Citation Nr: 18153688 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 06-33 541 DATE: November 29, 2018 ORDER Entitlement to service connection for left ear hearing loss is denied. Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for a psychiatric disability is granted. FINDINGS OF FACT 1. The weight of the probative evidence of record is against a finding of any etiologic relationship between any left ear hearing loss disability and the Veteran’s service. 2. The Veteran’s right ear hearing loss pre existed entry to service and did not permanently increase in severity during service. 3. Resolving all reasonable doubt in favor of the Veteran, the evidence supports a finding that the Veteran has a psychiatric disability that is related to active service. CONCLUSIONS OF LAW 1. A left ear hearing loss disability was not incurred during active duty. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.309, 3.385. 2. The Veteran’s pre-existing right ear hearing loss disability was not aggravated during active service. 38 U.S.C. §§ 1110, 1131, 1132, 1153, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309. 3. The criteria for service connection for a psychiatric disability have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA’s duty to assist also includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79 (2006). An adequate examination must consider the issue at hand and provide sufficient analysis for the Board to weigh that examination against others. Stefl v. Nicholson, 21 Vet. App. 120 (2007). However, there is no reasons or bases requirement imposed on examiners. Acevedo v. Shinseki, 25 Vet. App. 286 (2012). Rather, a medical opinion is adequate when it is based on consideration of a Veteran’s prior medical history and examinations, and the final report describes the disability in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one. Ardison v. Brown, 6 Vet. App. 405 (1994); Green v. Derwinski, 1 Vet. App. 121 (1991). Concerning the hearing loss claim, an opinion was obtained from a VA examiner most recently in November 2015. The Board acknowledges that the November 2015 opinion was provided by an audiologist. However, the November 2015 audiologist provided an extensive etiology opinion, well-supported by the examiner’s research. The Board finds that the VA opinion provided is adequate. Monzingo v Shinseki, 26 Vet. App. 97 (2012) (examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert’s judgment on a medical question and the essential rationale for that opinion even when the rationale does not explicitly lay out the examiner’s journey from the facts to a conclusion); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA provides an examination or obtains an opinion, VA must ensure that the examination or opinion is adequate). Further, in light of the extensive reasoning provided by the VA examiner, the Board is satisfied that there has been substantial compliance with the directives issued in the Board remands. Dyment v. West, 13 Vet. App. 141 (1999). Service Connection Service connection may be established for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in service incurrence or aggravation of a disease or injury; and (3) evidence, generally medical, of a causal relationship between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be established for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist 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. Furthermore, service incurrence will be presumed for certain chronic diseases if manifest to a compensable degree within the year after active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Impaired hearing will be considered a disability when the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of those frequencies are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The threshold for normal hearing is between 0 and 20 decibels and higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for left ear hearing loss 2. Entitlement to service connection for right ear hearing loss The Veteran’s June 1970 enlistment examination notes that his pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 30 30 30 -- 45 LEFT 20 25 30 -- 30 The service medical records are negative for any complaints or treatment of bilateral hearing loss. On separation examination in December 1971, the Veteran’s pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 45 35 25 -- 35 LEFT 30 25 35 -- 40 Post-service VA and private medical records show that the Veteran received intermittent treatment for bilateral hearing loss. In addition to and in conjunction with his decreased hearing, the Veteran also reported symptoms of tinnitus, dizziness, vertigo, and lightheadedness. On VA examination in August 2005, the Veteran’s chief complaint was of dizziness, even though he experienced episodes during which his dizziness, hearing loss, and tinnitus worsened. The examiner noted that the Veteran had been diagnosed with Meniere’s disease for the previous 12 years. The Veteran reported artillery noise exposure for two years during service and occupational noise exposure of construction work for 25 years. The examiner diagnosed sensorineural hearing loss and subjective tinnitus, consistent with a diagnosis of Meniere’s disease. The examiner opined that a relationship between the Veteran’s auditory symptoms and service noise exposure was purely speculative because the claims file was not available for review, any hearing loss in service would likely be obscured by Meniere’s disease and occupational noise exposure, and the Veteran’s auditory symptoms were reportedly first noticed 12 years prior to the examination and associated with the Meniere’s disease diagnosis. In a January 2006 addendum, the examiner reviewed the claims file. The examiner noted that the Veteran’s current right ear hearing loss was mild and similar to that identified in service while the left ear hearing loss was worse, likely from the Meniere’s disease. The examiner opined that it was therefore unlikely that the Veteran had hearing loss due to service noise exposure. The Veteran and his wife testified before the Board at a June 2007 Board hearing. Testimony stated that the Veteran was exposed to loud sounds and artillery noise during service with only regular rubber hearing aids for hearing protection. The Veteran testified that he had a ringing and whining in his ears at the end of a typical day during service. He reported that over the years, he also began to experience dizziness and vertigo. In a July 2007 letter, the Veteran’s private physician reported that he had been treating the Veteran since 1998 for complaints of tinnitus, hearing loss, and vertigo in the left ear. The physician indicated that the Veteran had reported significant noise exposure during service in 1971. The Veteran had stated that he had been exposed to artillery noise from both hand-held weapons and heavy artillery. The physician stated that certainly a significant component of the Veteran’s hearing loss was consistent with noise exposure. At an April 2010 VA examination, the Veteran reported in-service exposure to noise generated by M-16 rifle firing and when he was on duty as a gunner on a Howitzer. Although the Veteran is right-handed, he reportedly held the M-16 on his left shoulder while firing, and the Howitzer-generated noise was greater from the left side. The Veteran maintained that he experienced that type of noise exposure during daily firing training missions. Regarding occupational noise exposure, the Veteran stated that his career had been spent in construction as a plumber. He reported only occasional exposure to noise generated by power tools. The examiner diagnosed bilateral hearing loss and opined that it was not permanently aggravated by or due to active service. The examiner found that there was not a clinically significant difference between the thresholds obtained for hearing examination on induction with those obtained on separation. The examiner explained that the July 2007 private physician’s positive nexus opinion did not demonstrate knowledge of that information. The examiner also reported that the hearing loss currently evidenced by the Veteran was consistent with the private diagnosis of and treatment for Meniere’s disease. The examiner stated that Meniere’s disease was not associated with a noise-induced etiology. The examiner also noted that 6000 Hertz was a frequency that was commonly affected by noise exposure and that in 1999, there was an indication of high frequency hearing loss for each of the Veteran’s ears above 4000 Hertz, which were frequencies that were not tested at the time of induction and separation. However, the examiner stated that the Veteran’s occupational noise exposure was a confounding factor. In April 2011, the Board essentially found that the evidence clearly and unmistakably showed a bilateral hearing loss that pre-dated the Veteran’s service and was not permanently worsened or aggravated by his active duty. On appeal of the Board decision to the Court, in the subsequent March 2013 memorandum decision, the Court found that service treatment records indicated a hearing loss disability for VA compensation purposes in the left ear but not in the right ear. It was further noted that the April 2010 VA examination report, on which the Board had principally relied in an April 2011 decision, was inadequate to support the finding that clear and unmistakable evidence demonstrated that bilateral hearing loss pre-existed and was not permanently worsened, or aggravated, during service. The April 2010 VA examiner’s statement that “[t]here was not a clinically significant difference between the thresholds obtained for hearing examination in 1970 (induction) than those obtained in 1971 (separation)” was found not to have been supported by adequate rationale or explanation. The Court found “[i]n view of the fact that the right-ear audiometer readings increased as compared to the readings upon entry, that it is unclear whether these increases constituted a worsening, and that the examiner did not discuss whether there was clear and unmistakable evidence that any worsening was due to the natural progress of the disease, the failure of the Board to require an explanation for this bare conclusion is error.” The Board remanded the claim for another VA examination. At a May 2014 examination, the Veteran’s pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 30 35 30 70 70 LEFT 75 75 80 75 75 The examiner diagnosed sensorineural hearing loss. Concerning the right ear, the examiner opined that the Veteran’s right ear hearing loss was not at least as likely as not caused by or a result of an event in service. The examiner explained that although hearing loss was present at the time the Veteran entered service, and although there was a change in the 500 Hertz threshold, 500 Hertz was not a frequency that was susceptible to noise injury. The examiner further stated that there was no clinically significant difference when the 500 Hertz thresholds obtained on that day and in 2010 and in 2005 were compared to the 1970 audiogram. Therefore, the change shown in 1971 was not permanent. The examiner further opined that the Veteran’s right ear hearing loss existed prior to service and was not aggravated beyond normal progression while on active duty. For a rationale, the examiner explained that there was a 15-decibel change in the 5000 Hertz threshold only when the 1971 audiogram was compared to the 1970 audiogram. Concerning the left ear, the examiner the examiner opined that the Veteran’s left ear hearing loss was not at least as likely as not caused by or a result of an event in service. The examiner explained that although hearing loss was present at the time the Veteran entered service, there were no significant shifts in thresholds at some frequencies between the entrance audiogram and the separation audiogram. The examiner felt that the Veteran’s sensorineural hearing loss configuration was consistent with the diagnosis of Meniere’s disease that had an onset in about 1992. Further, the examiner felt that the Veteran’s hearing loss existed prior to service and was not aggravated beyond the normal progression during service. For rationale, the examiner explained that there were no clinically significant changes in hearing thresholds at any test frequency when the 1971 audiogram was compared to the 1970 audiogram. Upon return to the Board, the Board found it significant that the May 2014 VA audiologist’s opinions addressed the in-service right and left ear threshold findings and found that the Veteran had a right ear hearing loss at the time he entered service and that there were no significant shifts in the left ear during service. However, the examiner provided no indication as to what evidence was considered to have demonstrated a pre-existing right ear hearing loss or whether that evidence was noted upon enlistment examination or was shown by other clear and unmistakable evidence. It was further noted, in essence, that a change in the right ear thresholds at 500 Hertz was not indicative of a noise-induced hearing injury because that was not a frequency susceptible to noise injury and that there was no clinically significant difference in the right ear findings at this level as compared to the 1970 audiogram. In light of the Court’s prior finding that a similar statement addressing the absence of clinically significant threshold changes did not support the conclusion provided, the Board found that additional rationale was required for the provided opinions as to the right and left ear hearing loss issues. The Board further noted that the matters at issue were complex and involved determinations concerning whether specific audiogram findings indicated hearing loss disorders or disabilities that were noted upon enlistment examination and whether audiogram findings upon separation examination indicate changes sufficiently significant to demonstrate the onset of a right ear hearing loss disability or the aggravation of a left ear hearing loss disability during service. The Board previously found it unclear in this case whether the enlistment examination findings “note” a right ear hearing acuity that was less than normal but not disabling for VA compensation purposes and whether shifts in hearing acuity upon separation examination demonstrated the normal progression of abnormal right ear hearing acuity, the onset of a right ear hearing loss disability, or an unreliable 500 Hertz threshold finding. As to the left ear hearing loss claim, the basis for a conclusion that there were no significant threshold shifts was found to be unclear. Therefore, in October 2014, the Board again remanded the claim for a VA examiner opinion. The requested opinion was provided by a VA audiologist in November 2015. The examiner stated that a review of the claims file showed preexisting hearing loss bilaterally at the enlistment and separation examinations with no significant threshold shift aggravation noted at any frequency. The examiner found the service medical records to be silent for hearing loss or tinnitus complaints. Concerning the right ear, the examiner explained that the Veteran’s right ear hearing loss (aggravation, as the Veteran had hearing loss at enlistment) was less likely as not (less than 50/50 probability) caused by or a result of noise exposure in service. It was also less likely as not that the right ear hearing loss noted at induction increased in severity during active service. The examiner explained that the induction and separation audiograms indicated a preexisting hearing loss without significant threshold shift greater than 10 decibels at 1000 to 4000 Hertz. The examiner found that the records showed no significant changes in hearing thresholds greater than normal measurement variability during service. It was noted that a change in hearing is a significant change greater than normal measurement error (i.e. greater than 10 decibels HL). The examiner explained that although VBA will concede any change of 15 decibels or more at any frequency 1000 to 4000 Hertz, there was no change of 15 decibels or greater at 1000 to 4000 Hertz. There was a temporary change at 500 Hertz that was not evident at subsequent audiograms in 1990s. The examiner explained that the 500 Hertz frequency is not affected typically by noise exposure. The examiner found no record of complaint or treatment of hearing loss in the service records. The examiner further explained that the Institute of Medicine (IOM) concluded that based on current knowledge of cochlear physiology “there was not sufficient evidence from the longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one’s lifetime, long after the cessation of that noise exposure. Although the definitive studies to address this issue have not been performed, based on the anatomical and physiological data available on the recovery process following noise exposure, it is unlikely that such delayed effects occur.” Therefore, the examiner found that the IOM stated there was insufficient scientific basis to conclude that permanent hearing loss directly attributable to noise exposure will develop long after noise exposure. The IOM panel concluded that based on their current understanding of auditory physiology a prolonged delay in the onset of noise-induced hearing loss was unlikely. Based on the objective evidence (audiograms), the examiner concluded that there was no evidence on which to conclude that the Veteran’s current hearing loss aggravation in the right ear was caused by or a result of the Veteran’s military service, including noise exposure. Concerning the left ear, the examiner found clear and unmistakable evidence that the Veteran had a left ear hearing loss at entrance to the service. The examiner opined that the left ear hearing loss (aggravation, as the Veteran had hearing loss at enlistment) was less likely as not (less than 50/50 probability) caused by or a result of noise exposure in the military. The examiner opined that it was less likely as not that left ear hearing loss noted at induction increased in severity during the Veteran’s active service. For rationale, the examiner again explained that the induction and separation audiograms indicated a preexisting hearing loss without significant threshold shift greater than 10 decibels at 1000 to 4000 Hertz. The examiner observed that the records showed no significant changes in the Veteran’s hearing thresholds greater than normal measurement variability during his military service. The examiner explained that a change in hearing is a significant change greater than normal measurement error (i.e greater than 10 dedibels HL) and that VBA will concede any change of 15 decibels or more at any frequency 1000 to 4000 Hertz. However, in the Veteran’s case, there was no change of 15 decibels or greater from 500 Hertz through 4000 Hertz. There was no record of complaint or treatment of hearing loss in the service records. The examiner again commented that the Institute of Medicine concluded that based on current knowledge of cochlear physiology “there was not sufficient evidence from the longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one’s lifetime, long after the cessation of that noise exposure. Although the definitive studies to address this issue have not been performed, based on the anatomical and physiological data available on the recovery process following noise exposure, it is unlikely that such delayed effects occur.” Therefore, the examiner found that the IOM stated there was insufficient scientific basis to conclude that permanent hearing loss directly attributable to noise exposure will develop long after noise exposure. The IOM panel concluded that based on their current understanding of auditory physiology a prolonged delay in the onset of noise-induced hearing loss was unlikely. Based on the objective evidence (audiograms), the examiner concluded that there was no evidence on which to conclude that the Veteran’s current hearing loss aggravation in the left ear was caused by or a result of the Veteran’s military service, including noise exposure. The examiner reiterated that there was clear and unmistakable evidence that the Veteran had a left ear hearing loss (and right ear hearing loss) at entrance to the service. The examiner opined that the left ear (and right ear) hearing loss aggravation (as the Veteran had hearing loss at enlistment) was less likely as not (less than 50/50 probability) caused by or a result of noise exposure in the military, and it was less likely as not that left ear (and right ear) hearing loss noted at induction increased in severity during active service. Again citing to the IOM, the examiner reiterated that based on the objective evidence (audiograms), the examiner could conclude that there was no evidence on which to conclude that the Veteran’s current hearing loss aggravation in the left ear (and right ear) was caused by or a result of service, including noise exposure. The examiner added that Veteran was diagnosed with Meniere’s disease in 1992. Therefore, there was an intercurrent condition of Meniere’s disease with which the hearing loss was most likely related in etiology. The examiner also noted that there was also 25 years of occupational plumbing construction noise exposure after service. The examiner also reconciled the opinion with the other opinions of record, including the January 2006 VA audiology addendum opinion and the April 2010 audiology opinion. The examiner specifically noted that all VA examiners concurred that the Veteran’s hearing loss aggravation was less likely as not due to service noise exposure and more consistent with Meniere’s syndrome/disease after review of all VA and private records. The examiner again stated that the Veteran’s hearing loss aggravation neither occurred in nor was caused by service. The service medical records were reviewed, and the examiner specifically noted that the Veteran denied a history of “ear nose and throat trouble,” “running ears,” and “hearing loss” at both enlistment and separation examinations. The examiner found no evidence of hearing loss aggravation documented in the service records, and the examiner found that there was no other credible evidence to corroborate the aggravation of hearing loss during the Veteran’s service. The Veteran’s attorney has submitted a July 2016 report from K.E.K., Ph.D., a psychologist. Dr. K. noted that the Veteran worked in the artillery while in service. The psychologist noted that according to the Veteran, the Veteran experienced damage to hearing in both ears as a result of repeated exposure to high volume sounds while on active duty. The Veteran related that damage had caused considerable problems including vomiting, vertigo, and tinnitus. Dr. K. stated that based on all available information, including the Veteran’s perspective, the Veteran’s duty led to the onset of hearing issues. In March 2013 and January 2018 memorandum decisions, the Court instructed the Board to bifurcate the claim and analyze claims for service connection for left ear hearing loss and service connection for right ear hearing loss separately. The following analysis proceeds accordingly. Left Ear Hearing Loss As a preliminary matter, the Board has considered whether the presumption of soundness attaches to the Veteran’s left ear hearing acuity. A Veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C. § 1111. Only conditions that are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). When no preexisting condition is noted upon entry into service, a Veteran is presumed to have been sound upon entry, and the presumption of soundness arises. The burden then shifts to VA to rebut the presumption of soundness by clear and unmistakable evidence that a Veteran’s disability was both preexisting and not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). The determination of whether there is clear and unmistakable evidence that a defect, infirmity, or disorder existed prior to service should be based upon “thorough analysis of the evidentiary showing and careful correlation of all material facts, with due regard to accepted medical principles pertaining to the history, manifestations, clinical course, and character of the particular injury or disease or residuals thereof.” 38 C.F.R. § 3.304(b)(1). Mere history provided by a Veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. § 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466 (1995); Crowe v. Brown, 7 Vet. App. 238 (1995). The presumption of soundness upon entry into service may not be rebutted without contemporaneous clinical evidence or recorded history in the record. Miller v. West, 11 Vet. App. 345 (1998). However, that does not mean that without such evidence the presumption can never be rebutted. Any such determination must consider how strong the other rebutting evidence might be. Harris v. West, 203 F.3d 1347 (Fed. Cir. 2000). The threshold for normal hearing is 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993). A hearing loss disability for VA compensation purposes is defined by regulation and impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The June 1970 enlistment examination shows readings that do not meet the current VA criteria to be considered a hearing loss disability for the left ear. 38 C.F.R. § 3.385. Therefore, the presumption of soundness attaches concerning the left ear. In order to rebut the presumption of soundness, the evidence must include clear and unmistakable evidence of a preexisting disability, and clear and unmistakable evidence that the pre-existing condition was not aggravated by service. The Board finds that the presumption of soundness has not been rebutted concerning the left hear hearing loss. The “clear and unmistakable” standard is a high one. Although the November 2015 VA examiner opined that the Veteran clearly and unmistakably had left ear hearing loss at the beginning of his active duty, the examiner did not give any reasoning to support that the Veteran had left ear hearing loss at the beginning of his active duty. The Board again notes that the June 1970 enlistment examination does not show audiometric readings that meet the current VA criteria to be considered a hearing loss disability for the left ear. There is no further recorded evidence from the time surrounding the Veteran’s actual entry to active duty which gives any indication that he had a pre-existing left ear hearing loss disability. As there is a lack of contemporaneous medical evidence indicating that the Veteran had a left ear hearing loss disability at the time he entered active duty, the presumption of soundness has not been rebutted, and the Board finds that the Veteran’s left ear hearing loss disability did not pre-exist his active duty. The Veteran’s December 1971 service separation examination shows readings that meet the current VA criteria to be considered a hearing loss disability for the left ear. 38 C.F.R. § 3.385. The May 2014 VA examination also shows readings that meet the current VA criteria to be considered a hearing loss disability for the left ear. The remaining pertinent question concerning the left ear hearing loss is thus whether the Veteran’s current left ear hearing loss is related to his service. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303. The most probative evidence of record does not support the finding of a nexus between currently demonstrated left ear hearing loss and service. The Board finds the opinion offered by the November 2015 VA audiologist to be the most persuasive evidence of record in this matter and that the opinion of the November 2015 VA examiner outweighs the other evidence of record. The examiner opined that the Veteran’s current left ear hearing loss was less likely as not (less than 50/50 probability) caused by or a result of noise exposure in the military. The opinion of the November 2015 VA examiner is highly probative because it was supported by detailed rationale and supported by medical research, and provided by a trained and experienced medical provider. That examiner was an audiologist. The examiner specifically identified and discussed the Veteran’s contentions and theory concerning service and his left ear hearing loss. For these reasons, the November 2015 VA opinion is found to be highly probative and carry significant weight. The Board places less probative value on the July 2007 private medical opinion. While the July 2007 physician opined that certainly a significant component of the Veteran’s hearing loss was consistent with noise exposure, the Board finds that the July 2007 medical opinion is not supported by adequate rationale, as there is no explanation as to the relationship between the Veteran’s current left ear hearing loss and Meniere’s disease, and the opinion did not specifically link the left ear hearing loss to noise exposure in service. If the examiner does not provide a rationale for the opinion, that weighs against the probative value of the opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). The Board is not bound to accept medical opinions that are based on history supplied by the Veteran, where that history is unsupported by the medical evidence or based upon an inaccurate factual background. Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993). The Board also places less probative value on the July 2016 private examiner’s opinion. The July 2016 opinion was offered by a psychologist, not an audiologist. Therefore, the record does not suggest that the July 2016 examiner had the training necessary to offer a competent opinion regarding an audiological matter or that would make that opinion more persuasive than an opinion offered by an audiologist. The Board has considered the Veteran’s and his spouse’s statements. There is no indication that the Veteran or spouse have had any medical training. Therefore, their statements are considered lay evidence. As laypersons, the Veteran and his spouse are competent to diagnose and report on simple conditions. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). They are competent to testify as to the Veteran’s difficulty hearing, as that symptom is readily identifiable through casual observation. Further, the Veteran is competent to testify as to his experiences being surrounded by gunfire while on active duty. However, although the Veteran’s December 1971 service separation examination shows readings that meet the current VA criteria to be considered a hearing loss disability for the left ear, the Veteran specifically noted on the December 1971 Report of Medical History that he did not experience hearing loss; running ears; ear, nose, or throat trouble; or dizziness. The December 1971 Report of Medical History contains the Veteran’s own perceptions of his symptoms (or lack thereof) at the conclusion of his active duty service. Although the Veteran and his spouse now claim that they have observed a continuity of hearing loss symptoms from the time of the Veteran’s service through the present, these present statements differ from the Veteran’s own perception of his symptoms that he recorded on the December 1971 Report of Medical History. Ultimately, considering the record as a whole, the Board finds that the opinion of the November 2015 VA examiner outweighs the opinion of the Veteran and his spouse. Again, the opinion of the November 2015 VA examiner is highly probative because it was supported by detailed rationale and supported by medical research, and provided by a trained and experienced audiologist who specifically identified and discussed the Veteran’s contentions and theory concerning service and his left ear hearing loss. Certain chronic diseases listed in 38 C.F.R. § 3.309(a) will be service connected on a presumptive basis if they manifested to a compensable degree within one year after service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3). The Veteran’s attorney has argued that hearing loss is an organic disease of the nervous system and thus falls within 38 C.F.R. § 3.309(a). Fountain v. McDonald, 27 Vet. App. 258 (2015) (sensorineural hearing loss is considered subject to § 3.309(a) as an organic disease of the nervous system). However, the only audiometric findings of record contemporaneous to the one-year period following the Veteran’s service are those contained on the December 1971 service separation examination, and those do not show that the Veteran had left ear hearing loss to a compensable degree. 38 C.F.R. §§ 4.85. Therefore, service connection for left ear hearing loss is not warranted on a presumptive basis pursuant to 38 C.F.R. § 3.309(a). Service connection may be granted when all the evidence establishes a medical nexus between military service and current complaints. Degmetich v. Brown, 104 F. 3d 1328 (1997); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). In this case, the most probative evidence of record does not support a finding of a medical nexus between service and the Veteran’s left ear hearing loss. The Board finds that the evidence of record weighs against such a finding. Thus, the Board finds that service connection for left ear hearing loss is not warranted. Right Ear Hearing Loss As a preliminary matter, the Board has considered whether the presumption of soundness attaches to the Veteran’s right ear hearing acuity. The Veteran’s June 1970 enlistment examination clearly shows readings that meet the current VA criteria to be considered a hearing loss disability for the right ear. 38 C.F.R. § 3.385. Therefore, the presumption of soundness does not attach concerning the right ear. The pertinent question concerning the right ear hearing loss is whether the pre-existing bilateral hearing loss was aggravated by service. 38 U.S.C. §§ 1153; 38 C.F.R. §§ 3.304(b), 3.306. The Board finds the opinion offered by the November 2015 VA audiologist to be the most probative and persuasive evidence of record. The November 2015 VA audiologist opined that the Veteran’s pre-existing right ear hearing loss was less likely as not (less than 50/50 probability) caused by or a result of noise exposure in service. She also opined that it was also less likely as not that the right ear hearing loss noted at induction increased in severity during active service. The examiner reviewed and specifically commented on the in-service audiograms. The Board finds that the opinion of the November 2015 VA examiner is highly probative because it was supported by detailed rationale and supported by cited medical research, and provided by a trained and experienced medical provider. The examiner specifically identified and discussed the Veteran’s contentions and theory concerning service and right ear hearing loss. Accordingly, the November 2015 VA opinion is found to carry significant weight. Among the factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. Hayes v. Brown, 5 Vet. App. 60 (1993); Wood v. Derwinski, 1 Vet. App. 190 (1992). The probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). The Board places less probative value on the July 2007 private medical opinion. While the July 2007 physician opined that certainly a significant component of the Veteran’s hearing loss was consistent with noise exposure, the Board finds that the July 2007 medical opinion is not supported by adequate rationale, as there is no explanation as to the relationship between the Veteran’s current hearing loss and Meniere’s disease, and the opinion did not specifically link the hearing loss to noise exposure in service. More specifically, the July 2007 physician did not opine regarding in-service aggravation of a pre-existing right ear hearing loss. If the examiner does not provide a rationale for the opinion, that weighs against the probative value of the opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). The Board is not bound to accept medical opinions that are based on history supplied by the Veteran, where that history is unsupported by the medical evidence or based upon an inaccurate factual background. Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993). Similarly, the Board places less probative value on the July 2016 private examiner’s opinion. The July 2016 opinion was offered by a psychologist, not an audiologist. Therefore, the record does not suggest that the July 2016 examiner had the training necessary to offer a competent opinion regarding an audiological matter. The Board has considered the Veteran’s and his spouse’s statements and acknowledges that as laypersons, they are competent to diagnose and report on simple conditions. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, the question of whether a pre-existing right ear hearing loss was aggravated beyond the normal progression of the disease presents a complex question. As lay persons, the Veteran and his spouse have not been shown to have the training or expertise necessary to offer a competent opinion in such a complex medical matter. Therefore, the Board finds the November 2015 VA examiner’s opinion to be more probative than the Veteran’s assertions. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds accordingly that the most probative evidence of record in this case shows that the Veteran’s right ear hearing loss pre-existed his period of service and was not permanently worsened, or aggravated, during service. Service connection may be granted when all the evidence establishes a medical nexus between military service and current complaints. Degmetich v. Brown, 104 F. 3d 1328 (1997); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). In this case, the most probative evidence does not support a finding that the Veteran’s pre existing right ear hearing loss permanently increased in severity during active service. The Board finds that the most probative evidence of record weighs against that finding. Thus, the Board finds that service connection for right ear hearing loss is not warranted as clear and unmistakable evidence is against a finding that right ear hearing loss was aggravated during service. 3. Entitlement to service connection for a psychiatric disability The service medical records are negative for any complaints or treatment for any psychiatric disorder. On separation examination in December 1971, the Veteran’s psychiatric system was found to have no abnormalities. The Veteran indicated on a December 1971 Report of Medical History that he had frequent trouble sleeping. An examiner commented that the Veteran had rather irregular sleeping habits that were deemed to be nothing of significance. The first post-service evidence of symptoms of any psychiatric disorder is a November 1995 Social Security Administration (SSA) disability report where the Veteran complained of being depressed. Post-service VA and private medical records show that the Veteran received intermittent treatment for major depressive disorder, alcohol dependence, substance-induced mood disorder, and bereavement. A December 1997 SSA decision found that the Veteran was disabled due to L4 L5 spondylolisthesis, bilateral L5-S1 lumbar radiculopathy, and depression. The Veteran and his spouse testified before the Board at a June 2007 Board hearing. Testimony stated that the Veteran began experiencing depression during service. The Veteran’s spouse testified that the Veteran was isolated in the house and was not socializing or watching television. The spouse reported that the Veteran’s depression had been very hard on their marriage because he could not work after service, and she had to financially support both of them for almost two years. She stated that the Veteran had indicated to her that he was a burden to her and that she would be better off without him. On VA examination in April 2010, the Veteran complained of depressed mood, lack of interest, pleasure, and motivation; social withdrawal; tearfulness; hypersomnia; poor concentration and memory; fatigue; and suicidal ideation. He reported that those symptoms occurred every day and were moderate to severe. He stated that he had been experiencing those symptoms since he stopped working about 14 to 15 years ago. The Veteran’s wife felt that the Veteran had been depressed since he left service. The Veteran stated that there were events that occurred during service that bothered him. He felt that his military training had made him a different person and contributed to his depression. The examiner diagnosed recurrent major depression. The examiner opined that the Veteran’s major depression was less likely as not caused by or a result of active service. The examiner explained that while the Veteran and spouse reported that the Veteran’s depression was in part due to reactions to experiences he had during service, the depression actually appeared to be primarily a reaction to a motor vehicle accident and related injuries and impairments that occurred in 1994. The examiner reported that the Veteran’s depression was not documented in the medical record until after the motor vehicle accident and that it was repeatedly noted as being a reaction to the motor vehicle accident and related injuries and problems. The Veteran also indicated at the examination that he felt his depression truly became a problem after the accident in 1994 made him unable to work, but that he and his wife noted some personality changes had occurred after service. The examiner found that the personality changes occurring after discharge from service may have been due in part to the Veteran’s abuse of alcohol at the time. On VA examination in May 2014, the examiner diagnosed unspecified depressive disorder. The examiner noted that according to the medical record, the Veteran first became depressed in 1994 when he was involved in a motor vehicle accident. Specifically, the examiner opined that the Veteran’s depressive disorder was less likely than not incurred in or caused by service. The examiner opined that the Veteran’s symptoms were more likely related to a history of alcohol dependence and back injury that occurred in 1994. For a rationale, the examiner specified that the opinion was based on clinical experience and research, clinical interview data, DSM5 criteria, behavioral observation, and supporting service and medical records. The Veteran underwent a private psychological evaluation in July 2016. The Veteran reported that during his time in service, he worked in artillery training. After leaving service, he worked in plumbing and construction for the next 25 years. It was noted that the Veteran had not worked regularly since the 1990s due to back problems, complications from nerve damage to his ears, chronic depression, and alcoholism. The Veteran reported that he had limited mental health treatment despite experiencing depressive episodes and alcohol dependence since his early 20s. He stated that he first became aware of and willing to seek treatment in the 1990s. However, his treatment was brief, and he did not reestablish treatment until 2005. There was no history of consistent therapy. The examiner stated that the Veteran had a long history of problems with depression. Based on the Veteran’s report of symptoms and a review of the claims file, the examiner opined that the Veteran began experiencing a number of symptoms of depression and substance abuse problems subsequent to separation from service. According to the Veteran and his spouse, the Veteran began exhibiting irritability, sleep disturbance, and chronic sadness on discharge from service. The Veteran had begun drinking alcohol nightly while in service. Based on all available information, including the Veteran’s own perspective on the development of his mental health problems, the examiner felt that a few service-related activities during the Veteran’s duty led to the onset of independent psychological problems. The examiner noted that the 2014 VA examiner opined that the Veteran’s depression was less likely than not due to or the result of the Veteran’s service-connected condition, although the Veteran reported that he had experienced problems with depression since his early 20s. The examiner stated that the Veteran’s service separation examination corroborated that the Veteran had frequent trouble sleeping. It was the examiner’s opinion that the Veteran’s depression was at least as likely as not in the prodromal phase toward the end of service, quickly worsened during transition into civilian life, and was exacerbated by medical complications. The Veteran underwent another private mental examination in July 2018. After reviewing the available records and interviewing the Veteran and his spouse, the examiner opined that it was at least as likely as not that the Veteran’s current psychiatric symptom presentation emerged in prodromal form with the onset of sleep disturbance while the Veteran was actively serving in the Army. The examiner noted that the Veteran reported frequent trouble sleeping while on active duty, and his December 1971 Report of Medical History noted that he had irregular sleeping habits. The examiner reviewed and commented on the Veteran’s and spouse’s report of his post-service behavior. The examiner acknowledged the 1994 motor vehicle accident but opined that the Veteran’s depressive symptoms were present prior to the accident and aggravated by the accident. The examiner diagnosed persistent depressive disorder and reiterated that it was at least as likely as not that the Veteran’s psychiatric symptoms were present in prodromal form while he served in the Army. The Board acknowledges that April 2010 and May 2014 VA examiners opined that it was less likely as not that the Veteran’s claimed psychiatric disability was the result of active duty. The examiners commented on the evidence of record that had been assembled at that point, and an alternative etiology was given for the Veteran’s psychiatric symptoms. However, in July 2016 and July 2018, private examiners opined that it was at least as likely as not that the Veteran’s claimed psychiatric disability was the result of active duty. In particular, the July 2018 private examiner had the benefit of a review of the most complete and up-to-date evidence associated with the claim, and the July 2018 private examiner gave explicit consideration to both the positive and negative evidence of record. The alternative etiology posited by the prior VA examiners was acknowledged, considered, and explained within the given opinion. Considering the body of evidence as a whole, the Board finds that the negative VA opinions and opinions from the private examiners are at the very least in equipoise and the evidence for and against the claim is therefore in equipoise. As the Veteran’s in-service sleeping difficulties were documented, as he has a current psychiatric disability, and as the competent credible evidence regarding any connection between the currently diagnosed psychiatric disability and the Veteran’s service is in equipoise, the Board will resolve reasonable doubt in favor of the Veteran and finds that a current psychiatric disability is related to service. Therefore, service connection for a psychiatric disability is warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Layton, Counsel