Citation Nr: 18152346 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 16-28 973 DATE: November 21, 2018 ORDER Service connection for diabetes mellitus, type 2, to include as due to exposure to herbicides, is denied. Service connection for peripheral neuropathy of the upper extremities, as secondary to diabetes mellitus, is denied. Service connection for peripheral neuropathy of the lower extremities, as secondary to diabetes mellitus, is denied. Service connection for loss of right leg, as secondary to diabetes mellitus, is denied. Service connection for depressive disorder, as secondary to diabetes mellitus, is denied. Service connection for a left knee condition, as secondary to diabetes mellitus, is denied. Service connection for chronic left leg infection, as secondary to diabetes mellitus, is denied. Service connection for loss of the 4th toe, left foot, as secondary to diabetes mellitus, is denied. Service connection for erectile dysfunction, as secondary to diabetes mellitus, is denied. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran regularly and repeatedly operated, maintained, or served aboard C-123 aircraft known to have been used to spray an herbicide agent during the Vietnam era; or was otherwise exposed to herbicides during his period of active service. 2. The Veteran’s currently diagnosed diabetes mellitus cannot be presumed to be due to exposure to herbicides in service; is not shown to have had its onset during service, or to be causally or etiologically related to any disease, injury, or incident in service; and did not manifest within one year of the Veteran's discharge from service. 3. The Veteran's peripheral neuropathy of the upper extremities is secondary to his nonservice-connected diabetes mellitus, and did not manifest during, or as a result of, active military service. 4. The Veteran's peripheral neuropathy of the lower extremities is secondary to his nonservice-connected diabetes mellitus, and did not manifest during, or as a result of, active military service. 5. The loss of the Veteran's right leg was secondary to his nonservice-connected diabetes mellitus, and did not manifest during, or as a result of, active military service. 6. The Veteran’s depressive disorder did not manifest during, or as a result of, active military service or a service-connected disability. 7. The Veteran’s left knee condition did not manifest during, or as a result of, active military service or a service-connected disability. 8. The Veteran’s chronic left leg infection is secondary to his nonservice-connected diabetes mellitus, and did not manifest during, or as a result of, active military service. 9. The loss of the 4th toe of the Veteran’s left foot was secondary to his nonservice-connected diabetes mellitus, and did not manifest during, or as a result of, active military service. 10. The Veteran’s erectile dysfunction did not manifest during, or as a result of, active military service or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for diabetes mellitus, to include as due to exposure to herbicides, have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 5107(b) (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. The criteria for establishing entitlement to service connection for peripheral neuropathy of the upper extremities have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1153, 5103(a), 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.307, 3.309 (2017). 3. The criteria for establishing entitlement to service connection for peripheral neuropathy of the lower extremities have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1153, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.307, 3.309 (2018). 4. The criteria for establishing entitlement to service connection for loss of the right leg have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1153, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.307, 3.309 (2018). 5. The criteria for establishing entitlement to service connection for depressive disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.307, 3.309 (2018). 6. The criteria for establishing entitlement to service connection for a left knee condition have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1153, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.307, 3.309 (2018). 7. The criteria for establishing entitlement to service connection for a chronic left leg infection have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1153, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.307, 3.309 (2018). 8. The criteria for establishing entitlement to service connection for loss of the 4th toe of the left foot have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1153, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.307, 3.309 (2018). 9. The criteria for establishing entitlement to service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1153, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(f), 3.307, 3.309 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Air Force from January 1969 to December 1972. This appeal to the Board of Veterans' Appeals (Board) arose from a Department of Veterans Affairs (VA) Regional Office (RO) rating decision in March 2016. The Veteran perfected an appeal. See April 2016 Notice of Disagreement (NOD); May 2016 Statement of the Case (SOC); June 2016 VA Form-9. At the outset, the Board acknowledges that a VA medical opinion or examination was not provided in connection with the claims. An examination is required when there is (1) competent evidence of a current disability, (2) evidence establishing an "in-service event, injury, or disease," (3) and indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Board finds that a VA examination is not necessary. With regard to the diabetes mellitus disability, as the Board will discuss below, the Veteran does not have confirmed exposure to herbicides during service; the record does not otherwise reflect an in-service injury or disease related to diabetes mellitus, type 2, or chronic symptoms of diabetes mellitus, type 2 shown in or within a year of service; and the record does not show that there may be a nexus between the currently diagnosed diabetes mellitus, type 2 and some incident of service. The additional issues on appeal are claimed as secondary to diabetes mellitus, and as discussed below, medical opinions regarding the remaining issues are not warranted. Absent evidence that establishes an in-service event, injury, or disease, the Board finds that a VA examination is not necessary for disposition of the claim. See 38 U.S.C. § 5103A (a)(2) (West 2012); 38 C.F.R. § 3.159 (d) (2017). Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. 1110, 1131; 38 C.F.R. 3.303 (a). Establishing service connection requires (1) evidence of a presently existing disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be granted for certain chronic diseases, such as diabetes, if diagnosed as such in service or manifested to a compensable degree within one year after a veteran's separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Where a veteran asserts entitlement to service connection for a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303 (b) by demonstrating a continuity of symptomatology since service or diagnosis within the presumptive period after service, but only if the chronic disease is listed under 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013) (holding that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic 38 C.F.R. § 3.309 (a)). Diabetes is included in the list of chronic diseases under 38 C.F.R. § 3.309 (a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection also may be established on a secondary basis for: (1) a disability that is proximately due to or the result of a service-connected disease or injury; or, (2) any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury. 38 C.F.R. §§ 3.310 (a)-(b); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993) (explaining 38 C.F.R. § 3.310 (a)); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (explaining 38 C.F.R. § 3.310 (b)). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Diabetes Mellitus The Veteran seeks entitlement to service connection for diabetes mellitus, type 2. He contends that his diabetes resulted from exposure to herbicides from contaminated aircraft, equipment, and cargo, in the course of his duties as an aircraft radio and communications electronics repairman. The Veteran has also asserted that he was exposed to herbicide agents through human remains being transported on such aircraft. If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain enumerated diseases shall be service connected if the requirements of 38 U.S.C. § 1116, 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). Type 2 diabetes mellitus is among the enumerated diseases which are deemed to be associated with herbicide exposure. See 38 C.F.R. § 3.309 (e). A veteran who, during active military service, served in Vietnam during the period beginning in January 1962 and ending in May 1975 is presumed to have been exposed to herbicides. 38 C.F.R. §§ 3.307, 3.309. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307. The presumption requires that a veteran have actually been present on the landmass or the inland waters of Vietnam. Haas v. Peake, 525 F.3d 1168 (2008); VAOPGCPREC 27-97. Effective June 19, 2015, VA amended its regulation governing individuals presumed to have been exposed to certain herbicides by expanding the regulation to include individuals who performed service in the Air Force or Air Force Reserve under circumstances in which the individual concerned had regular and repeated contact with C-123 aircraft known to have been used to spray an herbicide agent (such as "Agent Orange") during the Vietnam era. Specifically, the new regulation states that an individual who performed service in the Air Force or Air Force Reserve under circumstances in which the individual concerned regularly and repeatedly operated, maintained, or served onboard C-123 aircraft known to have been used to spray an herbicide agent during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent. For purposes of this paragraph, "regularly and repeatedly operated, maintained or served onboard C-123 aircraft" means that the individual was assigned to an Air Force or Air Force Reserve squadron when the squadron was permanently assigned one of the affected aircraft and the individual had an Air Force Specialty Code indicating duties as a flight, ground maintenance, or medical crew member of such aircraft. Such exposure constitutes an injury under 38 U.S.C. 101 (24) (B) and (C). If an individual described in this paragraph develops a disease listed in 38 C.F.R. § 3.309 (e) as specified in paragraph (a)(6)(ii) of this section, it will be presumed that the individual concerned became disabled during that service for purposes of establishing that the individual served in the active military, naval or air service. 38 C.F.R. § 3.307 (a)(6)(v). VA has determined a list of affected units, Air Force Specialty Codes and dates of service for affected reservists and active service members who had regular and repeated exposure to contaminated C-123 aircrafts which were used to spray Agent Orange. Relevant to the instant appeal, the affected active duty units and dates of service for affected crew members were as follows: Hurlburt Auxiliary Field, Eglin Air Force Base, Florida (1970-1973), Langley Air Force Base, Virginia (1962-1963, 1970-1973), Luke Air Force Base, Arizona (1970-1973), Tainan Air Field, Taiwan (1969-1970), Howard Air Force Base, Panama (1970-1973), Osan Air Base, South Korea (1970-1973), and Clark Air Force Base, Philippines (1969-1970). See list of military units and Air Force Specialty codes, available at https://www.vets.gov/disability-benefits/conditions/exposure-to-hazardous-materials/agent-orange/c-123/ (last visited November 13, 2018). The list of specialty codes for military personnel who had regular and repeated exposure to contaminated Operation Ranch Hand (ORH) C-123s, used to spray Agent Orange in Vietnam, as flight, maintenance, or medical crew members include the following for enlisted personnel: flight engineer/aircraft loadmaster (1130-1149), aircrew life support specialist (1220-1229), and aircraft maintenance specialist/flight technicians (4314-4359). Id. Thus, to warrant presumptive exposure based on contact with a C-123, a veteran must have had duties at one of the above listed places, but also have had a duty that entailed that he regularly and repeatedly operated, maintained or served onboard C-123 aircraft. Turning to the evidence of record, the Veteran has a current diagnosis of diabetes mellitus as evidenced by VA treatment records. In regard to whether the Veteran was exposed to herbicides during his service, a review of the Veteran's DD-214 reveals that he was a member of the United States Air Force with an Air Force Specialty Code of avionic communications. Personnel records show that the Veteran’s specialties included communication electronic systems and aircraft radio repairs. The personnel records further document that the Veteran had assignment stations at Lackland Air Force Base (AFB), Texas; Keesler AFB, Mississippi; Mather AFB, California; and Elmendorf AFB, Alaska. See DD-214; Service Personnel Records. In his December 2015 claim for service connection, the Veteran reported that he was diagnosed with diabetes mellitus, type 2 in March 1983. He indicated his belief that the condition resulted from exposure to Agent Orange/herbicide while working inside and outside of C-130, C-141, F-4, and B-52 aircraft, as well as tankers. The Board notes that the Veteran submitted his claims in separate statements attached to his Application for Disability Compensation. Although the statement specifically detailing his diabetes claim did not list C-123 aircraft, statements regarding his hearing loss and tinnitus claims noted that the Veteran was exposed to loud noise from multiple types of aircraft, including C-123 aircraft. See December 2015 Statements of Claim. In February 2016, the Joint Services Records Research Center (JSRRC) coordinator issued a formal finding on a lack of information required to verify Agent Orange exposure in Vietnam. The finding noted that the Veteran asserted exposure to herbicide agents from working on different types of aircraft, such as C-130, C-141, F-4, and B-52 aircraft, as well as tankers. In December 2015, a VCAA letter was sent out with information regarding herbicide exposure and a request for the Veteran to submit a 60-day time frame for his alleged exposure. It was noted that personnel records showed the Veteran served as avionic communication personnel from May 1, 1971 to December 20, 1972. Personnel records did not show service in Vietnam and did not show evidence that the Veteran worked with C-123 aircraft. It was further noted that there is no presumption for exposure from working on aircraft other than the C-123. STRs were reviewed and contained no evidence of service in Vietnam or of exposure to herbicides. The memo concluded by noting that no response to the VCAA letter was received, and Agent Orange exposure was not conceded. See February 2016 Formal Finding Memo. Based on the above, the Board finds that the most competent and credible evidence or record is against a finding that the Veteran was exposed to herbicides during service. First, the Veteran does not allege, and the evidence of record does not indicate, that he set foot in Vietnam. The Veteran’s service personnel records also contain no notations suggestive of a temporary deployment to Vietnam. In regard to the Veteran’s specific claim that he was exposed while working on multiple aircrafts, including C-123s, the Board finds that such exposure could not be corroborated. As noted above, the Veteran’s Air Force Specialty Code was avionic communication, and the record documents that his primary duties involved repairing and maintaining communications and electronics equipment aboard aircraft. Such activity shows that his duties are indicative of ground maintenance of aircraft as required by 38 C.F.R. § 3.307 (a)(6)(v). The Veteran’s initial statement in support of his diabetes claim did not specifically mention C-123 aircraft, and as noted in the February 2016 JSRRC formal finding, there is no presumption for exposure from working on aircraft other than the C-123. However, the Veteran reported maintenance of C-123 aircraft in other statements throughout his appeal. Thus, the Board affords him the benefit of the doubt that his duties involved repair and maintenance of C-123 aircraft. Nonetheless, because official records do not show that the Veteran was assigned to an Air Force or Air Force Reserve squadron when the squadron was permanently assigned one of the affected C-123 aircraft, the Veteran cannot meet the requisite criteria to qualify for the presumption of an in-service incurrence due to herbicide exposure. See List of Affected Units and Air Force Specialty Codes; Service Personnel Records. Although the Veteran is competent to report his location and activities, he is not competent to opine on the technical matter of identifying herbicide compounds. Moreover, when compared to the official records documenting the specific units to which affected C-123 aircraft were assigned, such records tend to refute the Veteran’s assertions. The Veteran specifically identified his exposure to herbicides as having occurred during his duty at Elmendorf AFB, which is not amongst the recognized affected active duty units for which exposure to herbicides may be presumed. Additionally, the Veteran’s personnel records do not show assignment to any of the affected active duty units. While the Board acknowledges the Veteran’s sincere belief that aircraft he maintained and serviced were contaminated by herbicide agents, the Board finds the service personnel records and VA's listing of Air Force Specialty Codes and Units with C-123 aircraft associated with exposure to Agent Orange, to be more probative of the circumstances of the Veteran's active service. Thus, the Board finds the Veteran does not qualify for service connection under this theory of herbicide exposure, as such exposure cannot be corroborated. As the most probative evidence of record is against a finding that the Veteran had in-country service in the Republic of Vietnam or was otherwise exposed to herbicides during the course of his military service, the presumption of herbicide exposure and presumptive service connection based on exposure to herbicides is not warranted. Notwithstanding the foregoing presumption provisions, the fact that a Veteran is not entitled to the regulatory presumption of service connection based on herbicide exposure does not preclude an evaluation as to whether he is entitled to service connection on a direct basis or entitled to presumptive connection for a chronic disease. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). However, the preponderance of the remaining evidence of record also fails to demonstrate that the Veteran’s diabetes mellitus otherwise manifested during, or as a result of, active military service. In this regard, the evidence does not show, and the Veteran does not contend, that his diabetes mellitus is related to service in any manner other than as a result of his alleged exposure to herbicides. The Veteran's service treatment records reveal no complaints, treatment, or findings of diabetes mellitus symptoms or elevated blood sugar levels during service. Further, the evidence does not suggest that the Veteran's diabetes mellitus manifested during service or within one year of separation from service. Although the Veteran has a diagnosis of diabetes mellitus, the lay and medical evidence of record indicates diagnosis sometime between March 1983 and 1985; at earliest, almost 11 years after discharge from service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (finding lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim). The only evidence of record relating the Veteran's diabetes mellitus in any way to his military service are the Veteran's own lay statements. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, determining the etiology of diabetes mellitus, falls outside the realm of common knowledge of a lay person because it involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. In this regard, while the Veteran can competently report the onset of symptoms, any opinion regarding the nature and etiology of his diabetes mellitus requires medical expertise that the Veteran has not demonstrated. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). As such, the Board cannot assign any probative weight to the Veteran's assertions that his diabetes is in any way related to his military service. Thus, other than the possibility of exposure to herbicide agents, the Veteran has not identified any injury, disease or event during service to which his diabetes mellitus could possibly be related. Additionally, the record does not reasonably raise any other theory and the Veteran's diabetes mellitus has not been related to active service by a competent medical opinion or by evidence of a continuity of symptomatology. Accordingly, a medical opinion is not warranted and a preponderance of the evidence is against the claim for service connection for diabetes on a direct basis or on a presumptive basis as a chronic disease pursuant to 38 C.F.R. § 3.309 (a). See 38 U.S.C. §§ 1101, 1110, 1112; 38 C.F.R. §§ 3.303, 3.307, 3.309. In summary, although the Veteran has a current diagnosis of diabetes mellitus, type 2, the weight of the evidence reflects that there were no documented symptoms or diagnosis of diabetes during service, and the Veteran did not develop diabetes mellitus, type 2, until many years after service, and there is no persuasive evidence that the Veteran was exposed to herbicide agents, to include in the course of his duties performing aircraft maintenance, including C-123 aircraft not assigned to recognized units exposed to herbicide agents. For these reasons, the Board finds that a preponderance of the evidence is against the claim. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102 (2017), Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 2. Peripheral Neuropathy of the Bilateral Upper Extremities; Peripheral Neuropathy of the Bilateral Lower Extremities; Loss of the Right Leg; Depressive Disorder; Left Knee Condition; Chronic Left Leg Infection; Loss of the 4th Toe, Left Foot; Erectile Dysfunction As noted above, in addition to the elements of direct service connection, service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either proximately caused by or proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Veteran seeks entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, peripheral neuropathy of the bilateral lower extremities, loss of the right leg, depressive disorder, a left knee condition, a chronic left leg infection, loss of the 4th toe of the left foot, to include as secondary to diabetes mellitus; and erectile dysfunction. He asserts that these conditions are secondary to his diabetes mellitus. However, as discussed above, the Veteran is not entitled to service connection for diabetes mellitus and the preponderance of the evidence of record demonstrates that these disabilities did not otherwise manifest during, or as a result of, active military service. As such, the claims must be denied. The Veteran has not asserted, and the record does not reflect, that his claimed peripheral neuropathy of the bilateral upper and lower extremities, loss of the right leg, depression, left knee condition, chronic left leg infection, loss of the 4th toe of the left foot, and erectile dysfunction, first manifested during service or were related to his service. It has only been claimed that the disabilities are secondary to diabetes mellitus. Accordingly, because the Veteran does not contend that these disabilities are directly related to service and because the record similarly does not reasonably raise the theory of direct service connection, the Board will address only whether the Veteran was entitled to service connection for these disabilities on a secondary basis. See Robinson v. Mansfield, 21 Vet. App. 545, 552-56 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed.Cir.2009) (stating that "[w]here a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory"). The findings set forth earlier in this decision reflect that the Veteran is not entitled to service connection for diabetes mellitus. As service connection has not been established for diabetes, there is no legal basis upon which to award service connection for disabilities that are claimed as secondary to a disability that is not service connected. See 38 C.F.R. § 3.310. As there is there is no factual or legal merit to the secondary service connection claims, service connection on a secondary basis is denied. See Sabonis v. Brown, 6 Vet. App. 426 (1994). In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F. 3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55 REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2018). 1. Bilateral Hearing Loss and Tinnitus The Veteran seeks entitlement to service connection for bilateral hearing loss and tinnitus. He asserts that these disabilities resulted from in-service exposure to loud noise from aircraft, helicopters, jet engines, generators, and propellers in the course of his duties in avionic communications, repairing and maintaining communications and electronics equipment aboard aircraft. The Veteran has also asserted that exposure to various explosive devices during his basic training contributed to the disabilities. VA has conceded the Veteran’s likely exposure to acoustic trauma in-service based on his military occupation specialty of avionic communication. Although the Veteran was notified of a pending disability examination, the RO ultimately determined that it could resolve his claim through a review of the evidence of record. To this end, in February 2016, a VA audiologist reviewed the evidence of record and opined that it was less likely than not that the Veteran’s hearing loss was due to military noise exposure. As rationale, the examiner reported that audiograms from service all indicated normal hearing bilaterally from 500-4000Hz, and that there were no significant shifts in thresholds from induction to discharge. Further, the examiner noted that current science, as documented by the Institute of Medicine, indicates that “understanding of the mechanisms and processes involved in the recovery from noise exposure suggests that a delay of many years in the onset of noise-induced hearing loss following an earlier noise exposure is extremely unlikely.” Additionally, the examiner noted that “the evidence from laboratory studies in humans and animals is sufficient to conclude that the most pronounced effects of a given noise exposure on pure-tone thresholds are measurable immediately following the exposure.” Consequently, the examiner opined that, given normal hearing at discharge and no significant shift in thresholds from induction to discharge, it was her opinion that hearing impairment was less likely as not (less than 50/50 probability) caused by or aggravated by military noise exposure. See February 2016 VA Medical Opinion. Regarding tinnitus, the examiner reported that she reviewed a statement by the Veteran in which he reported his belief that tinnitus was caused by military noise exposure, but noted that onset was not addressed. The examiner reported that at two separate VA medical exams in July 2004 and August 2005, the Veteran denied experiencing any tinnitus. Rather, the examiner stated that the first report of tinnitus was found in 2011. The examiner opined that this would indicate that the Veteran’s tinnitus onset was sometime between 2005 and 2011, well after his separation from active duty military service. The examiner noted an Institute of Medicine finding that “as the interval between a noise exposure and the onset of tinnitus lengthens, the possibility that tinnitus will be triggered by other factors increases.” As a result, the examiner opined that since the Veteran’s tinnitus first started many years post discharge, it was less likely as not (less than 50/50 probability) that tinnitus was related to military noise exposure. Id. The Board finds the February 2016 opinion insufficient to allow the Board to determine whether the Veteran is entitled to service connection for bilateral hearing loss and tinnitus. As an initial matter, the Board notes that although a medical opinion was obtained, an audiogram were not performed. Although the March 2016 rating decision reports pure tone thresholds from a VA examination, there is no indication of a date for those readings, and the Board’s review of the record reveals no audiometric findings other than those contained in the service treatment records and referenced in the February 2016 VA opinion. Further, the February 2016 VA examiner based the negative nexus opinion on a finding that the Veteran's hearing at separation was within normal limits. Relying on the absence of evidence in medical records without regard for lay statement to provide a negative opinion is contrary to established case law, and such opinions are therefore inadequate. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Moreover, the Board notes that the fact that hearing loss was not identified during service, or for many years after separating from service, is not fatal to a claim for service connection. A veteran may establish direct service connection for a hearing loss disability, which initially manifested several years after separation from service, by showing evidence of a current hearing loss disability and a causal relationship to active duty service. See Hensley v. Brown, 5 Vet. App. 155 (1993); see also 38 C.F.R. § 3.303 (d). Although the February 2016 VA examiner cited a lack of significant threshold shifts in hearing acuity during service as part of the rationale for finding that the Veteran’s hearing loss was not related to service, the Board is not satisfied that the Veteran’s lay statements were considered in the formation of the examiner’s opinion. Here, in-service noise exposure has been established, and the Veteran has reported experiencing hearing loss symptoms since service. Additionally, with respect to tinnitus, in his June 2016 substantive appeal, the Veteran specifically denied telling anyone at VA that he did not suffer from tinnitus. Lastly, given the apparent lack of any audiometric testing other than that contained in the STRs, the Board finds that the Veteran should be afforded such testing to determine whether he has a hearing loss disability for VA purposes. As such, the Board finds that the Veteran should be afforded an in-person examination, complete with audiometric testing of pure tone thresholds, and, an opinion as to the etiology of any hearing loss and tinnitus which considers and addresses the Veteran’s lay statements in conjunction with the other evidence of record. 2. TDIU The Board also finds that the Veteran's claim for TDIU is inextricably intertwined with the issues being remanded herein and must be deferred pending the resolution of these preliminary matters. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issues has been rendered). Lastly, as the claim is being remanded, the Veteran should be afforded another opportunity to submit, or to request that VA obtain, any additional relevant treatment records that remain outstanding that he believes would be supportive of his claim. Accordingly, the matters are REMANDED for the following action: 1. Obtain and associate with the Veteran's claims file any outstanding VA treatment records documenting treatment for the issues on appeal. The Veteran should also be given the opportunity to identify and/or submit any additional private treatment records pertinent to his claim. 2. After all available records have been associated with the claims file, arrange for the Veteran to undergo a new VA audiological examination to address the current existence and cause of the Veteran’s claimed bilateral hearing loss disability and tinnitus. Provide the electronic file, to include a copy of this Remand, to the examiner, who should indicate in the examination report that the claims file was reviewed. Following review of the claims file, the VA examiner should confirm whether the Veteran has a hearing loss disability in either or both ears for VA purposes, and confirm whether he has a diagnosis of tinnitus. The examiner is then asked to provide an opinion as to the following: Is it at least as likely as not (that is, a 50 percent probability or greater) that any bilateral hearing loss disability or tinnitus that the Veteran now has, is related to his in-service exposure to loud noise. In this regard, the examiner is to consider the fact that the Veteran’s military noise exposure has been established by the record. 3. After completing the requested actions, and any additional notification and/or development deemed warranted, readjudicate the remaining claims on appeal. If any benefit sought in connection with these claims is denied, furnish to the Veteran and his representative an appropriate supplemental statement of the case that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Lewis