Citation Nr: 18152777 Decision Date: 11/26/18 Archive Date: 11/26/18 DOCKET NO. 16-05 546 DATE: November 26, 2018 ORDER New and material evidence having been received, the claim of entitlement to service connection for bilateral knee disability is reopened. New and material evidence having been received, the claim of entitlement to service connection for bilateral hearing loss, to include as due to service-connected residuals of a deviated septum and tinnitus, is reopened. Entitlement to a compensable disability rating for hemorrhoids is denied. Entitlement to service connection for degenerative osteoarthritis of the bilateral knees is granted. REMANDED Entitlement to a compensable disability rating for residuals of a deviated septum is remanded. Entitlement to service connection for bilateral hearing loss, to include as due to service-connected residuals of a deviated septum and tinnitus, is remanded. Entitlement to service connection for a dental disability, as due to dental trauma, is remanded. FINDINGS OF FACT 1. A July 1996 rating decision denied service connection for a bilateral knee disability and bilateral hearing loss. The Veteran was notified of this decision and of his appellate rights by letter dated July 12, 1996. 2. The Veteran did not submit a notice of disagreement within one year of the mailing of notice of the July 1996 rating decision, and no new and material evidence was obtained or received by VA within this one-year time period. 3. Additional evidence received since the July 1996 rating decision is neither cumulative nor redundant of the evidence previously of record, and raises a reasonable possibility of substantiating the claims for service connection for a bilateral knee disability and bilateral hearing loss. 4. The Veteran’s degenerative osteoarthritis of the bilateral knees is related to an in-service injury. 5. The Veteran’s hemorrhoids do not manifest as large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. CONCLUSIONS OF LAW 1. The July 1996 rating decision is final with regard to the claim for service connection for a bilateral knee disability. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence has been submitted to reopen the claim for service connection for a bilateral knee disability. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The July 1996 rating decision is final with regard to the claim for service connection for bilateral hearing loss. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 4. New and material evidence has been submitted to reopen the claim for service connection for bilateral hearing loss. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The criteria for service connection for degenerative osteoarthritis of the bilateral knees are met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 6. The criteria for a compensable disability rating for hemorrhoids are not satisfied. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.7, 4.114, Diagnostic Code 7336. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1956 to May 1959. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from multiple rating decisions. A December 2013 rating decision denied the Veteran’s claims for increased ratings for residuals of a deviated septum and hemorrhoids and his claims for service connection for a bilateral knee disability, teeth disability, and bilateral hearing loss. After the Veteran underwent VA examinations, a June 2014 rating decision reconsidered the Veteran’s claims for increased ratings for residuals of a deviated septum and hemorrhoids and continued the assigned noncompensable disability ratings. Although it appears that the Agency of Original Jurisdiction did not address the issue of new and material evidence concerning the Veteran’s claim for service connection for a bilateral knee disability and determined that new and material evidence had been submitted for his claim for service connection for bilateral hearing loss, the Board must determine of its own accord whether new and material evidence is of record to reopen the claims before it may consider these claims on the merits. Jackson v. Principi, 265 F. 3d 1366 (Fed. Cir. 2001). In April 2017, a new VA Form 21-22, Appointment of Veterans Service Organization as Claimant’s Representative, was received at the Agency of Original Jurisdiction appointing the attorney listed on the title page above. The Board recognizes this change in representation. In August 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a video-conference hearing. A transcript of that hearing is of record. New and Material Evidence A determination on a claim by the agency of original jurisdiction of which the claimant is properly notified is final if no notice of disagreement (NOD) is filed within the prescribed time period, or an appeal is not perfected pursuant to 38 C.F.R. § 20.302. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103; see 38 C.F.R. §§ 20.200, 20.201, 20.302 (setting forth requirements and timeframe for initiating and perfecting an appeal). In order to reopen a previously and finally disallowed claim, new and material evidence must be submitted by the claimant or secured by VA with respect to that claim since the last final denial, regardless of the basis for that denial. See 38 U.S.C. § 5108; Evans v. Brown, 9 Vet. App. 273, 282-83 (1996) (holding that § 5108 requires a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened). VA regulation defines “new and material evidence” as follows. “New evidence” means evidence not previously submitted to agency decision makers, and “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. 38 C.F.R. § 3.156(a), Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In order to warrant reopening, the new evidence must neither be 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. Id.; see Shade, 24 Vet. App. at 117 (holding that there is a “low threshold” for reopening). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion. Duran v. Brown, 7 Vet. App. 216, 220 (1994); Justus v. Principi, 3 Vet. App. 510, 513 (1992). If new and material evidence is received within one year after the date of mailing of a decision from the Agency of Original Jurisdiction, it prevents that decision from becoming final and will be “considered as having been filed in connection with the claim which was pending at the beginning of the appeal period.” 38 C.F.R. § 3.156(b); Young v. Shinseki, 22 Vet. App. 461, 466 (2009) (holding that new and material evidence received within one year of an RO decision prevents that decision from becoming final); 38 C.F.R. § 3.400(q) (providing that, as to new and material evidence received within appeal period, “effective date will be as though the former decision had not been rendered”). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Whether new and material evidence has been received to open a claim of entitlement to service connection for bilateral knee disability; and 2. Whether new and material evidence has been received to open a claim of entitlement to service connection for bilateral hearing loss, to include as due to service-connected residuals of a deviated septum and tinnitus. The Veteran’s claims for service connection for a bilateral knee disability and bilateral hearing loss were originally denied in a July 1996 rating decision. The Veteran was notified of this decision and of his appellate rights by letter dated July 12, 1996. He did not appeal the July 1996 rating decision. See 38 C.F.R. §§ 20.200, 20.201, 20.302. Further, no new and material evidence was received within one year of the date of mailing of the rating decision. See 38 C.F.R. § 3.156(b). Accordingly, the July 1996 rating decision is final with regard to these claims. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Concerning the Veteran’s bilateral knee disability, the Veteran submitted a medical opinion from his treating VA physician that provides a current diagnosis and a positive nexus opinion linking his current disability to his active service. Regarding the Veteran’s bilateral hearing loss, the Veteran submitted private treatment records that demonstrate recent audiological testing, VA treatment records demonstrate that he underwent ear surgery, and that he obtained hearing aids in 2010. During the August 2018 video-conference hearing, the Veteran stated that he believes he has hearing loss as a result of the ear surgery that was necessary because of his service-connected residuals of a deviated septum. The above evidence is new as it was not of record at the time of the July 1996 rating decision and it relates to unestablished facts necessary to support the claims for service connection. Thus, the Board finds the evidence is both new and material. See 38 C.F.R. § 3.156(a); see also 38 C.F.R. § 3.303; Shade, 24 Vet. App. at 122. Therefore, the Veteran’s claims for service connection are reopened. Increased Rating VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Diagnostic codes in the rating schedule identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. See 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not “duplicative or overlapping with the symptomatology” of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Because the level of disability may have varied over the course of the claim, the rating may be “staged” higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). 3. Entitlement to a compensable disability rating for hemorrhoids is denied. The Veteran’s hemorrhoids are rated under 38 C.F.R. § 4.114, Diagnostic Code 7336. Under this Code, a noncompensable rating is warranted where hemorrhoids are mild or moderate in degree. A 10 percent rating is warranted where the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. Finally, a 20 percent rating is warranted where there is persistent bleeding with secondary anemia, or with fissures. 38 C.F.R. § 4.114, Diagnostic Code 7336. Descriptive words such as “mild” and “moderate” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C. § 7104 (a); 38 C.F.R. §§ 4.2, 4.6. Based on the evidence of record, the Board finds that the Veteran’s hemorrhoids have not manifested to a level warranting a 10 percent or 20 percent disability rating. Specifically, there is no evidence contained in the Veteran’s claims folder that demonstrates that his hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences; or manifested by persistent bleeding with secondary anemia, or by fissures. Specifically, on VA Rectum and Anus Conditions (including Hemorrhoids) Examination in April 2014, the Veteran stated that he had intermittent rectal bleeding, especially with lifting heavy items, and during his August 2018 video-conference hearing, he stated that he experiences hemorrhoids only twice per year. Thus, the Veteran has not been shown to have frequent recurrences or persistent bleeding associated with his hemorrhoids. Further, his hemorrhoids have not been shown to be large or thrombotic, irreducible, with excessive redundant tissue. Rather, on VA examination in April 2014 the examiner described his hemorrhoids as mild or moderate, with a small external hemorrhoid at seven o’clock. And private treatment records dated in August 2018 showed that the Veteran had hemorrhoids present at three and six o’clock. There have been no complaints or findings of anemia or fissures. In sum, the preponderance of the evidence weighs against assignment of a compensable disability rating for the Veteran’s hemorrhoids. Consequently, the benefit-of-the-doubt rule does not apply and entitlement to a compensable disability rating for hemorrhoids is denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. Service Connection Service connection means that a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). 4. Entitlement to service connection for degenerative osteoarthritis of the knees is granted. The Board concludes that the Veteran has a current diagnosis of bilateral degenerative knee osteoarthritis that is related to an in-service bilateral knee injury. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). August 2018 private treatment records show the Veteran has a current diagnosis of bilateral degenerative knee osteoarthritis. Further, a September 2018 medical opinion from the Veteran’s treating VA physician stated that his bilateral degenerative knee osteoarthritis is at least as likely as not related to an in-service bilateral knee injury, which has been competently and credibly reported by the Veteran. The rationale provided by the VA physician concluded that the arthritic process that the Veteran experiences today is more likely than not rooted in the bilateral knee traumatic event that occurred during his active service. To that end, the Veteran’s claims folder contains consistent statements from the Veteran that he sustained a traumatic injury to his knees during his active service. The claims folder also contains a buddy statement that demonstrates the Veteran was injured when an air starter turned on too soon and he was thrown against a plane wing and then the ground. Further, the VA physician stated that medical literature supports the finding that post-traumatic arthritis is a common form of osteoarthritis and occurs as a result of physical injury to the joint. In the absence of any evidence that directly contradicts this conclusion, the Board finds that service connection for degenerative osteoarthritis of the knees is warranted. REASONS FOR REMAND 1. Entitlement to a compensable disability rating for residuals of a deviated septum is remanded. The Board finds that a new VA examination is warranted to assess the current nature and severity of the Veteran’s service-connected residuals of a deviated septum. See 38 C.F.R. § 3.327(a) (providing that reexaminations will be requested whenever VA needs to determine the current severity of a disability). The Veteran was last afforded a VA Sinusitis, Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Examination in April 2014. The examination report indicates that the Veteran does not experience complete obstruction on the right side due to traumatic septal deviation. However, during the August 2018 video-conference hearing, the Veteran advised that his right nostril is completely blocked. Considering that the Veteran’s last examination occurred more than four years ago and the evidence that his disability picture has changed, the Board finds that the current evidence of record does not adequately reveal the present state of the Veteran’s service-connected residuals of a deviated septum. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991) (where the record does not adequately reveal the current state of the claimant’s disability, a VA examination must be conducted); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (wherein the Court determined the Board should have ordered a contemporaneous examination of the Veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating); Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007), citing Caluza v. Brown, 7 Vet. App. 498, 505-06 (1998) (“Where the record does not adequately reveal the current state of the claimant’s disability…the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination.”); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995). 2. Entitlement to service connection for bilateral hearing loss, to include as due to service-connected residuals of a deviated septum and tinnitus, is remanded. A new VA examination and medical opinion must be obtained regarding the Veteran’s bilateral hearing loss. A December 2015 VA Hearing Loss and Tinnitus Examination indicates that the Veteran’s military occupational specialty (MOS) was aircraft mechanic and that he had a high probability of noise exposure during his active service. The examiner concluded that it was less likely than not that the Veteran’s bilateral hearing loss was related to his active service because audiological testing was normal at the time of the Veteran’s separation from active service. However, because the separation audiogram is dated in April 1959, which is prior to January 1, 1967, it must be converted from American Standards Association (ASA) units to units established by the International Standards Organization (ISO)-American National Standards Institute (ANSI). The conversion from ASA to ISO-ANSI units is accomplished by adding 15 decibels at 500 Hz, 10 decibels at 1000 Hz, 2000 Hz, and 3000 Hz, and 5 decibels at 4000 Hz. Thus, the Board finds another examination is necessary so that a VA examiner may reassess the Veteran’s bilateral hearing loss, taking into consideration the converted audiogram, as well as the latest research concerning delayed onset hearing loss from Dr. Sharon G. Kujawa. The Board also finds that a medical opinion must be provided that considers the potential link between the Veteran’s bilateral hearing loss and his service-connected residuals of a deviated septum. Evidence indicates that there may be outstanding relevant VA treatment records. During the August 2018 video-conference hearing, the Veteran reported that he received hearing aids at a VA Medical Center in 2010 in Seattle, Washington. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issue on appeal. A remand is required to allow VA to obtain them. Finally, in a statement received in April 1996 the Veteran stated that approximately two years ago he was evaluated by a hearing specialist who told him that his hearing loss was caused by working on the flight line and flight deck. These records should be obtained on remand. 3. Entitlement to service connection for a dental disability, as due to dental trauma, is remanded. The Veteran’s claim for service connection for a dental disability must be remanded to obtain service treatment records and to afford the Veteran a VA examination and opinion. If a dental or oral disability is found service connected for compensation purposes, the Veteran will be eligible for VA outpatient dental treatment despite the requirements of a timely application and the restriction to one-time treatment. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381(b), 17.161(c). Certain dental or oral disabilities may not be service connected for compensation purposes, or are noncompensable under the relevant diagnostic code. These include treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease with loss of periodontal bone. 38 C.F.R. § 3.381 (a); 38 C.F.R. § 4.150, Diagnostic Code 9913 (Note) (instructing that loss of the alveolar process due to periodontal disease is not compensable because it is not considered disabling); 64 Fed. Reg. 30,392 (June 8, 1999); but see 38 C.F.R. § 3.381(b) (treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, or periodontal disease may still be service connected, but solely for outpatient dental treatment purposes). Dental disabilities that are compensable include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible; loss of the mandible; nonunion or malunion of the maxilla or mandible; limited temporomandibular motion; loss of the ramus; loss of the condyloid or coronoid processes; and loss of the hard palate. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Loss of a tooth is compensable only if the loss was due to bone loss-the loss of substance of the body of the maxilla or mandible-caused by dental trauma or disease, such as osteomyelitis, and the masticatory surface cannot be restored by suitable prosthesis. See 38 C.F.R. § 4.150, Diagnostic Code 9913 (Note) (instructing that disability ratings apply only to bone loss through trauma or disease such as osteomyelitis). Whether the dental or oral disability is compensable or noncompensable, the result of combat wounds, or the result of service trauma must be considered. 38 C.F.R. § 3.381(a); but see Nielson v. Shinseki, 607 F.3d 802, 804 (Fed. Cir. 2010) (service trauma is “an injury or wound produced by an external physical force during the performance of military duties, and does not include the intended result of proper medical treatment”); 38 C.F.R. § 3.306(b)(1); VAOGCPREC 5-97 (“service trauma” does not include the intended effects of therapy or restorative dental care or treatment during active service). During the August 2018 video-conference hearing, the Veteran stated that during active service in Norman, Oklahoma, he engaged in a physical altercation that resulted in a loss of teeth. The Veteran’s service treatment records contain a July 1956 Report of Medical Treatment, Hospitalization, and Allied Services that demonstrates the Veteran was struck by an unknown assailant while on authorized leave. As a result, the Veteran stated that he underwent two root canal surgeries at the Millington Naval Station, Tennessee and one dental crown procedure at Naval Air Station Moffett Field, California. The Veteran’s entrance examination does not note missing teeth, but his separation examination shows 6 missing teeth. The Veteran stated he has ongoing dental health issues as a result. Because there is at least an indication that the Veteran’s current dental disability may be related to his active duty service, a VA examination and opinion must be provided to make an informed decision on this claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); see McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (the Board is not competent to substitute its own opinion for that of a medical expert). The Veteran’s service treatment records do not contain dental treatment records from Millington Naval Station, Tennessee. Therefore, a remand is required to obtain the Veteran’s complete service treatment records, including any treatment for a dental disability while at Millington Naval Station, Tennessee. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from April 2018 to the present, to include VA treatment records from VA Puget Sound Health Care System from 2010 to the present. 2. Obtain the Veteran’s complete service dental treatment records, to include from Millington Naval Station, Tennessee. 3. Ask the Veteran to identify the hearing specialist who evaluated him in approximately 1994 and told him that his hearing loss was caused by working on the flight line and flight deck. Then, make arrangements to obtain these records. 4. After the above development is completed, schedule the Veteran for an examination to determine the current severity of his residuals of a deviated septum. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his bilateral hearing loss. (a) The examiner must opine as to whether the Veteran’s current bilateral hearing loss is at least as likely as not related to in-service acoustic trauma. In providing this opinion, the examiner must consider the Veteran’s separation audiogram dated in April 1959. The April 1959 audiogram, when converted to ISO-ANSI standards, showed pure tone thresholds of 25 decibels at 500 Hz, 20 decibels at 1000 Hz, 20 decibels at 2000 Hz, and 20 decibels at 4000 Hz in the right ear and 15 decibels at 500 Hz, 20 decibels at 1000 Hz, 15 decibels at 2000 Hz, and 15 decibels at 4000 Hz in the left ear. The examiner must also consider the line of research concerning delayed onset hearing loss conducted by Dr. Sharon G. Kujawa, including the below: • “Acceleration of Age-Related Hearing loss by Early Noise Exposure: Evidence of a Misspent Youth” by S. Kujawa, M.D., and M. C. Liberman (2006). J Neurosci. 2006 Feb 15; 26(7): 2115-2123. • Kujawa SG, Liberman MC (2009) Adding insult to injury: cochlear nerve degeneration after “temporary” noise-induced hearing loss. J Neurosci. 2009 Nov 11;29(45):14077-85. • Lin HW, Furman AC, Kujawa SG and Liberman MC (2011) Primary neural degeneration in the guinea pig cochlea after reversible noise-induced threshold shift. JARO 12:605-616. • Furman AC, Kujawa SG, Libermann MC (2013) Noise-induced cochlear neuropathy is selective for fibers with low spontaneous rates. J. Neurophysiol.110, 577-586. (b) The examiner must opine as to whether the Veteran’s bilateral hearing loss is at least as likely as not: (i) proximately due to his service-connected residuals of a deviated septum; or (ii) aggravated beyond its natural progression by his service-connected residuals of a deviated septum. In providing this opinion, the examiner must consider the Veteran’s assertion that because of his deviated nasal septum he had surgery “to chisel out” his nose so he could breathe, and then put a tube in his left ear to drain. However, about three years later “it plugged up” again he had surgery to open up his Eustachian tube and put another tube in his ear to drain it. About six months after that, his right ear “plugged up” and he had a tube put in that ear as well. The Veteran asserts that his sinuses were damaged because of his deviated septum and that this caused his hearing loss. See Hearing Transcript, dated August 8, 2018. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any dental disabilities. (a.) The examiner must identify all current dental disabilities. (b.) The examiner must opine whether any identified dental disability is at least as likely as not related to an in-service injury, event, or disease, including dental trauma incurred during active service. All examination findings, along with the complete rationale for all opinions expressed, must be set forth in the examination report. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Mussey, Associate Counsel