Citation Nr: 18156376 Decision Date: 12/11/18 Archive Date: 12/07/18 DOCKET NO. 15-16 599 DATE: December 11, 2018 REMANDED Entitlement to an increased rating for bilateral onychomycosis is remanded. Entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1964 to June 1968. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an April 2013 rating decision. The Veteran’s onychomycosis is currently rated under 38 C.F.R. § 4.118, DC 7806. Under this rating criteria, one of the key considerations is whether the Veteran has been receiving topical treatment or systemic therapy for his skin condition. The Veteran’s most recent VA examination in June 2018 documents only topical treatment for his onychomycosis. Since that time, the Veteran has submitted a September 2018 private medical treatment record from his physician K.W.W. that appears to indicate treatment with a medication not previously documented in his records, described as Grisofulvin, which appears to possibly be an oral medication (as opposed to topical). Unfortunately, there is not sufficient information in the record currently to determine if the Veteran currently takes this medication to treat his service-connected condition and, if so, if it would meet the criteria for being defined as a systemic therapy. Furthermore, VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). “An opinion is adequate where it is based upon consideration of the Veteran’s prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one.” Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (internal citations and quotations omitted). A March 2013 VA examination determined that the Veteran has a current bilateral hearing loss condition, but the examiner opined that his hearing loss was not at least as likely as not caused by or the result of an event in military service. The rationale provided is based on the Veteran’s separation hearing test, which shows hearing within the normal range and, when compared to his enlistment test, reveals no shift of his hearing threshold. The examiner cites the holding in Hensley v. Brown, 5 Vet. App. 155 (1993) in support of his finding. The Veteran has submitted lay evidence in support of his claim that indicates he showed signs of hearing loss shortly after discharge from service. Along with his own testimony before a DRO at a VA Regional Office describing the hazardous noise he worked around in service, the Veteran has also provided a buddy statement from a friend who knew him in 1969, approximately one year after his discharge. This statement indicates the Veteran’s friends and family expressed concern regarding his hearing after his return home from the Air Force due to his lack of awareness regarding the volume of his own voice. This statement also indicates recent treatment has addressed this issue. In light of the lay evidence of record, the March 2013 opinion is inadequate, as the opinion fails to fully address whether the Veteran’s bilateral hearing loss is directly related to military service, particularly his reported noise exposure therein. The opinion relies solely on the lack of any hearing loss during military service; however, a lack of any noted hearing loss in service is not fatal to a claim of service connection. See Hensley, 5 Vet. App. at 159. Though the holding in Hensley cited declines in threshold hearing levels during service as evidence of a hearing disability, the Board notes this was not the sole evidence upon which the holding was based. Rather, adequate rationale must be provided to address the totality of the supporting evidence raised by the Veteran’s record. The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate clinician describing the nature of the medication noted in the September 2018 private treatment record from N.W.W. indicating treatment with Grisofulvin, to include whether the medication is topical or systemic (i.e. administered through any route other than the skin). If this medication is currently being taken by the Veteran to treat his service-connected disability, the clinician is asked to determine for how long the Veteran has taken this medication in the past 12 months. 2. Obtain an opinion from an appropriate clinician regarding whether the Veteran’s bilateral hearing loss is at least as likely as not related to acoustic trauma in service. The examiner should focus specifically on whether the noise exposure in service is the cause of any current hearing impairment. Facts and medical principles relied on to arrive at an opinion should be set forth, including any principles relating to the possibility of a delayed onset of loss of acuity due to noise exposure in service. In other words, if the examiner finds that the current hearing loss is not related to acoustic trauma in service solely because normal hearing was noted upon discharge, the examiner MUST explain the significance of normal hearing upon discharge and why this would preclude the current hearing loss from being related to acoustic trauma in service. The examiner should also address the lay statements of record regarding onset of symptomatology and any continuity of symptomatology since onset and/or since discharge from service. All opinions must be accompanied by an explanation. The lack of hearing loss documented in service cannot, standing alone, serve as the basis for a negative etiology opinion. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Pitman, Associate Counsel