Citation Nr: 18144683 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 15-03 883A DATE: October 25, 2018 ORDER As new and material evidence was received, the claim for entitlement to service connection for bilateral hearing loss is reopened. To this extent only the claim is granted. As new and material evidence was received, the claim for entitlement to service connection for a traumatic brain injury (TBI) is reopened. Entitlement to service connection for allergic rhinitis with epistaxis to include as due to an undiagnosed illness or other qualifying chronic disability, pursuant to 38 C.F.R. § 3.317, is denied. Entitlement to service connection for migraine and post-concussion traumatic headaches is granted. Entitlement to service connection for TBI is granted. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for right knee patellar tendonitis is remanded. Entitlement to service connection for lumbosacral strain is remanded. FINDINGS OF FACTS 1. In a final August 2004 rating decision, the RO denied the Veteran’s claim for entitlement to service connection for bilateral hearing loss. 2. The evidence received since the August 2004 rating decision is not cumulative or redundant of the evidence of record and raises a reasonable possibility of substantiating the Veteran’s claims of entitlement to service connection for bilateral hearing loss. 3. In a final September 2009 rating decision, the RO denied the Veteran’s claim for entitlement to service connection for TBI. 4. The evidence received since the September 2009 rating decision is not cumulative or redundant of the evidence of record and raises a reasonable possibility of substantiating the Veteran’s claims of entitlement to service connection for TBI. 5. The Veteran’s allergic rhinitis with epistaxis did not have its onset in service, did not manifest to a compensable degree within one year of separation from service, and is not otherwise related to service, to include as due to an undiagnosed illness or other qualifying chronic disability, pursuant to 38 C.F.R. § 3.317. 6. The Veteran has a diagnosis of migraine and post-concussion traumatic headaches that was attributable to his active service. 7. The Veteran has a diagnosis of TBI that was attributable to his active service. CONCLUSIONS OF LAW 1. The August 2004 rating decision denying the Veteran’s claims for entitlement to service connection for bilateral hearing loss is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1100. 2. New and material evidence has been received to reopen the claim for entitlement to service connection for bilateral hearing loss. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The September 2009 rating decision denying the Veteran’s claims for entitlement to service connection for TBI is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1100. 4. New and material evidence has been received to reopen the claim for entitlement to service connection for TBI. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The criteria for service connection for allergic rhinitis with epistaxis, to include as due to an undiagnosed illness or other qualifying chronic disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.317. 6. The criteria for service connection for migraine and post-concussion traumatic headaches have been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 7. The criteria for service connection for TBI have been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1999 to September 2003. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from April 2014 and May 2014 rating decisions. The Board observes that the Veteran requested a hearing before a Veterans Law Judge in connection with his appeal. He was informed in a February 2018 letter that his requested hearing had been scheduled for March 2018; however, he failed to report for such hearing. Therefore, his request for a Board hearing is considered withdrawn. 38 C.F.R. §§ 20.702(d), 20.704(d). New Material Evidence Historically, an August 2004 and a September 2009 rating decision denied the Veteran’s claim for service connection for bilateral hearing loss and TBI, respectively. The August 2004 rating decision denied service connection for bilateral hearing loss stating that a hearing disability for VA purposes had not been shown. The September 2009 rating decision denied service connection for TBI stating that diagnosis of TBI had not been shown. The Veteran did not appeal these decisions and they are now final. 38 U.S.C. § 7104. In August 2013, the Veteran sought to reopen his claims for service connection for bilateral hearing loss and TBI. VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of a Veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); Hodge v. West, 155 F. 3d 1356 (Fed. Cir. 1998). The Board must consider the question of whether new and material evidence has been received because it goes to the Board’s jurisdiction to reach the underlying claim and adjudicate the claim de novo. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no new and material evidence has been offered, that is where the analysis must end. Butler v. Brown, 9 Vet. App. 167 (1996). New evidence is evidence not previously submitted to agency decision makers. Material evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether new and material evidence has been received, VA must initially decide whether evidence associated with the claims file since the prior final denial is new. That analysis is undertaken by comparing newly received evidence with the evidence previously of record. After evidence is determined to be new, the next question is whether it is material. The Board must review all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. Evans v. Brown, 9 Vet. App. 273 (1996). For purposes of determining whether new evidence is material, the credibility of the new evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). New and material evidence is not required as to each previously unproven element of a claim. Shade v. Shinseki, 24 Vet. App. 110 (2010). The Board notes that its task is to first decide whether new and material evidence has been received, as opposed to whether the evidence actually substantiates the Veteran’s claim. Pertinent evidence added to the record since the final August 2004 and September 2009 RO decisions include the Veteran’s statements, VA examinations, VA medical records, and copies of the Veteran’s service treatment records, which were previously in the Veteran’s file. In regard to the Veteran’s hearing, a December 2008 VAMC record noted the Veteran had severe hearing difficulties. In May 2014, a VA audiology consult note showed the Veteran underwent a hearing consultation. The diagnosis of the examination was that there was evidence of possible hearing loss, but that the Veteran’s test results were not reliable or consistent. Further testing was recommended. In regard to the Veteran’s TBI, a January 2012 VAMC record stated that the Veteran’s had a past positive diagnosis for TBI and that an additional screening was not required due to TBI diagnosis. An October 2014 private medical examination indicated that the Veteran had suffered TBI. Consequently, as the prior denials stated that the Veteran did not have either a diagnosis of hearing loss which rose to the level of a disability for VA purposes or diagnosis of TBI, and there has now been evidence submitted which indicates the Veteran may have hearing loss which rises to the level of a VA disability and he has been diagnosed with TBI, and resolving all reasonable doubt in favor of the Veteran, the Board finds that new and material evidence has been submitted regarding the Veteran’s claims for service connection for bilateral hearing loss and TBI. Thus, the claim for entitlement to service connection for bilateral hearing loss and TBI are reopened. The Board is remanded the Veteran’s claim for bilateral hearing loss and granting the Veteran’s claim for TBI, as discussed below. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. That determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). Service connection may be presumed for certain chronic diseases which develop to a compensable degree within one year after discharge from service, even though there is no evidence of such disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. 3.307, 3.309(a). Where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has that chronic disability, service connection can be granted. That does not mean that any manifestations in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word chronic. When the disease entity is established, there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptoms after service may serve as an alternative method of establishing service connection. 38 C.F.R. § 3.303(b). Continuity of symptoms may be established if a claimant can demonstrate (1) that a condition was noted during service; (2) evidence of post- service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. Continuity of symptoms applies only to those conditions explicitly recognized as chronic. 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Additionally, pursuant to 38 U.S.C. § 1117, a Persian Gulf Veteran with a qualifying chronic disability that manifests to a degree of 10 percent or more before December 31, 2021, may be entitled to compensation. See 38 U.S.C § 1117; 38 C.F.R. § 3.317(a)(1). There are three avenues for finding that a chronic disability may qualify for presumptive service connection pursuant to 38 U.S.C. § 1117. Qualifying chronic disabilities include those that result from (1) an undiagnosed illness, (2) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders, or (3) any diagnosed illness that the Secretary determines in regulations... warrants a presumption of service connection. 38 U.S.C § 1117(a)(2)(A), (B), (C); 38 C.F.R. § 3.317(a)(2)(i)(B). A medically unexplained chronic multi-symptom illness is “a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities.” 38 C.F.R. § 3.317(a)(2)(ii). Disabilities that have existed for 6 months or more and disabilities that that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. 38 C.F.R. § 3.317(a)(4). A qualifying chronic disability shall be rated using the criteria from part 4 of the chapter for a disease or injury which the functions affected, anatomical localization, or symptomology are similar. 38 C.F.R. § 3.317(a)(4). Along with the three examples of a medically unexplained chronic multi-symptom illness provided by § 1117(a)(2)(B), the law provides a list of signs or symptoms that may be a manifestation of a medically unexplained chronic multi-symptom illness that includes: skin symptoms, headaches, muscle pain, joint pain, neurologic symptoms, neuropsychological symptoms, respiratory symptoms, sleep disturbances, gastrointestinal symptoms, cardiovascular symptoms, abnormal weight loss, and menstrual disorders. See 38 U.S.C. § 1117(g); 38 C.F.R. § 3.317(b). The standard of proof to be applied in decisions on claims for Veterans’ benefits is set forth at 38 U.S.C. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 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). Where a Veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of service as shown by the service record, the official history of each organization in which the Veteran served, the Veteran’s medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a). The provisions of 38 U.S.C. § 1154(b) provides, in pertinent part, that in any case where a Veteran is engaged in combat during active service, lay or other evidence of service incurrence of a combat related disease or injury will be considered sufficient proof of service connection if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence during service, and, to that end, VA shall resolve every reasonable doubt in favor of a Veteran. The United States Court of Appeals for the Federal Circuit has held that, in the case of a combat veteran, not only is the combat injury presumed, but so, too, is the presence of a disability due to the in-service combat injury. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). To establish entitlement to service connection, however, there still must be evidence of a current disability and a causal relationship between the current disability and the combat injury. Id. Allergic Rhinitis The Veteran has sought service connection for his allergic rhinitis. The Veteran’s service treatment records are silent for any complaints or concerns regarding his nose or nasal passages. In a July 2003 Report of Medical Assessment, the Veteran did not identify any nose or nasal symptomology from which he suffered. In April 2013, a VA medical center (VAMC) record showed the Veteran to have complaints of having nose bleeds 2-3 times a week on and off for the prior 5 months. A May 2015 VA examination found the Veteran had been diagnosed with allergic rhinitis with epistaxis in 2013. The Veteran reported that he had intermittent, brief, sporadic episodes of epistaxis two years prior. He reported that he typically has a nose bleed which lasts 2-3 minutes and occurs twice per week. He denied a history of nasal fracture or nasal surgery. He stated he had chronic nasal congestion for which he used prescription medication. The examiner stated that there was insufficient evidence to support a nexus between the Veteran’s allergic rhinitis and his military service, as there was no evidence which established that the Veteran had treatment for episodes of rhinitis or epistaxis while in-service or within a year of service. Furthermore, the examiner found that the Veteran’s allergic rhinitis with epistaxis was a condition with a clear and specific etiology and diagnosis, which indicated that it was less likely than not related to a specific exposure event experienced by the Veteran during his service in Southwest Asia. Direct service connection necessitates a link between the Veteran’s service and his claimed disability. As to the Veteran’s rhinitis, no such link is supported by the evidence of record. The Veteran’s STRs are void of treatment for or diagnosis of any condition regarding his nose or nasal passages. By the Veteran’s own statement, his rhinitis did not begin until 2013, 10 years after his separation from service. The passage of many years between discharge from active service and the documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F. 3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). The Board also notes that neither the Veteran or any of his providers related his rhinitis or his epistaxis to either his active duty service during his complaints of or treatment for his disorder. Furthermore, the only evidence of record to address the etiology of the Veteran’s liver cancer, the 2015 VA examination, did not find a link between the Veteran’s service and his rhinitis/epistaxis. There is no other evidence of record which directly addresses the etiology of the Veteran’s rhinitis/epistaxis. Presumptive service-connection via 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 is also not established in regard to the Veteran’s diagnosed allergic rhinitis with epistaxis. Though the Veteran did have active duty service in the Southwest Asia Theater of operations, his allergic rhinitis with epistaxis is not included on the list conditions afforded presumptive service connection. Furthermore, as the VA examiner explained, the Veteran’s disorder is a known clinical condition. Thus, the Veteran’s diagnosed allergic rhinitis with epistaxis which renders is not either an undiagnosed illness or a manifestation of medically unexplained chronic multisymptom illness. 38 C.F.R. § 3.317(a)(1)(i)-(ii). Accordingly, the Board finds that service connection for the Veteran’s diagnosed allergic rhinitis with epistaxis cannot be granted under the presumptive provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. The Board finds the May 2015 VA opinion highly probative to the issue of whether the Veteran’s rhinitis/epistaxis is related to service, to include his service in the Southwest Asia theater of operations. The examiner possessed the necessary education, training, and expertise to provide the requested opinion. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The opinion was based on a review of the claims file, which consisted of the Veteran’s STRs and post-service medical evidence, and the Veteran’s contentions contained therein, and consideration of medical literature, upon which the examiner relied upon in giving his opinion. It is clear that the examiner took into consideration all relevant factors in giving his opinion. Significantly, the Veteran has not presented or identified any contrary medical opinion that supports the claim for service connection, to include his service in the Southwest Asia theater of operations. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board finds that the only medical opinions of record showed that the Veteran’s rhinitis/epistaxis was not related to service, to include his service in the Southwest Asia theater of operations. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428 (2011), as to the specific issue being decided herein, an opinion as to the etiology of the Veteran’s rhinitis/epistaxis and whether it is etiologically related to the Veteran’s active service, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). That is, although the Board readily acknowledges that Veteran was competent to report his rhinitis/epistaxis, there is no indication that the Veteran was competent to etiologically link any such symptoms to his active service. In addition, the Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir. 2012). Accordingly, the Veteran statements are lay evidence that do not constitute competent medical evidence and lack probative value. In sum, the claims file does not contain competent and credible evidence that the Veteran’s allergic rhinitis with epistaxis was related to service, to include his service in the Southwest Asia theater of operations. Accordingly, as the preponderance of the evidence is against the claim for service connection, the benefit-of-the-doubt rule is not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Headaches and TBI The Veteran’s Certificate of Release or Discharge from Active Duty, DD-214, established that the Veteran had active duty in the United States Marine Corps with 1st Battalion, 5th Marine Regiment as a mortarman. The Board notes that the Veteran is service connected for posttraumatic stress disorder (PTSD) based on his combat experiences while deployed to Iraq on active duty, including a rocket propelled grenade (RPG) attack. The Veteran contends that his headaches and TBI are related to his active duty service, specifically that his headaches and TBI are associated with his combat experiences. In September 2005, a VAMC record indicated the Veteran had complaints of headaches. He denied vision changes. In November 2008, a VAMC record indicated the Veteran reported headaches which were a crushing feeling in his temporal region which lasted 15 to 30 minutes and required him to lie down and take over the counter medication. The Veteran reported that the vehicle in which he was riding was hit by a RPG and he saw an orange blast. He next remembered being woken up by a fellow Marine and feeling dazed and dizzy. In December 2008, a VAMC record indicated that the Veteran suffered from very severe headaches. The Veteran reported that while in-service he was deployed to Iraq. He stated that while deployed, the vehicle in which he was traveling was hit by a RPG. He stated that he saw an orange blast and next remembers was being shaken awake by a fellow Marine. He reported feeling dazed and dizzy. He reported his helmet was blown off by the attack. The physician noted the Veteran’s symptoms were consistent with a diagnosis of TBI and that the Veteran’s current clinical symptom presentation was most consistent with a combination of TBI and a behavioral health condition. The physician noted the Veteran’s diagnosis to be “probably mild TBI’ from the blast with post-concussion syndrome compounded by the Veteran’s PTSD. He was advised to have TBI follow-up. In September 2009, a VA examination determined that the Veteran reported headaches which occurred a few times a day and required him to lie down. He reported that he was involved in an RPG attack while deployed. He recalled an orange explosion and that his helmet was knocked off and he was momentarily unconscious. He stated that he was not aware that he had TBI, but received a letter stating that he might have a mild brain injury. The examiner noted that the Veteran scored in the normal range of the scales that were administered and that there were no indications of significant TBI in the examination. In January 2012, a VAMC record noted that the Veteran’ had already been diagnosed with TBI during a deployment and that screening was not required due to TBI diagnosis. In February 2012, a VAMC record indicated the Veteran had a past medical history positive for migraine headaches and required prescription medication. In May 2014, a VA examination determined that the Veteran had been diagnosed with migraine, including migraine variants, and post-concussion/traumatic headaches. The Veteran reported that his headaches began about 1 year after he separated from service. The VA examination opined that there was sufficient evidence to support a nexus between the Veteran’s current headache condition and his military service. The examiner opined that the etiology of the Veteran’s headaches were likely due to post-concussive syndrome of migraine-variant type due to the Veteran’s in-service involvement in a RPG blast while deployed in combat. In an October 2014 private medical record, the examiner noted that the Veteran had a diagnosed TBI which caused headaches, poor concentration, poor sleep, and autonomic reflexes in his bilateral lower extremities. After review of the record, the Board finds that resolving all reasonable doubt in favor of the Veteran, service connection is warranted for the Veteran’s headaches and TBI. As previously stated, the Veteran was a mortarman with a Marine Corps Battalion. He is service connected for PTSD based on his combat-related experiences. Thus, the Board finds that the Veteran was involved in combat and, as such, the provisions of 38 U.S.C. § 1154(b) are applicable. Therefore, the Veteran’s statements regarding the RPG attack while in-combat are accepted as fact. Additionally, the Board finds credible and probative that the Veteran, whose MOS indicated he was a mortarman with a Marine Corps Battalion was exposed to combat action while deployed to Iraq. As to a relationship to service, the May 2014 VA examiner opined that the Veteran’s headaches were related to his active service, specifically the RPG. The Board notes that the Veteran has been consistent in his recount of the RPG attack. The Board also notes that there is no evidence in the record which would indicate that the Veteran’s headaches were caused by or related to any other incident or etiology. Furthermore, it is clear from the VAMC records, that the Veteran was diagnosed with TBI due to the RPG attack he experienced while in-service. He was determined to have a mild TBI in December 2008 and his January 2012 VAMC record noted a prior TBI diagnosis due to his deployment. Thus, the Board finds that the record established the Veteran had TBI as a result of his in-service combat experiences. As such, service connection is warranted. Accordingly, by resolving all reasonable doubt in favor of the Veteran, the Board concludes that service connection is warranted for headaches and TBI and the claims are granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND As stated above, the Veteran’s VAMC records indicate that he may have hearing loss sufficient to be considered a disability for VA purposes. The Board again notes that the Veteran’s MOS was a mortarman and that noise exposure in service has been conceded. Based on the VAMC records which indicate the Veteran may have hearing loss, the Board finds that there is sufficient evidence to warrant a VA examination for the Veteran’s claim for service connection for bilateral hearing loss. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, remand is warranted in order to schedule the Veteran for an appropriate VA examination. In regard to the Veteran’s claim for service connection for his lumbosacral spine, in May 2014, a VA examination stated the Veteran had been diagnosed with lumbosacral strain in 2002. The examiner opined that the Veteran’s current low back condition was less likely than not related to his military service as he had not had complaints or treatment for low back pain until 2009. A July 2005 VAMC record noted the Veteran complained of occasional lower back pain; an October 2005 VAMC record showed the Veteran complained of occasional low back pain; a February 2006 VAMC record showed the Veteran noted occasional low back pain; a July 2008 VAMC record noted the Veteran had complaints of back pain; a November 2008 VAMC record indicated the Veteran had complaints of low back pain. Based on these documented complaints of back pain prior to the examiner’s reported history of no back pain until 2009, the Board finds that the May 2014 VA examination is inadequate for adjudication purposes. A March 2014 VA examination stated the Veteran had been diagnosed with chronic right knee strain and posterior tibial tendinitis in 2003, which was within the same year of his active service. In May 2014, a VA examination of the Veteran’s right knee determined that the Veteran’s right knee disorder was less likely than not related to his military service. The examiner stated that the Veteran did not have complaints of knee symptomology while in-service or within a year of his separation from service. Based on the indication that the Veteran may have had a diagnosed knee condition in 2003, the Board finds that the May 2014 VA examination of the Veteran’s right knee is inadequate for adjudication purposes. 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 (2007). When an examination is inadequate, the Board must remand the case for further development. Bowling v. Principi, 15 Vet. App. 1 (2001), 38 C.F.R. § 4.2. Accordingly, and based on the foregoing, the Board finds that new VA examinations of the Veteran’s lumbar spine and right knee are warranted. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate audiological examination, by an examiner who has not previously examined him, to determine the nature and likely etiology of his claimed bilateral hearing loss. The claims file and all pertinent records must be made available to the examiner for review. The examiner should indicate whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s claimed hearing loss had onset during service or is otherwise related to his active military service. A discussion of the facts and medical principles involved (to include acoustic trauma and military noise exposure) including the Veteran’s service treatment records and lay assertions should be considered in giving this opinion. The examiner should note that the Veteran’s exposure to noise in service has been conceded. The examiner is reminded that it is not a sufficient rationale for a negative nexus opinion merely to state that the Veteran’s hearing was within normal limits on audiometric testing during service. In such a case, service connection is not precluded if there is sufficient evidence to demonstrate a relationship between the appellant’s service and a current disability which satisfies 38 C.F.R. § 3.385. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The examiner must explain the rationale for all opinions, citing to supporting clinical data and/or medical texts or treatises as deemed appropriate. If the examiner determines that a requested opinion cannot be given without resort to speculation, the examiner must explain the reason for that conclusion. 2. Schedule the Veteran for a VA medical examination by a physician (M.D.) who has not previously examined the Veteran to determine the nature and etiology of his right knee condition. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner should indicate in his/her report whether or not such was reviewed. All necessary tests and studies should be accomplished. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s right knee disability had onset in service or within one year following separation from service, or was causally related to service. The examiner is asked to reconcile the prior March 2014 and May 2014 VA examinations which have conflicting statements regarding the history of the Veteran’s right knee condition. The examiner must provide a complete rationale on which his/her opinion is based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. The Veteran’s lay assertions as to onset and continuity and symptomatology should be recorded and considered. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a conclusion as it is to find against it. If the examiner finds that he/she cannot provide an opinion without resorting to speculation, he/she should explain the inability to provide an opinion. 3. Schedule the Veteran for a VA medical examination by a physician (M.D.) who has not previously examined the Veteran to determine the nature and etiology of his lumbar spine disorder. The claims file, including a copy of this Remand, must be made available to the examiner and the examiner should indicate in his/her report whether or not such was reviewed. All necessary tests and studies should be accomplished. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s lumbar spine disorder had onset in service or within one year following separation from service, or was causally related to service. The examiner must provide a complete rationale on which his/her opinion is based, and must include a discussion of the medical principles as applied to the medical evidence and facts used in establishing his or her opinion. The Veteran’s lay assertions as to onset and continuity and symptomatology, as well as the Veteran’s documented complaints of low back pain, should be recorded and considered. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a conclusion as it is to find against it. If the examiner finds that he/she cannot provide an opinion without resorting to speculation, he/she should explain the inability to provide an opinion. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Parrish, Associate Counsel