Citation Nr: 18147890 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 18-35 960 DATE: November 6, 2018 ISSUES 1. Whether new and material evidence has been received to reopen the claim for service connection for a left cerebrovascular disability, also claimed as stroke, and claimed as due to jet fuel exposure. 2. Whether new and material evidence has been received to reopen the claim for service connection for oropharyngeal cancer, claimed as cancer of the left cheek and mouth, and claimed as due to jet fuel exposure. 3. Whether new and material evidence has been received to reopen the claim for service connection for bilateral hearing loss disability. 4. Whether new and material evidence has been received to reopen the claim for service connection for tinnitus. 5. Whether new and material evidence has been received to reopen the claim for service connection for hypertension. 6. Entitlement to service connection for a kidney disability, claimed as due to jet fuel exposure. 7. Entitlement to service connection for a left cerebrovascular disability, also claimed as residuals of a stroke, and claimed as due to jet fuel exposure. 8. Entitlement to service connection for oropharyngeal cancer, claimed as cancer of the left cheek and mouth, and claimed as due to jet fuel exposure. 9. Entitlement to service connection for bilateral hearing loss disability. 10. Entitlement to service connection for tinnitus. 11. Entitlement to service connection for a lung disability, aneurysm, claimed as due to jet fuel exposure. 12. Entitlement to service connection for a heart disability. 13. Entitlement to service connection for hypertension. ORDER New and material evidence sufficient to reopen the claim of service connection for a left cerebrovascular disability, also claimed as stroke, and claimed as due to jet fuel exposure has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for oropharyngeal cancer, claimed as cancer of the left cheek and mouth, and claimed as due to jet fuel exposure has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for bilateral hearing loss disability has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for tinnitus has been received, and to that extent only, the claim is granted. New and material evidence sufficient to reopen the claim of service connection for hypertension has been received, and to that extent only, the claim is granted. Entitlement to service connection for a kidney disability, claimed as due to jet fuel exposure, is denied. Entitlement to service connection for a left cerebrovascular disability, also claimed as stroke, and claimed as due to jet fuel exposure, is denied. Entitlement to service connection for oropharyngeal cancer is granted. REMANDED Entitlement to service connection for bilateral hearing loss disability is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for a lung disability, aneurysm, claimed as due to jet fuel exposure is remanded. Entitlement to service connection for a heart disability is remanded. Entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. A May 2015 rating decision denied service connection for a left cerebrovascular disability, oropharyngeal cancer, bilateral hearing loss disability, tinnitus, and hypertension. The Veteran was notified of his rights, but did not express timely disagreement or submit new evidence within one year. That decision became final. 2. The evidence associated with the record since the May 2015 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for a left cerebrovascular disability, also claimed as stroke, and claimed as due to jet fuel exposure. 3. The evidence associated with the record since the May 2015 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for oropharyngeal cancer. 4. The evidence associated with the record since the May 2015 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for bilateral hearing loss disability. 5. The evidence associated with the record since the May 2015 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for tinnitus. 6. The evidence associated with the record since the May 2015 rating decision relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of service connection for hypertension. 7. A kidney disability, claimed as due to jet fuel exposure, was not manifest in service or within one year of separation, and is not otherwise associated with service. 8. A left cerebrovascular disability, also claimed as stroke, and claimed as due to jet fuel exposure, was not manifest in service, and is not otherwise attributable to service. 9. Oropharyngeal cancer, claimed as cancer of the left cheek and mouth, has not been satisfactorily disassociated by competent evidence from the Veteran’s period of service. CONCLUSIONS OF LAW 1. New and material evident sufficient to reopen the claim of service connection for a left cerebrovascular disability, also claimed as stroke, and claimed as due to jet fuel exposure has been received. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2017). 2. New and material evident sufficient to reopen the claim of service connection for oropharyngeal cancer has been received. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2017). 3. New and material evident sufficient to reopen the claim of service connection for bilateral hearing loss disability has been received. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2017). 4. New and material evident sufficient to reopen the claim of service connection for tinnitus has been received. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2017). 5. New and material evident sufficient to reopen the claim of service connection for hypertension has been received. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (a) (2017). 6. A kidney disability, claimed as due to jet fuel exposure was not incurred in or aggravated by service, and nephritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 7. A left cerebrovascular disability, also claimed as stroke, and claimed as due to jet fuel exposure was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 8. Oropharyngeal cancer is presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1966 to June 1970. This matter is before the Board of Veterans Appeals (Board) on appeal from a May 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, Philippines, and a subsequent March 2018 rating decision. The July 2018 VA Form 8 certified the appeal to the Board by way of the RO in Cleveland, Ohio. Jurisdiction is currently held by the RO in Winston-Salem, North Carolina. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Finality of Service Connection Claims 1. Whether new and material evidence has been received to reopen the claim for service connection for a left cerebrovascular disability, also claimed as stroke, and claimed as due to jet fuel exposure. 2. Whether new and material evidence has been received to reopen the claim for service connection for oropharyngeal cancer. 3. Whether new and material evidence has been received to reopen the claim for service connection for bilateral hearing loss disability. 4. Whether new and material evidence has been received to reopen the claim for service connection for tinnitus. 5. Whether new and material evidence has been received to reopen the claim for service connection for hypertension. As a threshold issue, service connection was denied in an May 2015 rating decision for a left cerebrovascular disability, oropharyngeal cancer, bilateral hearing loss disability, tinnitus, and hypertension. The Veteran was informed of the decision and of the right to appeal. He did not appeal or submit new and material evidence within one year of notification. That decision is final. At the time of the decision, the record included the claims, VA treatment records, VA examinations, and the service records. There was no accepted evidence of disability due to disease or injury in service or post service for some disabilities, and there was also no evidence of a nexus to service. However, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. 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. 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. 38 C.F.R. § 3.156 (a). The United States Court of Appeals for Veterans Claims (Court) interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which “does not require new and material evidence as to each previously unproven element of a claim.” See id. For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). However, VA is not bound to consider credible the patently incredible. Duran v. Brown, 7 Vet. App. 216 (1994). Next, in November 2017, VA received the application to reopen the claim of service connection for a left cerebrovascular disability, oropharyngeal cancer, bilateral hearing loss disability, tinnitus, and hypertension. Upon the receipt of new medical and lay evidence, the issue was revisited in a March 2018 rating decision. The additional evidence presented includes treatment reports from hospitals and medical centers. Of particular note, the Veteran submitted competent lay evidence in the June 2018 VA Form 9. It includes lay reports of ringing in the ears, which the Veteran asserted was not previously considered, as well as a lay history of jet fuel exposure in service, and a report of no significant noise exposure after discharge. The evidence suggests that the Veteran has various relevant disabilities, with a possible nexus to service. As a lack of evidence supporting the presence of disability and a nexus were the bases for the previous denials of the claims, this evidence is new and material under 38 C.F.R. § 3.156. The specific evidence is discussed further in each respective section below, and incorporated by reference. In light of this new and material evidence, the Veteran’s claims of service connection for a left cerebrovascular disability, oropharyngeal cancer, bilateral hearing loss disability, tinnitus, and hypertension are reopened. Service Connection To establish service connection a Veteran must generally 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.” Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease 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). 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.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 6. Entitlement to service connection for a kidney disability, claimed as due to jet fuel exposure By way of background, the Veteran’s Service Treatment Records (STRs) include a June 1970 Report of Medical Examination from separation. It disclosed a clinically normal evaluation of the ears - general, ear drums, mouth and throat, lungs and chest, heart, vascular system, abdomen and viscera, G-U system, and endocrine system. In the related June 1970 Report of Medical history, the Veteran endorsed that his overall health was “Good.” He denied hearing loss, high or low blood pressure, dizziness or fainting spells, history of head injury, asthma, shortness of breath, palpitation or pounding of heart, frequent or painful urination, and kidney stones or blood in urine. VA treatment records from November 2011 show testing for and impressions of kidney disease. A VA treatment record from February 27, 2012 from the Jacksonville VA Clinic shows an active problem list of chronic kidney disease, unspecified, with a date of identification of November 1, 2011. The Veteran filed his initial claim for service connection for six disabilities, received by VA in October 2014. VA treatment records from the Fayetteville, North Carolina VA Medical Center (VAMC) include a September 16, 2016 kidney ultrasound. There were diagnostic impressions of, “No evidence of Renal Mass or Hydronephrosis. Echogenic Kidneys Bilaterally which may be due to Medical Renal Disease. Correlate Clinically.” An April 12, 2017 VA Dialysis Nutrition Education Note shows a diagnostic impression of chronic kidney disease. Procedurally, the Veteran filed a supplemental claim for service connection in November 2017, adding two additional disabilities, including “kidney disease due to jet fuel exposure.” He also requested to reopen his claims for five of the previously denied disabilities. Months later, the Veteran was afforded a March 2018 VA nephrology examination. The VA examiner examined the Veteran in person and reviewed the entire claims file. The VA examiner identified chronic renal disease, noting a date of diagnosis of March 1, 2018, the date of the VA examination. The Veteran reported that his kidney disease began after breathing aviation fuel while on active duty 30 years ago. There were no current symptoms reported, though the disease was identified, and he did not require dialysis. Laboratory studies from March 1, 2018 revealed abnormal creatine levels. Next, the March 2018 VA examiner rendered a medical opinion. The VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner reasoned that there is a lack of medical evidence to support a causal relation between jet fuel causing chronic kidney disease. Ultimately, a March 2018 rating decision denied service connection for all eight claims, including confirming and continuing the previous denials. The Veteran filed his Notice of Disagreement (NOD) for the eight disabilities currently on appeal, from both applications, received by VA in May 2018. In June 2018, the Veteran perfected his appeal. He asserts in part, “I continue to disagree with your decision to deny service connection of the issues on appeal. I feel that the benefti (sic) of the doubt should be taken into consideration for the claimed condition of tongue cancer due to the possibility that it could have been caused by fuel exposure while on active duty. I also believe that the other serious health conditions were likely caused by chemical exposure while on activity duty. Since discharge from active duty I have not had exposure to chemicals such as the ones on active duty.” The Veteran’s central theory of entitlement is that he was exposed to jet fuel in service, resulting in subsequent chronic kidney disease. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). More specifically, the Veteran is competent to report exposure to jet fuel. The Veteran is competent to relate what he has been told by a professional. He is competent to report when he began receiving treatment for his kidneys, that has chronic kidney disease, and when this was first identified by physicians. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran’s own lay opinion as to the diagnosis and cause of chronic kidney disease is not probative evidence, although the Veteran’s observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran has medical expertise, the Veteran’s lay opinion beyond a description of his symptoms is of limited probative value. The most probative evidence is the contemporaneous treatment records, including the Service Treatment Records (STRs) and VA treatment records, and the opinion of the March 2018 VA examiner. First, the separation examination is clinically normal for the vascular system, abdomen and viscera, G-U system, and endocrine system. Decades later, in November 2011, the Veteran presented for testing of the kidneys. Thus, the first documentation of the Veteran having a kidney disability was a diagnostic impression from November 2011. Second, the Board also assigns significant probative weight to the detailed opinion of the March 2018 VA examiner. The physician reviewed the entire claims file, and provide detailed reasons and bases. The physician opined, “that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness.” The VA examiner again noted the remote onset of kidney disease 30 years after discharge, as related by the Veteran’s own competent lay history. The physician also utilized his medical knowledge regarding a possible relationship between jet fuel exposure and the subsequent development of kidney disease. Therefore, the Board assigns significant probative weight to the findings of the March 2018 VA examiner. Here, regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. A kidney disability was not manifest in service and is not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity, such as nephritis, pales in probative weight when compared to the objective medical evidence of record. The Veteran’s theory of entitlement is largely based upon conclusory statements regarding a relationship between his alleged jet fuel exposure and kidney disease. We note that a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In short, the most probative evidence is the clinically normal STRs upon discharge, VA treatment records, and the March 2018 VA examination with medical opinion. The weight of the evidence establishes a remote onset of kidney pathology several years after discharge. Consequently, service connection for a kidney disability is not warranted. 7. Entitlement to service connection for a left cerebrovascular disability, also claimed as residuals of a stroke, and claimed as due to jet fuel exposure The Board incorporates its discussion from the sections above by reference. A VA treatment record from July 13, 2010 shows a notation of status post stroke from two years ago in August. A VA treatment record from December 9, 2010 shows, “Had stroke 2 1/2 years ago and since then has had feeling of lighheadiness (sic) when standing no problem when lying down.” The Veteran’s Application for Disability Compensation and Related Compensation Benefits from October 2014 shows a claim for “Stroke, 2008.” A VA treatment record from January 23, 2017 shows, “8.5 years ago- trouble with understanding when a person is speaking too softly or too fast.” A VA treatment record from January 17, 2018 shows, “Pt denies any unusual bleeding or sx of stroke.” Next, the Veteran was afforded a March 2018 VA examination with medical opinion. The VA examiner reviewed the entire claims file, and interviewed the Veteran in person. The VA examiner considered the Veteran’s medical history that his impairment began in 2005 with a stroke and was getting worse over time. Ultimately, the VA examiner opined that, “The claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness.” The VA examiner reasoned that there is a lack of medical evidence to support a causal relationship between jet fuel and a cerebrovascular accident. The Veteran’s central theory of entitlement is that his stroke and the ensuing residual impairment is related to jet fuel exposure in service. The most probative evidence is the contemporaneous treatment records, including the VA treatment records, and the opinion of the March 2018 VA examiner. First, the separation examination is clinically normal for the vascular system and heart. The Veteran has at various times reported the onset of his stroke in 2005 or around 2008. This is consistent with the VA treatment records, which show a stroke in 2008. The Veteran is competent to report that which he has been told by his treating physicians. The Board finds these reports credible. Thus, the first documentation of the Veteran having a stroke with associated residuals was in 2008. Second, the Board also assigns significant probative weight to the detailed opinion of the March 2018 VA examiner. The physician reviewed the entire claims file, and provided supporting reasons and bases. The physician also considered the Veteran’s contentions regarding jet fuel exposure, and rendered a negative nexus opinion. The Board assigns significant probative weight to the findings of the March 2018 VA examiner. Here, regarding direct service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. Residuals of a stroke are not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report lightheadedness, the Veteran’s own lay opinion regarding identifying a potential injury, such as a cerebrovascular incident, pales in probative weight when compared to the objective medical evidence of record. The Veteran’s theory of entitlement is largely based upon a remote onset of a stroke and subsequent residuals in 2008. The Board has considered this competent and credible evidence, including considering what the Veteran was told by treatment providers and the contemporaneous medical records. Lastly, we note that regarding a possible presumption, the chronic disease of ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. See 38 C.F.R. § 3.309 (e), Note 3; 75 Fed. Reg. 53202. As such, this is not applicable to the instant case. In short, the most probative evidence is the clinically normal STRs upon discharge, VA treatment records, and March 2018 VA examination with medical opinion. The most probative evidence establishes a remote onset of residuals of a stroke several years after discharge. Consequently, service connection for a residuals of a stroke is not warranted. In reaching these conclusions, the Board finds that the preponderance of the evidence is against the claims. As such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 8. Entitlement to service connection for oropharyngeal cancer, claimed as cancer of the left cheek and mouth. The Board incorporates its discussion from the sections above by reference. Ongoing VA treatment records from the Durham VA Medical Center (VAMC) show impressions of and treatment for oropharyngeal cancer. A VA Radiation Oncology Note from August 15, 2014 shows a diagnostic impression of, “Malignant neoplasm of base of tongue.” In June 2018, the Veteran perfected his appeal. He specifically averred that his tongue cancer was likely caused by chemical exposures while on active duty, and that he should be entitled to the benefit of the doubt. The Veteran’s central theory of entitlement is that oropharyngeal cancer was caused by jet fuel exposure in service. We have found the Veteran to be competent and credible in reporting his symptoms and medical history, including what he has been told by his physician. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The most probative evidence is the VA treatment records and the opinion of the March 2018 VA examiner. First, VA treatment records show that malignant neoplasms of the base of the tongue were identified by treatment providers. The Veteran received subsequent treatment. Second, the Board also assigns significant probative weight to the nexus opinion of the March 2018 VA examiner. The physician reviewed the entire claims file, and provide detailed reasons and bases. The physician opined, “The claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness.” The Board assigns this significant probative weight. Here, regarding presumptive service connection, we find that the Veteran’s oropharyngeal cancer may be presumed to have been incurred in service. The most probative evidence in the contemporaneous treatment records shows a remote diagnostic impression of oropharyngeal cancer. Nevertheless, there is a positive nexus opinion indicating that this is at least as likely as not attributable to service based upon a review of the claims file and medical expertise. The Board notes the Veteran’s consistent lay contentions regarding jet fuel exposure, as also discussed by the VA examiner. At the very least, the evidence of record is in relative equipoise as to the cause of the Veteran’s oropharyngeal cancer. Therefore, resolving reasonable doubt in the Veteran’s favor, the Board finds that it is at least as likely as not that the Veteran’s oropharyngeal cancer may be presumed to have been incurred in service. The Veteran is therefore entitled to the benefit of the doubt. See 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 3.102 (2017). Accordingly, service connection for oropharyngeal cancer, as a malignant tumor, is warranted. 38 C.F.R. §§ 3.307 (b), 3.309 (a). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND A remand is necessary for additional development. 1. Entitlement to service connection for bilateral hearing loss disability is remanded. 2. Entitlement to service connection for tinnitus is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the Veteran was most recently afforded a February 2018 VA audiometric examination. The VA examiner found in part, “The claimant denies tinnitus bilaterally, but complains of a pressure/fullness in his ears that affects his concentration.” It shows that the Veteran did not report recurrent tinnitus. He also reported impairment due to hearing loss. Of particular note, the Veteran submitted competent lay evidence in the June 2018 VA Form 9 of ringing in his ears, which he reported was not previously considered. He also reported a lay history of jet fuel exposure in service, and no significant noise exposure after discharge. The Veteran asserted, “I tried to explain to the doctor the sensation that I have in my ears than and he took that as me stating I do not have ringing in my ears.” On remand, these lay contentions should be considered and discussed with complete reasons and bases for all opinions given by the VA examiner. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). VA regulations do not preclude service connection for a hearing loss which first met VA’s definition of disability after service. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). In this regard, the opinion cannot be the basis upon which we fully adjudicate the Veteran’s bilateral hearing loss and tinnitus claims. For these reasons, a new, adequate VA audiological examination is necessary. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (noting that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Reexamination will be requested whenever VA determines that there is a need to verify the current severity of a disability. 38 C.F.R. § 3.327 (a). Consequently, a supplemental VA audiometric examination is warranted. 3. Entitlement to service connection for a lung disability, aneurysm, claimed as due to jet fuel exposure is remanded. The Board incorporates its discussion from the sections above by reference. Recently, the Veteran was afforded a March 2018 Welch Allyn CardioPerfect Workstation examination from Carolina Prime Internal Medicine. It showed a diagnostic impression of “moderate lung restrictions with poor effect after.” There was an abnormal spirometry report showing “moderate restriction” for pre forced vital capacity (FVC) and “Very severe restriction” for post FVC. Next, the VA examiner rendered a negative nexus opinion. The only rationale given is, “Rationale is based on veterans claim that he does not have a lung condition and normal examination during todays evaluation.” There is no medical evidence cited or other reasons and bases to support this conclusion. This is also inconsistent with the contemporaneous VA treatment records. The June 2018 Statement of the Case (SOC) shows in part that the medical evidence of record fails to show that a disability had been clinically diagnosed. However, the examination discussed immediately above appears to show impairment. The Veteran also has contended that he has impairment, and has continued with his claim. In the June 2018 VA Form 9, the Veteran contends that his health conditions were likely caused by chemical exposure while on active duty. Similar to above, there is an incomplete discussion of the evidence of record showing possible impairment, and more detailed reasons and bases are necessary. Consequently, a remand is warranted. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 4. Entitlement to service connection for a heart disability is remanded. The Board incorporates its discussion from the sections above by reference. A VA Primary Care Nursing Note from July 13, 2017 shows, “Patient has Heart Disease.” Additional VA treatment records show impressions of and treatment related to the heart, including cardiology consultations. In the June 2018 VA Form 9, the Veteran contends that his health conditions were likely caused by chemical exposure while on active duty. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. An examination or opinion shall be treated as being necessary to make a decision on the claim if the evidence of record, taking into consideration all information and lay or medical evidence (including statements of the claimant) contains competent evidence that the claimant has a current disability, or persistent or recurring symptoms of disability; and indicates that the disability or symptoms may be associated with the claimant’s active service; but does not contain sufficient medical evidence for VA to make a decision on the claim. Given the Veteran’s contentions and the record evidence of heart disability, the Board finds that a VA examination is warranted. 38 U.S.C § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 5. Entitlement to service connection for hypertension is remanded. The Board incorporates its discussion from the sections above by reference. A February 28, 2012 VA Primary Care Note shows an active problems list that includes hypertension, with a date of identification of July 17, 2010. A VA treatment record from May 9, 2012 shows “History of: High Blood Pressure/Vascular hypertension.” Next, the current March 2018 VA medical opinion shows a negative nexus opinion. The only reasons and bases offered are one sentence discussing a relationship to jet fuel exposure. The Board observes that this is part of the Veteran’s contentions. However, it appears the VA examiner did not generally consider direct service connection and offer complete reasons and bases. Furthermore, in the related March 2018 VA examination, the VA examiner found date of diagnosis to be 2013, which is the date that medication first began. The Board notes that it is unlikely the Veteran only began taking medication on the very day the disease entity first manifest. As shown above, such a finding is inconsistent with the contemporaneous VA treatment records, and the Veteran’s lay contentions. Consequently, a remand for a supplemental VA examination is necessary. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006), Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. If the Veteran identifies other evidence, obtain updated copies of the Veteran’s VA treatment records, and associate them with the Veteran’s claims folder. 2. Please schedule the Veteran for a VA audiological examination to determine the nature and etiology of any bilateral hearing loss disability and tinnitus. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. The VA examiner should consider the evidence in the claims file, as well as the Veteran’s lay contentions regarding jet fuel exposure causing his present disability. The examiner should provide a complete rationale for all opinions expressed. 3. Please schedule the Veteran for a VA examination to determine the nature and etiology of any lung disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. The VA examiner should consider the evidence in the claims file, as well as the Veteran’s lay contentions regarding jet fuel exposure causing his present disability. The examiner should provide a complete rationale for all opinions expressed. 4. Please schedule the Veteran for a VA examination to determine the nature and etiology of any heart disability. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. The VA examiner should consider the evidence in the claims file, as well as the Veteran’s lay contentions regarding jet fuel exposure causing his present disability. The examiner should provide a complete rationale for all opinions expressed. 5. Please schedule the Veteran for a VA examination to determine the nature and etiology of any hypertension. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. The VA examiner should consider the evidence in the claims file, as well as the Veteran’s lay contentions regarding jet fuel exposure causing his present disability. The examiner should provide a complete rationale for all opinions expressed. (Continued on the next page.) 6. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his representative an appropriate supplemental statement of the case (SSOC). Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel