Citation Nr: 18146147 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-21 770 DATE: October 30, 2018 ORDER New and material evidence has been submitted sufficient to reopen a claim for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and a nervous condition, and the petition is granted. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for diabetes mellitus, type II, is denied. Entitlement to service connection for peripheral neuropathy, left foot, is denied. Entitlement to service connection for peripheral neuropathy, right foot, is denied. Entitlement to an increased rating greater than 30 percent for a bilateral hearing loss disability is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and a nervous condition, is remanded. Entitlement to service connection for headaches is remanded. FINDINGS OF FACT 1. An unappealed January 1994 rating decision denied entitlement to service connection for a nervous condition finding that new and material evidence had not been submitted; a March 2009 rating decision denied entitlement to service connection for PTSD finding that new and material evidence had not been submitted. 2. Evidence received since the January 1994 and March 2009 rating decisions is new, relevant and probative as to the nervous condition and PTSD claims, respectively. 3. The Veteran’s left knee disability was not incurred in service, arthritis of the left knee was not manifested to a compensable degree within one year of separation from service, and the left knee disability is not otherwise caused by service. 4. The Veteran’s right knee disability was not incurred in service, arthritis of the right knee was not manifested to a compensable degree within one year of separation from service, and the right knee disability is not otherwise caused by service. 5. The Veteran’s diabetes mellitus, type II, was not incurred in service, within one year of separation from service, and is not otherwise caused by service. 6. The Veteran’s peripheral neuropathy, left foot, was not incurred in service, within one year of separation from service, and is not otherwise caused by service. 7. The Veteran’s peripheral neuropathy, right foot, was not incurred in service, within one year of separation from service, and is not otherwise caused by service. 8. The Veteran’s service-connected bilateral hearing loss had been manifested by no worse than level I hearing acuity in the right ear and level I hearing acuity in the left ear. CONCLUSIONS OF LAW 1. The January 1994 and March 2009 rating decisions that denied entitlement to service connection for nervous condition and PTSD, respectively, are final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1103 (2018). 2. Evidence received since the January 1994 and March 2009 decisions in relation to the Veteran’s claims for entitlement to service connection for nervous condition and PTSD is new and material, and, therefore, the overarching acquired psychiatric disorder claim is reopened. 38 U.S.C. §§ 5108, 7104 (2012); 38 C.F.R. § 3.156 (2018). 3. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 4. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 5. The criteria for entitlement to service connection for diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 6. The criteria for entitlement to service connection for peripheral neuropathy, left foot, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 7. The criteria for entitlement to service connection for peripheral neuropathy, right foot, have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 8. The criteria for an increased rating greater than 40 percent for a bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.85, Diagnostic Code (DC) 6100 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Air Force as an aircraft systems fuel mechanic from May 1971 and October 1974 with service in Thailand. The Veteran’s decorations and awards included the National Defense Service Medal and the Air Force Medal. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131 (2012). Certain diseases, to include arthritis, diabetes mellitus, type II, nephritis, and other organic diseases of the nervous system, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2018). As there is no evidence or claim that the Veteran was diagnosed with arthritis of the knees, diabetes mellitus, type II, or peripheral neuropathy of the lower extremities and feet within one year of service the above provision is not applicable. Alternatively, a “veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service.” 38 U.S.C. § 1116(f) (2012); 38 C.F.R. § 3.307(a)(6)(iii). If a veteran was exposed to a herbicide agent during active military, naval, or air service, certain diseases shall be service connected if the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C. § 1113; 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Such diseases include, among others, Type 2 diabetes and early onset peripheral neuropathy. 38 C.F.R. § 3.309(e). In addition, VA has determined that there was significant use of herbicides on the fenced-in perimeters of military bases in Thailand intended to eliminate vegetation and ground cover for base security purposes as evidenced in a declassified Vietnam-era Department of Defense document titled “Project CHECO Southeast Asia Report: Base Defense in Thailand.” Special consideration of herbicide exposure on a facts-found or direct basis is extended to those veterans whose duties placed them on or near the perimeters of Thailand military bases. If exposure is shown on a direct basis, this allows for presumptive service connection of the diseases associated with herbicide exposure. The majority of U.S. servicemen in Thailand during the Vietnam era were stationed at the Royal Thai Air Force Bases of U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, and Don Muang. A Veterans Benefits Administration internal manual provides that if a veteran served on one of these air bases as a security policeman, security patrol dog handler, member of a security police squadron, or otherwise served near the air base perimeter, as shown by military occupational specialty (MOS), performance evaluations, or other credible evidence, then herbicide exposure may be acknowledged on a facts found or direct basis. However, this applies only during the Vietnam era, from February 28, 1961, to May 7, 1975. In DAV v. Secretary of Veterans Affairs, 859 F.3d 1072 (Fed. Cir. 2017), the Federal Circuit held the internal manual used to guide VA adjudicators and does not establish substantive rules. The Federal Circuit specifically noted that the Board is not bound by the internal manual. See also Overton v. Wilkie, 2018 U.S. App. Vet Claims LEXIS 1251). When relying on any internal provision, the Board must independently review the matter and if, after such review, the Board chooses to rely on the internal manual as a factor in its analysis or as the rule of decision, it must provide adequate reasons or bases for doing so. To establish a right to compensation for a present disability, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 1. Whether new and material evidence sufficient to reopen a claim for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and a nervous condition, has been submitted The Veteran claims that he has an acquired psychiatric disorder due to incidents and experience during his service in Thailand. The Veteran has one year from notification of a RO decision to initiate an appeal by filing a notice of disagreement (NOD) with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C. § 7105(b) and (c) (2012); 38 C.F.R. §§ 3.160(d), 20.201, and 20.302(a) (2018). In January 1994 and March 2009 rating decisions, the RO found that new and material evidence sufficient to reopen claims for a nervous condition and PTSD, respectively, had not been submitted. The Veteran failed to timely appeal or otherwise express disagreement with either rating decision. As such, the January 1994 and March 2009 rating decisions ultimately became final. 38 C.F.R. § 20.1103 (2018). As a result, the claims of entitlement to service connection for an acquired psychiatric disorder, to include a nervous condition and PTSD, may now be considered if new and material evidence has been received since the time of the last final adjudication. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2018); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); Evans v. Brown, 9 Vet. App. 273 (1996). Under 38 C.F.R. § 3.156(a), evidence is considered “new” if it was not of record at the time of the last final disallowance of the claim. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Finally, new and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. In determining whether evidence is new and material, the “credibility of the evidence is to be presumed.” Justus v. Principi, 3 Vet. App. 510, 513 (1992). Additionally, when determining whether the Veteran has submitted new and material evidence to reopen a claim, consideration must be given to all the evidence since the last final denial of the claim. Evans v. Brown, 9 Vet. App. 273 (1996). Moreover, the Veteran need not present evidence as to each element that was a specified basis for the last disallowance, but merely new and material evidence as to at least one of the bases of the prior disallowance. See Shade v. Shinseki, 24 Vet. App. 110 (2010) (holding that it would be illogical to require that a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element). The January 1994 rating decision declined to reopen the claim for entitlement to service connection for a nervous condition because there was no evidence of a chronic acquired psychiatric disorder in service or within one year of separation from service. The March 2009 rating decision declined to reopen a claim for entitlement to service connection for PTSD because although there was a current diagnosis of PTSD there was no verified stressor relating this disability to service. Since that time, a December 2016 Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire (DBQ) concluded that the Veteran suffered from major depressive disorder that more likely began in service and was aggravated by his service-connected tinnitus and bilateral sensorineural hearing loss. As an initial matter, the Board recognizes that the diagnosis of major depressive disorder differs from the Veteran’s explicit prior claims for a nervous condition and PTSD, but the Court has held in Clemons v. Shinseki, 23 Vet. App. 1 (2009) that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. As such, the foregoing diagnosis relates to the acquired psychiatric disorder claim on appeal. In addition, the original rating decisions considered the Veteran’s claim only on a direct basis. New and material evidence, however, is also necessary to reopen a claim for the same benefit asserted under a different theory of entitlement, so the mere fact that a veteran alleges different theories of entitlement, from those previously alleged, does not obviate the need to have new and material evidence to reopen his or her claim. See Boggs v. Peake, 520 F.3d 1330, 1336 (Fed. Cir. 2008); see also Roebuck v. Nicholson, 20 Vet. App. 307, 313 (2006). Pursuant to the Court’s holding in Shade and presuming the credibility of the evidence for the sole purpose of determining whether the acquired psychiatric disorder claim should be reopened, the Board concludes that the above evidence suggests the possibility that an acquired psychiatric disorder was aggravated by his service-connected tinnitus and/or bilateral hearing loss disabilities. The evidence is new and material. Having reopened the acquired psychiatric disorder claim, the Board finds that a remand is necessary prior to final adjudication of the claim. 2. Entitlement to service connection for a left knee disability 3. Entitlement to service connection for a right knee disability The Veteran appears to argue that his current right and left knee disabilities were incurred in service or are otherwise related to service. The Veteran’s service treatment records include no complaints of, treatment for, or diagnosis of a right or left knee disability. In a September 1974 Report of Medical Examination, the examiner noted normal examination of the lower extremities. A contemporaneous Report of Medical History included the Veteran’s denial of a history of trick or locked knee. In December 1992, the Veteran complained of left knee pain for the previous week. On examination, there was no swelling or tenderness and the Veteran had normal range of motion in the knee. In April 2001, the Veteran was noted to have a history of degenerative joint disease of the left knee. In April 2005, the Veteran had a diagnosis of arthritis of the knees from 1989. In September 2007, the Veteran reported bilateral leg pain following two motor vehicle accidents and prolonged driving, as well as a gunshot wound to the left leg. The Veteran noted that ibuprofen helped his knee pain. The assessment included obesity and knee pain. In August 2014, the Veteran reported bilateral knee pain that had been getting worse for years, but had been continuously getting worse. In October 2014, the Veteran reported left knee pain after falling down 8 steps. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not caused by an in-service injury, event, or disease. The evidence demonstrates that the Veteran has current diagnoses of right and left knee arthritis. That said, the Board concludes that the preponderance of the evidence weighs against finding that the Veteran’s right or left knee disability began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Thus, the evidence establishes that the Veteran was not diagnosed with a right or left knee disability until multiple years after his separation from active service. While the Veteran is competent to report having experienced right or left knee symptoms, in this case the evidence does not support a finding of a continuity of symptoms from service, based on the records wherein the Veteran denied a history of knee problems at separation from service. The evidence otherwise demonstrates ongoing knee pain for years prior to seeking treatment, but the evidence indicates treatment / diagnoses from approximately 1989. The Board finds it reasonable to conclude that had he been experiencing ongoing right or left knee problems in service and thereafter that he would have reported such problems during examination or on questioning prior to separation from service. The Board also has considered whether service connection would be warranted pursuant to the provisions of 38 C.F.R. § 3.303(b) (2018), based on chronicity and continuity. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board recognizes that arthritis is a chronic disease listed under 38 C.F.R. § 3.309(a). That said, 38 C.F.R. § 3.303(b) clearly indicates that, “This rule does not mean that any manifestation of joint pain... in service will permit service connection of arthritis... first shown as a clearcut clinical entity, at some later date. For the showing of 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.’“ In this case, the Veteran specifically denied a history of trick or locked knee in September 1974 and had a contemporaneous normal examination of the lower extremities, which clearly indicates that there was not a continuity of right or left knee problems from service. As such, service connection based on the provisions of 38 C.F.R. § 3.303(b) is not warranted. In summary, the Board concludes that the preponderance of the evidence is against the claims for service connection, and the benefit of the doubt rule enunciated in 38 U.S.C. § 5107(b) is not for application. There is not an approximate balance of evidence. See 38 U.S.C. § 5107(b); see generally Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 4. Entitlement to service connection for diabetes mellitus, type II 5. Entitlement to service connection for peripheral neuropathy, left foot 6. Entitlement to service connection for peripheral neuropathy, right foot The Veteran contends that his diabetes mellitus is the result of in-service herbicide exposure during his service at Korat Royal Thai Air Force Base (RTAFB) and that his peripheral neuropathy of the feet was caused or aggravated by the diabetes mellitus, type II. The Veteran’s service treatment records include no complaints of, treatment for, or diagnosis of diabetes mellitus or lower extremity neuropathy. In a September 1974 Report of Medical History prior to separation from service, the Veteran denied a history of foot trouble or neuritis. A September 1974 Report of Medical Examination included a urinalysis that was negative for albumin or sugar and a normal examination of the lower extremities. The Veteran has not contended that he experienced symptoms related to the diabetes mellitus or lower extremity neuropathy during service or for many years after service. In January 2004, the Veteran reported pain in the bilateral legs, but mostly in the calves, since a motor vehicle accident 9 weeks previously. The impression was pain in the calves of questionable etiology. A September 2007 VA treatment record indicated that the Veteran had a strong family history of diabetes. In July 2008, the Veteran was seen for left leg pain the previous year that felt like “pins & needles” from above the knee to the ankle. He had no symptoms in the right leg, but there were occasional symptoms in both feet. The assessment was peripheral neuropathy versus restless leg syndrome. Thereafter, the Veteran has had ongoing assessments of neurogenic pain. From November 2015, the Veteran has been treated for diabetic neuropathy. As noted, the Veteran contends that his diabetes mellitus was the result of exposure to herbicides during his service in Thailand. A September 2013 memorandum noted the Veteran’s service as an Aircraft Systems Fuel mechanic, but indicated that while aircraft were stored on the flight line at Korat Royal Thai Air Force Base, occupational maintenance of aircraft (including fueling) would not require daily exposure to the perimeter of the flight line or base. As such, exposure to herbicides could not be conceded at that time. The Board agrees with the RO’s assessment. There is no lay contentions or other evidence to suggest regular service along the base perimeter at Korat RTAFB. The Veteran’s service on the flight line does not conclusively demonstrate exposure to herbicides and the Veteran has not otherwise suggested any source of herbicide exposure. He did not indicate that he had actual contact with herbicide such as contact during spraying operations, entry into defoliated areas where skin contact was made, or any other direct physical contact with herbicide agents or residue. Given the foregoing, exposure to herbicide is not presumed and service connection is not warranted on this presumptive basis for the diabetes mellitus or the lower extremity neuropathy. The Board has considered whether the claims could be granted on some basis other than the claimed exposure to herbicides, but concludes that the claimed disabilities had their onset after service and are not otherwise related to service. The sole evidence in support of the Veteran’s claims are his lay statements. As to the Veteran’s general contentions that his disabilities were incurred in service and/or are the result of exposure to herbicides, he is competent to report symptoms related to his claimed disabilities; however, there is not a continuity of symptoms from service and the Veteran is not otherwise competent to link his claimed disabilities to his active service based on his lack of demonstrated medical expertise and the complexity of attributing these disabilities to service (including claimed exposure to herbicides). See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that 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). The Board is aware of the provisions of 38 C.F.R. § 3.303(b), relating to chronicity and continuity of symptomatology in establishing service connection and that such provisions apply to those chronic conditions, such as diabetes mellitus, neuritis, and other organic diseases of the nervous system, specifically listed in 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013). However, diabetes mellitus and/or lower extremity neuropathy was not noted during service or within one year of separation from service. Moreover, there is not a clear contention of a continuity of symptoms from service that could serve as a basis for granting the claims pursuant to the above provisions. As such, the Board finds that there is no credible contention of a continuity of associated symptoms or problems from service and the provisions of 38 C.F.R. § 3.303(b) are not for application. In summary, the Veteran is not competent to attribute his claimed disabilities to his active service, to include exposure to herbicides. There is no evidence of a chronic disability during service or for many years after service. There is no medical evidence linking any of the claimed disabilities to service. In light of the evidence, the Board concludes that the preponderance of the credible evidence is against the service connection claims. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt rule does not apply, and the claims must be denied. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 7. Entitlement to an increased rating greater than 30 percent for a bilateral hearing loss disability Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C. § 1155 (2012). Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2018). The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2018). VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2018). VA must consider whether the Veteran is entitled to “staged” ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. If there is a question as to which evaluation to apply to the Veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2018). The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Veteran alleges that the RO erroneously failed to assign him a higher rating for his bilateral hearing loss. The evaluation assigned for a service-connected disability is established by comparing the manifestations shown with the criteria in the VA’s Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Evaluations for defective hearing are based upon organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests, along with the average hearing threshold level as measured by pure tone audiometric tests in the frequencies of 1000, 2000, 3000 and 4000 cycles per second. 38 C.F.R. § 4.85. To evaluate the degree of disability for service-connected bilateral hearing loss, the rating schedule establishes eleven (11) auditory acuity levels, designated from level I for essentially normal acuity, through level XI for profound deafness. Id. Where there is an exceptional pattern of hearing impairment, a rating based on pure tone thresholds alone may be assigned. 38 C.F.R. § 4.86 (a) & (b). Ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2018). VA must consider whether the Veteran is entitled to “staged” ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. Here, the disability has not significantly changed and a uniform evaluation is warranted. In September 2010, the Veteran brought a claim for increased rating for his service-connected hearing loss disability that was not a notice of disagreement with the prior denial of an increased rating in an August 2010 rating decision, as there was no discussion of the prior rating decision or disagreement with any of the analysis therein. The Veteran was scheduled for a VA contract examination in January 2011, but failed to appear. VA treatment involving the Veteran’s hearing aids were ongoing during the appellate time period. In November 2014 and November 2015, the Veteran denied any change in his hearing acuity. The Veteran underwent a VA examination in April 2016. The Veteran denied significant communication difficulties, but noted trouble in the presence of background noise and when a speaker was not directly in front of him. The examiner indicated that the Veteran’s hearing acuity was essentially adequate for daily communication when in a quiet one-on-one setting; however, the Veteran could struggle with speech understanding when listening in a less than ideal setting (background noise, speaker at a distance, etc.). During such time, the Veteran would benefit from a raised speaking voice, increased visual cues, and a slightly slower rate of speech. The results of the audiological test are as follows, with pure tone thresholds recorded in decibels: HERTZ 1000 2000 3000 4000 RIGHT 25 30 35 40 LEFT 25 35 45 45 Speech audiometry revealed speech recognition ability on the Maryland CNC word list of 98 percent for the right ear and 96 percent for the left ear. The average of the pure tones between 1000-4000 Hz was 33 for the right ear and 38 for the left. Using Table VI in 38 C.F.R. § 4.85, the Veteran received a numeric designation of I for the right ear and I for the left ear. Such a degree of hearing loss warrants only a noncompensable evaluation under Table VII. The Board notes that it also considered the alternative rating scheme for exceptional patterns of hearing impairment and found it inapplicable here. See 38 C.F.R. § 4.86 (a) & (b). The Board has considered the lay statements provided by the Veteran. As was indicated above, rating a hearing loss disability on a schedular basis involves the mechanical application of rating criteria to the results of specified audiometric studies. The Veteran has not contended that his hearing acuity has worsened since the last examination and, therefore, there is nothing to suggest that an additional VA examination would be beneficial. Considering the results of the VA examinations, entitlement to a rating in excess of 30 percent is denied for any period on appeal. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and a nervous condition, is remanded. As noted above, a December 2016 DBQ by a consulting psychologist concluded that the diagnosed major depressive disorder began in service and continued to the present, as well as having been aggravated by the Veteran’s service-connected tinnitus and hearing loss disabilities. The consulting psychologist’s address is in a state distant from that of the Veteran so that any interview was likely by electronic means vice personal examination. That said, the examiner failed to attribute the disability to any specific in-service incidents (while noting in discussion of the Veteran’s treatment records his reports of handling deceased body/body parts) and failed to provide any rationale for the conclusion that the Veteran’s tinnitus and hearing loss disabilities aggravated his depression. The DBQ cited to studies suggesting that hearing problems could affect mental health problems, but there was no indication in the DBQ that the Veteran specifically had problems related to his tinnitus or hearing loss disabilities. Indeed, the DBQ specifically referenced the Veteran’s report during an April 2016 VA audio examination where he denied significant communication difficulties due to the hearing problems. Moreover, the psychologist citations to the record were incomplete and she made no mention of traumatic head injuries, seizures, or substance abuse after service. As no VA examination has been conducted and in light of the inadequacies in the foregoing opinion, the Board concludes that a remand for a VA examination is required. 2. Entitlement to service connection for headaches The Veteran’s service treatment records include no complaints of or treatment for headaches. A Report of Medical History in September 1974 prior to separation from service included the Veteran’s denial of a history of frequent or severe headaches. An October 2005 VA mental health treatment record included the Veteran’s contention that he had chronic headaches from exposure to jet fuel. In May 2010, the Veteran reported a history of headaches. A September 2017 Headaches (including Migraine Headaches) Disability Benefits Questionnaire (DBQ) included the Veteran’s reports of chronic headache pain beginning during service. The report was prepared by a consulting physician whose office is shown as in a state distant from the Veteran’s residence. Any interview was likely by electronic means and not personal examination. The physician noted the Veteran’s reports of headache pain and symptoms had increased in severity and frequency over the years to the point that he would experience prostrating attacks anywhere from 8 to 16 times per month. Following examination, the examiner concluded that it was as likely as not that the Veteran’s chronic headache pain began during his time in service and was precipitated and aggravated by his service-connected tinnitus, as well as symptoms of major depressive disorder. The rationale noted that, “It is well known that damage to the auditory system resulting in tinnitus can also cause headaches. Medical research has shown that in patients with tinnitus, frequency of headache is strongly correlated with the severity of tinnitus symptoms and tinnitus has been associated with multiple types of headache disorders. Furthermore, research shows that anxiety and depression facilitate the onset of headache and patients with chronic headache pain present with high levels of anxiety and depressive symptomatology. Psychological stress can be a predisposing factor that contributes to headache disorder onset, exacerbate individual headache episodes and accelerate the progression of a headache disorder into a chronic condition.” The Veteran reported that his ringing in the ears was a constant source of headache pain. The Veteran had been consistent in his reports of tinnitus and the onset of symptoms. The Veteran’s current reports regarding the onset of his headache pain was consistent with his report from 12 years previously. Although the examiner did not agree with the Veteran’s reports that his headaches were caused by exposure to jet fuel, the examiner found the Veteran’s overall reports of symptoms to be credible. Based on the medical evidence, medical research, interview with the Veteran, and decades of medical experience, the examiner concluded that it was as likely as not that the Veteran’s chronic headache pain began during his time in service and was caused and aggravated by his service-connected tinnitus, as well as his major depressive symptoms. The Board finds the above medical opinion inadequate, as it presumed ongoing headaches from service based on the Veteran’s October 2005 attribution of his headaches to in-service exposure to jet fuel. Moreover, the physician’s citations to the record were incomplete and he made no mention of traumatic head injuries, seizures, or substance abuse after service. That said, the October 2005 statement did not report ongoing headaches from service and, indeed, the September 1974 Report of Medical History prior to separation from service included the Veteran’s explicit denial of a history of frequent or severe headaches. As such, the Board concludes that a remand is necessary to afford the Veteran a VA examination, which he has yet to receive with respect to his headache claim. The matter is REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder. The examiner must opine whether it is at least as likely as not (a) related to an in-service injury, event, or disease, (b) was proximately due to service-connected disability, or (c) was aggravated beyond its natural progression by service-connected disability, specifically to include his service-connected bilateral hearing loss disability and tinnitus. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any headache disorder. The examiner must opine whether it is at least as likely as not (a) related to an in-service injury, event, or disease, (b) was proximately due to service-connected disability, or (c) was aggravated beyond its natural progression by service-connected disability, specifically to include his service-connected bilateral hearing loss disability and tinnitus. (Continued on the next page)   3. After the above is complete, readjudicate the Veteran’s claims. If a complete grant of the benefits requested is not granted, issue a supplemental statement of the case (SSOC) to the Veteran and his representative. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel