated expertise concerning the etiology of knee disabilities, his assertion may not be afforded any probative value. See e.g. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, the weight of the evidence is against a finding that the Veteran’s current disability of the right or left knee, including mild degenerative arthritis, is related to his military service, including the knee problems he experienced therein. Consequently, the weight of the evidence is against the presence of a nexus between the Veteran’s current right or left knee disability and service. Accordingly, an award of service connection is not warranted for right knee disability or for left knee disability. 38 C.F.R. § 3.303; Hickson, 12 Vet. App. 247, 253 (1999); Alemany, 9 Vet. App. 518 (1996). 1. Service connection for right and left ankle disability. Regarding potential right or left ankle injury in service, the Veteran’s service treatment records do not show that any such injury occurred. On his April 1973 report of medical history, the Veteran did not report any ankle problems and reported that his health was fine except for a stiff neck. Similarly, at the April 1973 medical examination, no abnormalities of either ankle were found. Also, at the January 1974 medical visit following the in-service auto accident, it was noted that there were no physical injuries and no external signs of trauma. Additionally, at the Veteran’s July 1974 separation examination, the Veteran’s lower extremities, other than his right knee, were found to be normal and no right or left ankle pathology was found. Moreover, on his July 1974 report of medical history at separation, the Veteran reported that he was in good health and did not report having any ankle problems. Accordingly, a chronic ankle disability was not shown to have been present during service. Post-service, the earliest medical evidence of record of any right or left ankle pathology is an August 2016 private medical record. At that time, a treating physician noted that the Veteran presented with a new problem, right ankle pain. The Veteran reported that the pain had been present for approximately one year. He also indicated that he thought he injured the ankle in service in a severe motor vehicle accident at the age of 20. X-rays of the ankle showed medial and lateral joint space narrowing, osteophyte formation and flattening of the talar dome. The physician diagnosed degenerative joint disease of the right ankle. He administered a corticosteroid injection for pain and recommended an ankle brace. At a subsequent August 2016 follow-up visit, the Veteran again informed the physician that he thought he injured the ankle during a severe auto accident in service. He also reported that he had a second auto accident at age 26 in which he broke his femur. The physician informed the Veteran that he felt that the arthritis was likely posttraumatic in that it was certainly possible that the active duty military accident caused the development of the arthritis. The physician’s finding establishes the presence of a current right ankle disability. The evidence of record does not show the presence of a current left ankle disability, however. Also, the Board is not able to attach any probative value to the physician’s finding that it was possible that the Veteran’s active duty auto accident caused the development of his arthritis because it is not based on an accurate report of the Veteran’s medical history. Once again, the Veteran did not complain of any injury to the ankle during the medical visit in January 1974 following his in-service auto accident and no ankle problems (or other physical problems other than headaches) were found during the post-accident physical examination. Also, there are no other findings or complaints of any ankle problems during service either before or after the accident. Additionally, as explained above, the Veteran has not been found to be a credible historian concerning the lower extremity injuries he asserts occurred during the in-service auto accident given his specific report to the May 2013 VA examiner (which is consistent with the service treatment records) that his lower extremity injuries, including the shattering of the bones in his right leg, occurred in a post-service motor vehicle accident. Thus, his report to the August 2016 private physician that he injured his ankle during the auto accident in service is also not deemed credible. Consequently, the private physician’s conclusion of a possible relationship between in-service ankle injury and current ankle disability is based on an inaccurate factual premise and cannot be afforded any probative value. Moreover, to the extent the Veteran more generally asserts that the current right ankle disability and the alleged left ankle disability were more generally incurred in or caused by his duties in service, as a layperson without any demonstrated expertise concerning the etiology of ankle disabilities, this general assertion may not be afforded any probative value. See e.g. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In sum, because the Veteran is not shown to have a current left ankle disability, because a right ankle disability did not become manifest during service or for many years thereafter, and because there is no probative evidence of a medical nexus between current right ankle disability and any alleged left ankle disability and military service, the preponderance of the evidence is against this claim and it must be denied. 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309; Hickson, 12 Vet. App. 247, 253 (1999); Alemany v. Brown, 9 Vet. App. 518 (1996). The Board also notes that a VA ankle examination was not necessary in this case. In this regard, there is no credible evidence that a right or left ankle injury occurred during service and no probative evidence, which even suggests a medical nexus between current right ankle disability (and alleged left ankle disability) and the Veteran’s military service. See 38 C.F.R. § 3.159(c)(4). REASONS FOR REMAND The claims for entitlement to service connection for right hand/wrist disability bilateral hearing loss, tinnitus, seizure disorder, cognitive disorder and psychiatric disorder are remanded. Regarding the claim for service connection for right hand/wrist disability, the service treatment records show that the Veteran was seen by medical personnel for right hand/wrist pathology in April 1973. At the visit, it was noted that he had been in a fight and had injured his right hand. Physical examination showed mild tenderness to the wrist, and swelling, tenderness and erythema of all the metacarpals. Also, at the August 2016 Board hearing, the Veteran reported that he had a current disability of the wrist and hand in that he had had right carpal tunnel release surgery two years previously. Additionally, in an August 2016 statement, the Veteran indicated that his right hand and wrist disability resulted from his machine repair shop work during service and the rigors of the Marine lifestyle. He also asserted that he had arthritis of the right hand and wrist and appeared to assert continuity of wrist and hand symptomatology since service. Given the evidence of injury in service, the apparent assertion of continuity and the report of current hand and wrist disability, including the reported surgical procedure, the Board finds that a VA wrist hand/examination is warranted prior to final adjudication of this claim. Regarding the claim for hearing loss, the Veteran underwent a VA audiological evaluation in May 2012 where the examining audiologist determined that the Veteran’s current hearing loss disability was less likely than not caused by or the result of an event in military service. The audiologist’s rationale for this opinion was that the Veteran had a frequency specific hearing test at discharge on July 23, 1974, indicating hearing within normal limits bilaterally. No further rationale was provided. Service connection for hearing loss is not precluded where hearing was within normal audiometric testing limits at separation from service. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Because the examiner’s negative etiology opinion appears to be based solely on the fact that the Veteran’s hearing was normal during active military service, it is not adequate and another medical opinion is needed. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination, it must obtain a fully adequate one). As the audiologist also determined that the Veteran’s tinnitus was at least as likely as not a symptom associated with his hearing loss, the claim for service connection for tinnitus is inextricably intertwined with the claim for hearing loss and must also be remanded. Regarding the claims for service connection for seizures and for cognitive disorder, at the January 1974 medical visit following the Veteran’s in-service auto accident, it was noted that he appeared to be in a state of intoxication and that he complained of a headache. Also, the account of the visit appears to indicate that the Veteran was released to the custody of the California Highway Patrol (CHP). Additionally, at a follow-up visit a couple of days later, the Veteran was noted to have a soft tissue contusion of the left temporal region and post-concussion headache. Further, private psychiatric records from November 2013 to September 2016 appear to indicate that the Veteran may have some impairment attributable to past head trauma. Moreover, a specific July 2015 private treatment record indicates that the Veteran was taking anti-parkinsonian medication for “shakiness.” The reports in the service treatment records suggest that the Veteran may have been driving while intoxicated at the time of his auto accident in service. However, the Veteran’s service personnel records have not been associated with the claims file and these records may include such a determination along with other information pertaining to the auto accident. Consequently, because there is evidence of a head injury in service and evidence of current cognitive disorder and seizure-like disorder that could potentially have resulted from head trauma (i.e. enough evidence to warrant a VA examination), on remand the Veteran’s complete personnel file should be obtained. Also, any available records of arrest or incarceration for driving while under the influence or similar criminal infractions during service should also be obtained. Regarding the Veteran’s claim for psychiatric disorder, his service treatment records include the report of a May 1974 psychiatric examination. At this examination, the Veteran was noted to have poor impulse control and to be engaging in non-duty related dangerous behavior with firearms and his motorcycle. It was also implied that he may have had suicidal impulses. There was evidence of mild depression in terms of a sleep disorder and problems with self-esteem and the diagnosis was emotionally unstable personality, severe. The Veteran was also afforded a VA psychiatric examination in May 2012 where the examiner rendered diagnoses of alcohol dependence, polysubstance dependence and cognitive disorder NOS. The examiner commented that it was clear that the Veteran had significant depression and anxiety in the past. However, whether these symptoms were principally due to alcohol and drugs (either use or withdrawal); due to his neurologic problems; or were independent in origin was unclear. The examiner also could neither confirm or rule out a bipolar illness or an underlying axis II disorder. The examiner recommended that the Veteran enter psychiatric treatment with the aim of achieving sobriety, which in turn would make a clear diagnosis possible. Subsequent private mental health treatment records show that the Veteran did receive psychiatric treatment from November 2013 to September 2016 and that diagnoses included depression, anxiety, PTSD and closed head trauma. Given this subsequent psychiatric treatment considered in conjunction the findings of the May 2012 VA examiner and the psychiatric symptomatology noted during the psychiatric examination in service, on remand, the Veteran should be afforded a new VA examination to assess the likelihood that any current psychiatric disability is related to his military service. Prior to arranging for the examinations and medical opinion, the AOJ should ask the Veteran to identify all sources of treatment or evaluation he has received since service for right hand/wrist disability, bilateral hearing loss, tinnitus, seizure disorder, cognitive disorder and psychiatric disorder, and should secure copies of complete records of the treatment or evaluation (that are not already of record) from all sources appropriately identified. The matters are REMANDED for the following action: 1. Obtain the Veteran’s complete personnel file. 2. Make appropriate efforts to obtain any available records from the San Bernardino Department of Corrections, the California Highway Patrol and any other appropriate source concerning any arrest, incarceration or other law enforcement contact of the Veteran during service for driving under the influence or similar criminal infractions in approximately January 1974. 3. Ask the Veteran to identify all sources of treatment or evaluation he has received for right hand, right wrist, hearing loss, tinnitus, head injury, seizure disorder, cognitive disorder and psychiatric disorder since service, and secure copies of complete records of the treatment or evaluation from all sources appropriately identified. In particular, the Veteran should be asked to provide appropriate releases of information so that VA may attempt to obtain any additional outstanding records of treatment or evaluation from Dr. Hakim, Baystate Wing Hospital Behavioral Health and Orthopedics, and Mark Lange (therapist and LHMC). 4. If and only if, the Veteran’s January 1974 car accident in service is found to be in the line of duty, the Veteran should be scheduled for a VA neurological examination. The examiner should review the claims file in conjunction with the examination. This review should include the service treatment records, including the January 19, 1974 and January 21, 1974 progress notes, the May 1974 psychiatric examination, the July 1974 separation examination and the July 1974 report of medical history; any pertinent service personnel records; the May 2012 VA psychiatric examination, including the Veteran’s reported history of multiple head injuries; pertinent post-service medical and psychiatric records; any pertinent lay statements and testimony; and any other information in the record deemed pertinent. The examiner should then render any appropriate neurological diagnoses. A) If the Veteran is diagnosed with a seizure disorder, the examiner should provide an opinion as to whether such disorder is at least as likely as not (i.e. a 50 percent chance or greater) related to the head injury the Veteran suffered in his January 1974 auto accident in service. B) If the Veteran is diagnosed with any cognitive disorder, the examiner should provide an opinion as to whether such disorder is at least as likely as not (i.e. a 50 percent chance or greater) related to the head injury the Veteran suffered in his January 1974 auto accident in service. C) If the Veteran is diagnosed with any other neurological disorder, the examiner should provide an opinion as to whether such disorder is at least as likely as not (i.e. a 50 percent chance or greater) related to the head injury the Veteran suffered in his January 1974 auto accident in service. The examiner should provide a specific rationale for all opinions provided. 5. The Veteran should be scheduled for a VA psychiatric examination. The examiner should review the claims file in conjunction with the examination. This review should include the service treatment records, including the May 1974 psychiatric examination; any pertinent service personnel records; the May 2012 VA psychiatric examination; all post-service mental health treatment records; any pertinent lay statements and testimony; and any other information in the record deemed pertinent. The examiner should make note of all the different diagnoses of acquired psychiatric disorder made during the appeal period (i.e. the period from September 2010 to the present). The examiner should then render his or her psychiatric diagnoses. A) For each acquired psychiatric disorder diagnosed by the examiner, he or she should provide an opinion as to whether such disorder is at least as likely as not (i.e. a 50 percent chance or greater) related to the Veteran’s military service, including the psychiatric pathology noted by the May 1974 psychiatric examination in service. B) For any other acquired psychiatric disorders diagnosed from September 2010 to the present but not currently diagnosed by the examiner, the examiner should provide an opinion as to whether such disorders are at least as likely as not (i.e. a 50 percent chance or greater) related to the Veteran’s military service, including the psychiatric pathology noted by the May 1974 psychiatric examination in service. The examiner should provide a specific rationale for each opinion provided. 6. The Veteran should be scheduled for a VA examination of his right wrist/hand. The examiner should review the claims file in conjunction with the examination. This review should include the service treatment records, including, the April 1973 record pertaining to hand/wrist injury; any pertinent post-service medical records, including any records pertaining to surgery for carpal tunnel syndrome; any pertinent lay statements and testimony; and any other information in the record deemed pertinent. The examiner should then render opinions in answer to the following questions: A) Is it at least as likely as not (i.e. a 50 percent chance or greater) that any current right wrist disability is related to service, to include a right wrist injury noted in April 1973? B) Is it at least as likely as not (i.e. a 50 percent chance or greater) that any current right hand disability is related to service, to include a right hand injury noted in April 1973? The examiner should provide a specific rationale for each opinion provided. 7. Obtain an addendum opinion as to the etiology of the Veteran’s hearing loss by an appropriate medical professional. If the professional determines that an additional examination is necessary before rendering this opinion, such should be scheduled. The professional should review the claims file, including the service treatment records, the March 2012 VA audiological evaluation report, a description of the Veteran’s military occupational specialty (MOS) associated with the claims file in August 2016 and any other information deemed pertinent. The professional is then asked to render an opinion in answer to the following question: Is it at least as likely as not (50 percent probability or more) that the Veteran has a current hearing loss disability that had its onset during military service or is otherwise related to military service. In providing the opinion, the medical professional should consider the Veteran’s assertion that his bilateral hearing loss stems from his noise exposure in-service consistent with his military occupational specialty (MOS) as a repair shop machinist. The professional should also explain why the Veteran’s current bilateral hearing loss is, or is not, a delayed response to his in-service noise exposure. If the professional relies on the audiometric findings at separation in offering a negative opinion, the medical significance of such findings should be explained. Also, if applicable, the professional should indicate whether any pertinent hearing threshold shifts were shown during service. The medical professional should provide a clear rationale for the opinion provided. 8. Readjudicate the claims. If any remain denied, issue an appropriate supplemental statement of the case and provide the Veteran the opportunity to respond. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Dan Brook, Counsel