Citation Nr: 18146255 Decision Date: 10/31/18 Archive Date: 10/30/18 DOCKET NO. 12-36 156 DATE: October 31, 2018 ORDER The application to reopen the claim for service connection for a psychiatric disorder to include posttraumatic stress disorder (PTSD) and anxiety disorder not otherwise specified (NOS) is granted. Entitlement to service connection for a psychiatric disorder to include PTSD and anxiety disorder NOS is denied. Entitlement to service connection for thoracolumbar spine disability (low back disability) is granted. Entitlement to service connection for bilateral knee osteoarthritis (bilateral knee disability) is granted. Entitlement to service connection for bilateral hearing loss is granted. Entitlement to service connection for tinnitus is granted. REMANDED Entitlement to service connection for bilateral carpal tunnel syndrome (CTS) is remanded. FINDINGS OF FACT 1. In an April 2004 decision, the Agency of Original Jurisdiction (AOJ) denied service connection for PTSD; the Veteran did not submit additional evidence or timely initiate an appeal of that decision within one year of notification. 2. Evidence added to the record since the April 2004 decision denying service connection for PTSD, relates to an unestablished fact necessary to substantiate the claims and raises a reasonable possibility of substantiating the claims. 3. The Veteran does not have a current diagnosis for PTSD and his anxiety disorder NOS did not have its onset in service, and was not caused by an in-service event, injury or disease. 4. The evidence is at least evenly balanced as to whether the Veteran’s low back disability is related to an in-service injury. 5. The evidence is at least evenly balanced as to whether the Veteran’s bilateral knee disability is related to an in-service injury. 6. The evidence is at least evenly balanced as to whether the Veteran’s bilateral hearing loss is related to his in-service exposure to acoustic trauma. 7. The evidence is at least evenly balanced as to whether the Veteran’s tinnitus is related to his in-service exposure to acoustic trauma. CONCLUSIONS OF LAW 1. The April 2004 AOJ decision that denied service connection for PTSD is final. 38 U.S.C. § 7105(c); 38 C.F.R. §20.1103. 2. The criteria for reopening a claim of entitlement to service connection for PTSD have been met. 38 U.S.C. § 5108; 38 C.F.R. §3.156 (a). 3. The criteria for service connection for a psychiatric disorder, to include PTSD and anxiety disorder NOS have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(f). 4. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for low back disability are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 5. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for bilateral knee disability are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 6. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for bilateral hearing loss have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1969 to May 1971. This case comes before the Board of Veterans’ Appeals (Board) on appeal of an March 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii which among other things, denied reopening service connection claims for bilateral hearing loss, carpal tunnel syndrome (CTS), tinnitus, left knee condition, right knee condition, back condition, and PTSD. In November 2010, the Veteran filed his notice of disagreement, was issued a statement of the case in November 2012, and in December 2012 perfected his appeal to the Board. In March 2015, the Board reopened the Veteran’s claims for lumbar spine disability, right knee disability, left knee disability, bilateral hearing loss, tinnitus, and CTS, and remanded the Veteran’s petition to reopen the claim for a psychiatric disorder. The RO subsequently denied the Veteran’s service connection claims for PTSD, lumbar spine disability, right knee disability, left knee disability, bilateral hearing loss, tinnitus, and CTS and issued a supplemental statement of the case detailing its decision in February 2016. New and Material The Board notes to the extent that the AOJ appears to have adjudicated the claims involving the Veteran’s psychiatric disorder to include PTSD on the merits, regardless of the AOJ’s actions, the Board must still determine whether new and material evidence has been received. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (reopening after a prior unappealed AOJ denial); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). In April 2004, the AOJ denied service connection for PTSD finding no medical evidence showing existence of the condition, and no confirmed in-service stressor. The Veteran neither appealed this decision, nor submitted new and material evidence within the one-year appeal period. The decision is therefore final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. A previously denied claim may be reopened by submission of new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New and material evidence cannot be cumulative or 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. When determining whether submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). At the time of the April 2004 rating decision, evidence relevant to the claims included: service treatment records, and the Veteran’s personnel file. Evidence received since that prior final denial includes Veteran statements dated June 1, 2009 and August 13, 2009, a statement from the Veteran’s wife, and post-service VA treatment records from March 29, 2006 through January 12, 2010. This new evidence was not previously submitted, relates to unestablished facts necessary to substantiate this claim, is neither cumulative nor redundant, and raises a reasonable possibility of substantiating the service connection claims. See Shade, supra. Specifically, the new evidence provides a diagnosis for anxiety and PTSD symptomatology. Thus, the evidence is new and material and the criteria for reopening the claim for service connection for a psychiatric disorder to include PTSD have been met. Furthermore, as the AOJ considered the claim for a psychiatric disorder to include PTSD to be reopened in the February 2016 supplemental statement of the case and addressed the claim on the merits, there is no prejudice to the Veteran in the Board also reaching the merits of the claim, and the Board may proceed to adjudicate all claims on the merits. See Hickson v. Shinseki, 23 Vet. App. 394, 399 (2010). Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from a disease or injury incurred in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service incurrence of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including osteoarthritis and organic diseases of the nervous system such as CTS, bilateral hearing loss and tinnitus, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307) to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. For the showing of chronic disease, there are required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. 38 C.F.R. § 3.303 (b). Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. Id. There are particular requirements for establishing service connection for PTSD in 38 C.F.R. § 3.304 (f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD requires: (1) a medical diagnosis of PTSD utilizing the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM 5) criteria, in accordance with 38 C.F.R. § 4.125 (a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. See 38 C.F.R. § 3.304 (f). The Board notes that the DSM-IV has been recently updated with a Fifth Edition (DSM-V). Effective August 4, 2014, VA issued an interim rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to refer to certain mental disorders in accordance with DSM-V. The provisions of the interim final rule only apply, however, to all applications received at the AOJ on or after August 4, 2014, but not to claims certified to or pending before the Board, the Court, or the United States Court of Appeals for the Federal Circuit (Federal Circuit). 79 Fed. Reg. 45,093, 45,094-096 (Aug. 4, 2014). The psychiatric claim was pending before the Board prior to that date. 1. Entitlement to service connection for a psychiatric disorder to include PTSD and anxiety disorder NOS The Veteran contends that he suffers from a psychiatric disorder due to having to transport dead bodies from shore to the USS Constellation for further transport to Da Nang Air Base. He stated he is unable to get over this particular mission which included exposure to incoming fire and explosions nearby. While the Veteran’s claim was initially characterized as entitlement to service connection for PTSD, the United States Court of Appeals for Veterans Claims (Court) addressed the scope of claims generally in regard to what is claimed versus what should be addressed by VA. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In Clemons the Court explained that in determining the scope of a claim, the Board must consider the Veteran’s description of the claim, symptoms described, and the information submitted or developed in support of the claim. Id. at 5. In light of the Court’s decision in Clemons, the Board has recharacterized the claim for PTSD to entitlement to service connection for a psychiatric disorder as stated on the title page of this decision and his appeal is perfected to the Board as to all psychiatric disorders. The Veteran’s May 1971 medical examination report upon discharge does not note any treatment or diagnosis for any psychiatric disorder, and an undated medical history report notes the Veteran has no significant illnesses including depression or excessive worry, or frequent or terrifying nightmares. A January 2008 post-service private treatment note indicates the Veteran was diagnosed with chronic anxiety which required medication. An October 2012 disability benefits questionnaire (DBQ) noted that the Veteran did not have a diagnosis for PTSD which conformed to the DSM-IV criteria, but did diagnose the Veteran with anxiety not otherwise specified (NOS). The Veteran denied psychiatric concerns and no family history of psychiatric concerns prior to military service. The examiner found that the Veteran’s reported stressors did not meet the criterion to support a diagnosis of PTSD. The Veteran stated that he began to experience anxiety in the 1990s. The examiner opined that as the anxiety symptoms manifested many years after service, there is no proximal link to military service, thus anxiety is less likely than not caused by or a result of military service. A September 2015 DBQ noted the Veteran did not have a diagnosis for PTSD that conformed to the DSM-5 criteria, noting only a diagnosis for unspecified anxiety disorder. The examiner noted insufficient exposure to traumatic stressors for a diagnosis for PTSD under both the DSM-IV and DSM-5 criteria. The Veteran does meet DSM 5 criteria for unspecified anxiety disorder for which the Veteran did not seek professional assistance until 1992. The examiner concluded the Veteran’s anxiety symptoms are less likely than not caused by or associated with military service. The examiner stated the Veteran meets to pattern of having immediate symptoms after exposure to Criteria A stressors which resolved to baseline or near baseline function over a relatively short period of time. The examiner indicated that the Veteran appeared to have adapted well and recovered with minimal impairment in functioning and has not developed full or chronic PTSD. Based upon a preponderance of the evidence, the Veteran is not entitled to service connection for PTSD. The Board notes that for the Veteran’s claim of service connection for PTSD to be granted, the record would have to contain a diagnosis of PTSD. As discussed above, the Veteran’s private treatment records are predominantly negative for signs, notations, or a diagnosis of PTSD. The October 2012 and September 2015 examiners both determined that the Veteran did not meet the criteria for PTSD, and provided an explanation for their conclusions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). A PTSD diagnosis is not otherwise shown by the evidence of record. The weight of the evidence is thus against a diagnosis of PTSD. As such a diagnosis is an essential element of the claim, entitlement to PTSD is not warranted. The Board acknowledges the Veteran’s contention that the September 2015 examiner did not address the Veteran’s statements regarding various stressors. There is no reasons or bases requirement imposed on VA examiners. Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012). Moreover, regardless of whether an in-service stressor occurred, without a diagnosis of PTSD as required by regulation, service connection for PTSD is not warranted. As for the Veteran’s claim for service connection for anxiety disorder NOS as raised by the record, both the October 2012 and September 2015 examiners diagnosed the Veteran with anxiety disorder NOS, thus the Veteran meets the current disability requirement for service connection. However, the Veteran’s service treatment records do not indicate treatment or complaints of anxiety in service, and his May 1971 medical examination report upon discharge is normal as to psychiatric issues. The Veteran does not contend that his anxiety disorder began in service, or that it was caused by an in-service injury or event, and indicated that he first sought treatment for anxiety in the 1990s, many years after service. In addition, the VA examiners opined that the Veteran’s anxiety disorder was not likely caused or associated with his military service, noting that he did not seek treatment until many years after service and that the symptoms did not manifest until many years after service. Reading the opinions as a whole and in the context of the evidence of record, the examiners were indicating that the fact that the Veteran did not seek treatment for many years after service and that the symptoms did not appear to have manifested for many years after service made it less likely that the Veteran’s current anxiety disorder was related to his military service. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner “did not explicitly lay out the examiner’s journey from the facts to a conclusion,” did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). See also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (the Board may consider in its assessment of a service connection claim the passage of a lengthy period of time wherein the veteran has not complained of the malady at issue). For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for a psychiatric disorder to include PTSD and anxiety disorder NOS. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102. 2. Entitlement to service connection for thoracolumbar spine disability The Veteran contends his thoracolumbar spine disability was caused by an in-service injury. The Veteran’s service treatment records do not note any treatment or complaints for a thoracolumbar spine disability and his May 1971 medical examination report upon separation from service is normal. An August 2008 post-service private treatment record noted a diagnosis for mild cervical and thoracic spondylosis. October 2008 post-service private treatment records note complaints of severe cervical, thoracic and lumbar pain for 8 months. October 2008 VA treatment notes indicate the Veteran initially was treated for low back pain which started in the military and progressed to additional neck and mid-back pain. November 2008 private physical therapy notes indicate the Veteran reported a 5-year history of back pain starting infrequently and progressing to occurring almost every day when at the computer. A November 2015 DBQ noted diagnoses for degenerative arthritis of the spine, spinal stenosis, lumbar spondylosis, L5-S1 disc bulge, and lumbar foraminal stenosis. The Veteran stated he experienced sharp back pain while doing overhaul of a ship in Pearl Harbor carrying debris to the deck, but he did not undergo an evaluation. Since then he complains of pain which rates a 9 out of 10 that varies in frequency and lasts up to 2 hours in duration. The examiner opined that the Veteran’s lumbar spondylosis, L5-S1 disc bulge and lumbar foraminal stenosis were less likely as not incurred or caused by claimed in-service injury, event or illness. The examiner noted the first evaluation of back pain occurred in 2006 which noted chronic lower back pain probably due to lumbar strain/ obesity. The examiner indicated the changes are consistent with normal wear and tear. The evidence noted in the examination report and treatment notes establish that the Veteran has a current low back disability, and the Veteran’s statements establish that he suffered an in-service injury for which he never sought treatment. The Veteran is competent to provide testimony or statements relating to symptoms or facts of events that he has observed and are within the realm of his personal knowledge. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The dispositive issue is whether there is a nexus between the two. As indicated above and as contended by the Veteran’s representative, the November 2015 examiner did not address the Veteran’s contentions of recurrent back pain, occurring regularly through the years since service. Rather, the examination reports focused on a lack of evidence of a back disability at the time of the Veteran’s discharge and the fact that the Veteran did not seek treatment for a back disability until 2006. However, the lack of treatment is not dispositive if there is competent, credible evidence of symptoms during the relevant time period, as is the case here. Thus, the opinion is inadequate. See Buchanan v. Nicholson, 451 F.3d 1331, 1336, n. 1 (Fed. Cir. 2006) (noting that a VA’s examiner’s opinion, which relied on the absence of contemporaneous medical evidence, “failed to consider whether the lay statements presented sufficient evidence of the etiology of [the veteran’s] disability such that his claim for service connection could be proven without contemporaneous medical evidence”). As the medical opinion is inadequate, it is afforded no probative weight. In contrast, there is competent and credible lay evidence of back pain and other symptoms continuing since service. Although there is some discrepancy as to when the Veteran’s severe back pain commenced, he has consistently maintained that his initial back pain began in service and has progressed since that time. In these circumstances, a remand for yet another medical opinion could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304(c) (“The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination”); Mariano v. Principi, 17 Vet. App. 305, 312 (2003). The above analysis reflects that the evidence is at least evenly balanced as to whether the Veteran’s current low back disability is related to his in-service low back injury. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for a low back disability is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006) (“[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself”). 3. Entitlement to service connection for bilateral knee disability The Veteran has asserted that his bilateral knee disability was caused by an in-service injury. The Veteran’s service treatment records do not note any complaints or treatment for an in-service knee disability, and his May 1971 medical examination report was normal indicating no knee disabilities upon discharge. August 2003 post-service private treatment notes indicate the Veteran was diagnosed with bilateral knee pain. March 2006 treatment notes indicate the Veteran was treated for bilateral knee pain which he reported started 1 year after service. A November 2015 DBQ noted a diagnosis for right knee joint osteoarthritis from 2003. The Veteran stated that he felt his knee pop while dragging a GI can during service and that he self-treated with an ice pack, but did not undergo any evaluation. Since then the Veteran complains of bilateral knee pain rated 9 out of 10 which varies in frequency and lasts up to 3 days in duration and which is precipitated by prolonged sitting, walking, bending or squatting. The Veteran treats the pain with medication and uses braces and a cane. The Veteran reported flare-ups which limit his physical activities. The examination report noted diagnoses for mild degenerative joint disease of the right knee, and mild osteoarthritis of the left femur and tibia. The examiner noted that the Veteran’s medical records contain no complaints or evaluations for any knee issues during service, and that the first evaluation of a right knee complaint was in 2003 for 2 days from getting off a ladder and twisting his knee. The examiner stated the Veteran’s subsequent evaluations of degenerative joint disease of the knee is consistent with normal wear and tear, therefore, his right knee osteoarthritis is less likely as not incurred or caused by the claimed inservice injury, event or illness. The evidence noted in the examination report establishes that the Veteran has a current bilateral knee disability, and the Veteran’s statements establish that he suffered an in-service injury for which he never sought treatment. The Veteran is competent to provide testimony or statements relating to symptoms or facts of events that he has observed and are within the realm of his personal knowledge. Layno, 6 Vet. App. 465, 469-70. The dispositive issue is whether there is a nexus between the two. The November 2015 medical opinion reflects a lack of relationship between the current bilateral knee disability and military service. However, it appears that the examiner did not take into consideration the Veteran’s statements, specifically his account of his injury in service. The examiner based his opinion solely on the fact that service treatment records contain no complaints of, or evaluations for knee issues, thus, the opinion is inadequate. Buchanan, 451 F.3d at 1336 (noting that VA’s examiner’s opinion, which relied on the absence of contemporaneous medical evidence, “failed to consider whether the lay statements presented sufficient evidence of the etiology of [the veteran’s] disability such that his claim for service connection could be proven without contemporaneous medical evidence”). There is also lay evidence suggesting a nexus between the current bilateral knee disability and service, specifically lay testimony of some continuity of bilateral knee strain symptomatology. Buchanan, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (“If the Board concludes that the lay evidence presented by a veteran is credible and ultimately competent, the lack of contemporaneous medical evidence should not be an absolute bar to the veteran’s ability to prove his claim of entitlement to disability benefits based on that competent lay evidence”). March 2006 treatment notes indicate the Veteran’s bilateral knee problems began a year after service and have worsened since that time, and he stated during his November 2015 examination that he has suffered from bilateral knee pain since hearing a pop during service. While there is some discrepancy as to whether the Veteran’s bilateral knee pain began in-service or a year after service, the Board finds it reasonable to conclude that the Veteran’s report of hearing a “pop” during service constituted an in-service injury which subsequently resulted in the Veteran’s onset of pain. Additionally, the Board will resolve any discrepancy in the light most favorable to the Veteran considering the pro-claimant nature of Veterans law and with the understanding that it would be unreasonable to expect the Veteran to recollect the exact moment his bilateral knee pain commenced several years after the fact. The Veteran’s statements regarding bilateral knee pain since service are competent and there is no indication that the Veteran’s statements lack credibility. See Buchanan, 451 F.3d at 1337 (“[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence”). Given the evidence in favor of service connection before the Board, a remand for another examination or opinion could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304 (c) (“The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination”); Mariano v. Principi, 17 Vet. App. 305, 312 (2003). Thus, there is an inadequate negative medical nexus opinion and competent, credible lay evidence of current bilateral knee strain that had its onset in service. The evidence is therefore at least evenly balanced as to whether the Veteran’s bilateral knee disability is related to his in-service injury. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for bilateral knee disability is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for bilateral hearing loss and tinnitus The Veteran contends that he was exposed to acoustic noise while working in the engine room in service which caused his current bilateral hearing loss. The Veteran’s DD-214 indicates the Veteran’s military occupational specialty was in mechanics, thus his reports about military noise exposure is supported by service department records. A hearing loss disability is defined for VA compensation purposes with regard to audiological testing involving pure-tone frequency thresholds and speech discrimination criteria. 38 C.F.R. § 3.385. For purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz (Hz) is 40 decibels (dB) or greater; or when the auditory thresholds for at least three of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hz are 26 dB or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. Id. The Veteran’s May 1971 medical examination report upon discharge notes normal hearing with pure tone thresholds, in decibels as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 5 5 0 LEFT -5 5 5 0 0 March 2009 post-service treatment notes indicate the Veteran complained of ringing in the ears which started recently. On the authorized audiological evaluation in October 2012, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 20 30 35 30 LEFT 25 20 25 40 35 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 94 percent in the left ear. The audiologist diagnosed bilateral sensorineural hearing loss, noting that the Veteran stated people must repeat themselves when speaking to him and sometimes voices are muffled. The audiologist opined that the Veteran’s hearing loss was not at least as likely as not caused by or a result of an event in military service noting that his audiogram upon separation from service was normal in both ears. The audiologist noted that the Veteran worked at a ship repair facility after service where he was exposed to occupational noise exposure, but consistently used ear protection. The Veteran’s service duties included exposure to hazardous noises, but the audiologist stated that there is no delay effect between noise exposure and hearing loss and referenced the leading authority on noise exposure and hearing loss to support his rationale. The audiologist stated the Veteran’s noise exposure is most likely the result of civilian occupational noise exposure. The audiologist diagnosed recurrent tinnitus and noted that the Veteran stated it made it hard to sleep. The audiologist opined that his tinnitus was less likely than not the result of military noise exposure as there were no complaints, diagnoses, or treatment for tinnitus while in service. Additionally, the Veteran had normal hearing upon separation from service. The audiologist concluded that the Veteran’s tinnitus was most likely the result of his post-service occupational noise exposure. On the authorized audiological evaluation in October 2015, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 25 35 35 LEFT 20 20 30 45 45 Speech audiometry revealed speech recognition ability of 98 percent in the right ear and of 94 percent in the left ear. The Veteran stated hearing loss was a problem in all situations. He also stated that he suffers recurrent tinnitus which makes it difficult to sleep, but is not able to say when it started. The audiologist opined that the Veteran’s hearing loss was less likely than not the result of military noise exposure stating that the Veteran’s audiogram upon release from military service was normal. The examiner also stated that the Veteran’s tinnitus was less likely than not the result of military noise exposure as it is usually a symptom associated with hearing loss and the Veteran had normal hearing bilaterally upon discharge from military service. Tinnitus is capable of lay observation, and the Veteran has offered competent, credible evidence that he experiences tinnitus, and the above audiological examinations and statements confirm an in-service injury or event and a current bilateral hearing loss disability. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) (“ringing in the ears is capable of lay observation”). The remaining issue is whether there is a nexus to military noise exposure for the current bilateral hearing loss and tinnitus. In this case, the Board does not find that the probative value of either medical opinion outweighs the Veteran’s competent and credible reports regarding his bilateral hearing loss history. The October 2012 examiner referenced the Veteran’s post-service career as a more likely cause for his hearing loss despite use of hearing protection, and both the October 2012 and October 2015 examiners relied on the fact that the Veteran’s audiological examination upon separation from service was normal. However, these opinions are flawed because normal hearing upon separation is not necessarily fatal to a claim for service connection for hearing loss or tinnitus. Ledford v. Derwinski, 3 Vet. App. 87 (1992). Additionally, while the Veteran stated he is unsure as to the onset of his tinnitus, the passage of time prior to the onset of a disability is not dispositive in determining whether it is related to service. See 38 C.F.R. § 3.303 (d) (service connection is warranted for a disease first diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service). The evidence is, thus, at least evenly balanced as to whether the Veteran’s current bilateral hearing loss disability and tinnitus is related to service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for bilateral hearing loss is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for CTS is remanded. The Veteran asserted that his duties as a machinist in service caused his CTS. The Veteran’s service treatment records do not note any issues regarding bilateral CTS and his May 1971 medical examination report upon discharge is normal. December 2008 private treatment records note bilateral median sensory neuropathy at the wrist and elbow. A November 2015 DBQ noted a diagnosis for bilateral CTS which the Veteran stated began around 1972 or 1973. He stated he was evaluated by a physician and was told he had CTS, but did not undergo any specific treatment. The examiner stated the Veteran’s bilateral CTS is less likely as not incurred in or caused by the claimed in-service injury, event or illness, noting that there are no records of complaints or evaluations of any neurological symptoms suggestive of CTS. The examiner also stated that while the Veteran reported his hands took a beating during service, the examiner stated that performing these types of activities do not typically cause CTS. The Board finds the November 2015 DBQ inadequate, thus it is afforded no probative value as the examiner relied heavily on the fact that there were no in-service complaints or evaluations for neurological symptoms which is impermissible. See Buchanan, 451 F.3d at 1336 In a September 2018 Informal Hearing Presentation, the Veteran’s representative requested a new examination noting that the November 2015 examiner relied on a lack of complaints for CTS symptoms in service and post-service treatment records to formulate his opinion. As the November 2015 examiner’s opinion is inadequate and the Veteran has provided competent lay evidence of CTS symptomatology within a year after discharge from service which the examiner failed to address, the Board will grant this request. The matter is thus REMANDED for the following action: Schedule the Veteran for an examination by an appropriate physician to determine the nature and etiology of the Veteran’s CTS. The examiner must opine: whether it is at least as likely as not related to an in-service injury, event, or disease; began during active service; manifested within the 1-year presumptive period after discharge from service; or was noted during service with continuity of the same symptomatology since service. The physician must take into consideration the Veteran’s contentions of CTS symptoms around 1972 or 1973, shortly after discharge from active duty service. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Maddox, Associate Counsel