Citation Nr: 18156379 Decision Date: 12/11/18 Archive Date: 12/07/18 DOCKET NO. 16-51 931 DATE: December 11, 2018 REMANDED Entitlement to service connection for a bilateral hearing loss disability is remanded for additional development. Entitlement to service connection for tinnitus is remanded for additional development. Entitlement to service connection for an erectile dysfunction disability is remanded for additional development. REASONS FOR REMAND The Veteran had active military service with the U.S. Army from June 1970 to March 1972. During this time, he was awarded the Vietnam Service Medal, the Vietnam Campaign Medal, and the National Defense Service Medal. These matters come to the Board of Veterans’ Appeals (Board) on appeal from an May 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada. 1. Entitlement to service connection for bilateral hearing loss and tinnitus disabilities are remanded. The Veteran maintains that he developed bilateral hearing loss and tinnitus as a result of his active service, asserting that he developed both after being exposed to loud noises as a result of combat exposure as well as his job as a quarry machine operator while deployed to Vietnam. In conjunction with this claim, the Veteran underwent a VA hearing loss and tinnitus examination in March 2014. See March 2014 VA Hearing Loss and Tinnitus Disability Benefits Questionnaire (DBQ). The VA examiner did not establish diagnoses for any of the claimed conditions, indicating that the Veteran could not be tested for either puretone thresholds or speech discrimination scores. Id. The examiner determined that the exam results were invalid because the Veteran “showed inconsistent responses to all pure tones.” Id. The examiner further stated that “recognition thresholds were consistent and repeatable” and the “[three] frequency pure tone average was 36dBL in the right ear and 30dBL in the left ear,” ultimately determining, “[t]his difference between SRT and PTA is consistent with non-organic hearing loss.” Id. Regarding the Veteran’s reports of manifestations of tinnitus, the examiner provided the same rationale as had been previously provided for hearing loss to why the etiology of the Veteran’s claimed tinnitus could not be determined, again stating, “[t]his examination is not valid for rating purposes.” Id. These opinions are not adequate for rating purposes. In this regard, the VA examiner did not provide any measurements for either puretone threshold testing or speech discrimination, instead repeatedly stating the examination was invalid for rating purposes, and while an opinion was put forth regarding the possibility of nonorganic hearing loss, there was no discussion in the rationale as to why the Veteran’s results were inconsistent, instead focusing on the examiner’s multiple unsuccessful attempts to find true organic thresholds and speech discrimination scores. Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). An adequate medical opinion with regard to etiology should consist of a thorough review of the claims file and discussion of the relevant evidence (including the disability in question), a consideration of the lay contentions of the Veteran, and clear conclusions with a supporting rationale. Barr, 21 Vet. App. at 311; Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Accordingly, new hearing loss and tinnitus examinations are necessary to determine the nature and etiology of the Veteran’s claims with respect to entitlement to service connection. 2. Entitlement to service connection for an erectile dysfunction disability is remanded. The Veteran also maintains that he developed his currently-diagnosed erectile dysfunction as a result of his active service, specifically indicating his belief that his claimed condition was related to herbicide agent exposure while deployed to Vietnam. In conjunction with this claim, the Veteran underwent a VA male reproductive conditions examination in March 2014. See March 2014 VA Male Reproductive System Conditions DBQ. The VA examiner ultimately determined that the Veteran’s erectile dysfunction was of “unknown etiology” but provided no rationale as to why the etiology was unknown. Id. Again, this medical opinion is inadequate for rating purposes. The VA Mal reproductive examination contained a sole notation as to the “unknown etiology” of the Veteran’s erectile dysfunction without any explanation as to why this was the case. Again, once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one. Barr, 21 Vet. App. at 311-12. An adequate medical opinion regarding etiology should consist of a thorough review of the claims file and discussion of the relevant evidence (including the disability in question), a consideration of the lay contentions of the Veteran, and clear conclusions with a supporting rationale. Id.; Stefl, 21 Vet. App. at 123; Nieves-Rodriguez, 22 Vet. App. at 301. Accordingly, a new male reproductive systems examination is necessary to determine the nature and etiology of the Veteran’s claim with respect to entitlement to service connection. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records for the Veteran. All attempts to secure any identified records and any response received must documented in the case file. 2. After any available records are associated with the claims file, schedule the Veteran for additional VA examinations in the appropriate specialty to determine the nature and etiology of the Veteran’s current 1) bilateral hearing loss, 2) bilateral tinnitus, and 3) erectile dysfunction disabilities. The examinations should include any diagnostic testing or evaluation deemed necessary for each specific claimed disability. The electronic claims file, including a copy of this remand, must be made available for the examiner to review. The examination report must include a notation that this record review took place. The Veteran must be interviewed. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. The examiner must provide a clear explanation for the opinion, to include any comment on any credibility issues raised by the record from a medical perspective. With respect to the hearing loss examination, the examination should include any diagnostic testing or evaluation deemed necessary, including the Maryland CNC test and a puretone audiometry test. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results as to each claimed condition, that is: 1) bilateral hearing loss, 2) bilateral tinnitus, and 3) erectile dysfunction disabilities, the examiner is requested to provide an opinion as to the following question: Is it at least as likely as not (i.e. a 50 percent probability or greater) that the disability began during, or is otherwise related to the Veteran’s active duty service? The examiner must provide a complete rationale for all opinions expressed. As part of the rationale, the examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the issues on appeal should be readjudicated. If the benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case and allowed an appropriate period of time for response. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Raj, Associate Counsel