Citation Nr: 18152029 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-24 155 DATE: November 20, 2018 REMANDED Entitlement to service connection for a disability manifested by vertigo is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from June 1967 to January 1971. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a May 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, that denied service connection for a disability manifested by vertigo (listed as vertigo). In February 2017, the Veteran appeared at a Board videoconference hearing before the undersigned Veterans Law Judge. Service connection is in effect for bilateral hearing loss and for tinnitus. The Veteran contends that he has a disability manifested by vertigo that is related to service. He specifically maintains that he suffered a head injury when he fell from a radar tower during his period of service, which he believes may have caused his episodes of vertigo. The Veteran also reports that he had episodes of dizziness during service and since that time. The Veteran essentially asserts that he suffered from vertigo, and/or dizziness, during service and since service. The Veteran’s spouse has also indicated that the Veteran reported that he had dizziness after his discharge from service. The Veteran is competent to report symptoms he thought were due to vertigo, as well as dizziness, during service and since service. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Board finds that the Veteran’s reports of dizziness during and since his period of service are credible. The Veteran’s service treatment records do not specifically show treatment for vertigo and/or dizziness. Post-service private and VA treatment records show treatment for disorders, including vertigo. A July 2011 treatment report from M. Lionberger, D.O., notes that the Veteran was seen for multiple medical problems, as well as for a follow-up to check his laboratory reports. Dr. Lionberger reported that the Veteran stated that he woke up that morning with dizziness and nausea. It was noted that the Veteran reported that his dizziness was worse with a change of position. Dr. Lionberger indicated that the Veteran admitted that he had diminished hearing, but that he did not report buzzing in his ears. The assessment was vertigo; cerumen impaction in both ears; and hyperlipidemia. A May 2014 VA ear conditions examination report includes a notation that the Veteran’s claims file was reviewed. The Veteran reported that he had suffered dizziness and balance issues for many years-five years, and that he never sought medical treatment. The examiner indicated that the Veteran did not currently have, and had never been diagnosed with, an ear or peripheral vestibular condition. The examiner also reported, however, that the Veteran had signs and symptoms attributable to Meniere’s syndrome (endolymphatic hydrops), a peripheral vestibular condition or another diagnosed condition. The examiner stated that the Veteran had tinnitus, unilateral or bilateral, more than once weekly, with episodes of less than twenty-four hours. The examiner also indicated that the Veteran had vertigo, with a frequency of more than once weekly, and with a duration of less than one hour. The examiner stated that there was no diagnosis, or even complaint of, vertigo, in recent examinations within the VA system. The Board observes that the examiner indicated that the Veteran did not currently have, and had never been diagnosed with, an ear or peripheral vestibular condition. The Board notes, however, that the examiner also reported that the Veteran had signs and symptoms attributable to Meniere’s syndrome, a peripheral vestibular condition or another diagnosed condition. Therefore, the examiner’s conclusions appear somewhat contradictory. Additionally, the examiner maintained that there was no diagnosis of, or even complaint of, vertigo in recent examinations within the VA system. The Board notes, however, that a July 2011 treatment report from Dr. Lionberger (noted above) clearly relates a diagnosis of vertigo. The Board observes that the “current disability” requirement for service connection is satisfied if a claimant has a disability at any time during the pendency of a claim, even if the disability resolves prior the adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Further, the Board notes that the examiner did not specifically address the credible reports by the Veteran that he suffered from dizziness during and since service. See Davidson, 581 F.3d at 1313. A February 2017 treatment report from Dr. Lionberger notes that the Veteran was seen for a follow-up of multiple problems, including a complaint of vertigo, and to review recent test results. Dr. Lionberger reported that the Veteran indicated that he had vertigo, and that he stated that he fell ten feet off a radar tower in 1968, while serving in the Army. It was noted that the Veteran related that he was wearing a safety belt to catch him from falling, and that he smacked his head against the radar tower, at that time. Dr. Lionberger indicated that the Veteran denied recalling a loss of consciousness, but that he maintained that he was groggy for some time afterwards. It was noted that the Veteran reported that he was checked by a medic who gave him aspirin and advised that he return to duty. Dr. Lionberger stated that the Veteran currently reported vertigo with bouts of nausea, which was disabling two to three times per year. Dr. Lionberger indicated that the Veteran’s chart was reviewed and that she had discussed a bout of vertigo with the Veteran in 2011. The Board notes that the February 2017 report from Dr. Lionberger appears to be missing pages. There is a notation that there are four pages in the report, but only the first two pages, which do not include an assessment (diagnosis), are of record. Therefore, as there may be outstanding treatment records available that may be pertinent to the Veteran’s claim, an attempt should be made to obtain those records. See also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). In light of the above, the Board finds that the Veteran has not been afforded a VA examination, with the opportunity to obtain responsive etiological opinions, following a thorough review of the entire claims file, as to his claim for service connection for a disability manifested by vertigo. Such an examination must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matter is REMANDED for the following action: 1. Obtain a copy of the complete February 2017 treatment report from M. Lionberger, D.O. 2. Ask the Veteran to identify all other medical providers who have treated him for a disability manifested by vertigo since August 2013. After receiving this information and any necessary releases, obtain copies of the medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 3. Notify the Veteran that he may submit additional lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptomatology regarding his claimed disability manifested by vertigo. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 4. Schedule the Veteran for an appropriate VA examination to determine the nature and likely etiology of his claimed disability manifested by vertigo. The entire claims file must be reviewed by the examiner. The examiner must specifically indicate if the Veteran has a diagnosed disability manifested by vertigo. The examiner must also specifically indicate if the Veteran has currently diagnosed Meniere’s syndrome. The examiner must opine as to whether it is as at least as likely as not that any currently diagnosed disability manifested by vertigo, and/or Meniere’s syndrome, are etiologically related to or had their onset during his period of service. The examiner must specifically acknowledge and discuss the Veteran’s credible reports of dizziness during service and since service. Please note that the Veteran has requested that he be scheduled for a VA examination at the Huntington,   West Virginia VA Medical Center, rather than at the Chillicothe, Ohio VA Medical Center. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. D. Regan, Counsel