Citation Nr: 18157034 Decision Date: 12/11/18 Archive Date: 12/11/18 DOCKET NO. 18-19 768 DATE: December 11, 2018 ORDER Entitlement to service connection for a back disorder is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for alcohol dependence with alcohol induced mood disorder is granted. Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for bilateral hearing loss disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) by reason of service connected disabilities is remanded. FINDINGS OF FACT 1. The weight of the evidence is against a finding that the Veteran does not has a low back disorder at any time during the appeal. 2. The weight of the evidence is against a finding that the Veteran has a current diagnosis of sleep apnea at any time during the appeal. 3. The evidence is at least in equipoise as to whether the Veteran has PTSD caused by his active military service stressors. 4. The evidence is at least in equipoise as to whether the Veteran has a current diagnosis of alcohol dependence with alcohol induced mood disorder secondary to his PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for a back disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for PTSD, which also encompasses other acquired psychiatric disorders and symptoms related to depression and anxiety, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 4. The criteria for service connection for alcohol dependence with alcohol induced mood disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1966 to June 1968. This matter comes before the Board of Veterans’ Appeals (hereinafter Board) on appeal from an April 2015 rating decision, which denied the Veteran’s claims of entitlement to service connection for a back disorder, service connection for sleep apnea, service connection for PTSD, service connection for bilateral hearing loss, service connection for alcohol dependence with alcohol induced mood disorder with psychotic features, and entitlement to a TDIU. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, organic diseases of the nervous system, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2017). A layperson can provide competent reports of factual matters of which he has first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Similarly, laypersons are competent to diagnose and provide nexus opinions to some extent, notably where the diagnosis or opinion is not of a complex nature. Id, see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for a back disorder The Veteran essentially contends that he sustained a back injury when he fell from a tree while on active duty at an observation post in Vietnam. He indicated that he was taken to the Field Medic Unit and was prescribed pain medication. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a low back disorder, and he has not had such at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). In this regard, the Board notes that the service treatment records (STRs) are completely silent with respect to any complaints or clinical findings of a back disorder. Separation examination was normal and no relevant complaints were raised in the accompanying report of medical history. Post-service treatment records, including VA as well as private treatment reports, do not reflect any complaints or clinical findings of a low back disorder. Moreover, the Veteran has not submitted any competent evidence supporting the claims that he has a back disorder. The threshold requirement here (as in any claim seeking service connection) is that there must be competent evidence that the Veteran has (or during the pendency of the claim has had) the disability for which service connection is sought, i.e., a low back disorder. The record does not include any such evidence. Notably, the treatment records associated with the record do not show any diagnosis or treatment for a back disorder. The Veteran's contentions do not support a finding that he has had persistent or recurrent symptoms of a back disorder. Accordingly, there is no valid claim of service connection for a back disorder. Brammer v. Derwinski, 3 Vet. App. 223 (1992). In so finding, the Board notes that the Veteran is considered competent to describe his symptoms, but he is not competent to render or provide current diagnoses of a back disorder which requires knowledge of the musculoskeletal system. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The evidence does not show that the Veteran has a back disorder. Absent a current diagnosis, service connection is not warranted. Even in consideration of the Veteran's statements, he has not specifically alleged a current diagnosis. Consequently, the preponderance of the evidence is against the claim for service connection for a back disorder. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for a back disorder. In denying this claim, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). 2. Entitlement to service connection for sleep apnea The Veteran essentially contends that he developed sleep apnea due to his exposure to environmental hazards in Vietnam, including burning trash, solvent, fuels, as well as exhaust fumes from trucks, as explained in his VA Form 9 dated in March 2018. The question for the Board is whether the Veteran has a current disability due to disease or injury that began during service or is at least as likely as not related to an in-service injury, event, or disease. Initially, the Board finds that Veteran's STRs do not reflect complaint, treatment, or diagnosis of sleep apnea or any sleep related disorder during service. His post-service medical records do not indicate treatment for or diagnosis of sleep at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303 (a), (d). In this regard, the Board notes that while the VA treatment reports reflect complaints of sleep problems, no health professional has attributed such problems to a sleep disorder, namely sleep apnea. Significantly, during a clinical visit in February 2015, the Veteran reported episodes of sleeping disturbances and nightmares since his time in Vietnam; he also reported restless sleep awakening with palpitations. The assessment was male patient who presents with anxiety, depressive symptoms, sleeping disturbances, with nightmares and recurrent thoughts of combat experiences in context of PTSD. Subsequently, at a DBQ examination in April 2015, the Veteran reported problems with restless sleep and noted that he is not sleeping well and waking up with nightmares; however, no diagnosis of a sleep disorder was noted. Despite the Veteran's assertions that he has sleep apnea, he has not offered any competent and credible medical evidence to support his assertions nor has he demonstrated that he has the knowledge, training, or education required to diagnose a medical disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). The Board therefore finds that service connection for sleep apnea is not warranted as there is no current diagnosis of a disability. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). The Veteran has not submitted any medical evidence that shows he has been diagnosed with sleep apnea during the appellate period or a diagnosis close in time to the appeal period. In short, service connection for sleep apnea cannot be granted, because there is no evidence of a present disability related to a disease or injury during service or since. The appeal must be denied as to this issue; there is no doubt to be resolved. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for posttraumatic stress disorder (PTSD) The Veteran essentially contends that he developed a psychiatric disorder as a result of traumatic events that he witnessed while on active duty in Vietnam. In a statement in support of his claim, dated in February 2015, the Veteran related that his unit was in charge of distributing communication materials to their troops; as a result, the Viet Cong troops constantly attacked their location in an attempt to destroy the communication site. The Veteran stated that he was in constant fear for his life. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f). Effective March 19, 2015, VA adopted as final, without change, an interim final rule amending the portion of its Schedule for Rating Disabilities dealing with mental disorders. The interim final rule replaced outdated references with references to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and updated the nomenclature used to refer to certain mental disorders in accordance with DSM-5. Specifically, the rulemaking amended 38 C.F.R. §§ 3.384, 4.125, 4.126, 4.127, and 4.130. However, the provisions of this final rule do not apply to claims that were certified to the Board on or before August 4, 2014, even if such claims are subsequently remanded to the agency of original jurisdiction. As this appeal was certified to the Board in April 2018, the criteria set forth in the DSM-5 applies but any examination performed using the DSM-IV will be considered. A diagnosis of PTSD requires that a Veteran have been exposed to a traumatic event, and that he experience a number of specified current symptoms. The traumatic event, or stressor, involves having experienced, witnessed, or being confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. In addition, the response must involve intense feelings of fear, hopelessness, or horror. Satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service even though there is no official record of such incurrence or aggravation. 38 C.F.R. § 3.304 (d); see also Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996) (under 38 U.S.C. §1154 (b), a combat Veteran’s assertions of an event during combat are to be presumed if consistent with the time, place and circumstances of such service). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). As an initial matter, the Board finds that the Veteran in this case engaged in combat with the enemy. Significantly, his military personnel records indicate that he served in Vietnam from February 1967 to February 1968; he participated in the Vietnam Counteroffensive Phase II. The Veteran received the Vietnam Service Medal, and the Republic of Vietnam Campaign Medal, sufficient evidence to conclude that he engaged in combat with the enemy. The combat provisions of 38 U.S.C. § 1154 (b) are applicable in this case. The Veteran has also provided several statements about his experiences in Vietnam. Specifically, in a statement in support of claim for PTSD, dated in February 2015, he related that his unit was in charge of distributing communication materials to their troops; as a result, the Viet Cong troops constantly attacked their location in an attempt to destroy the communication site. The Veteran was in constant fear for his life. He also reported that they were constantly under attack by the enemy; they received fire with mortar, artillery, RPG and small arms weapons. The Veteran indicated that they had to hide in the bunker due to enemy firing. He witnessed and walked through body parts of dead American as well as Vietnamese soldiers. As noted above, the Veteran was afforded a DBQ examination in April 2015. The examiner found that the DSM-V criteria for PTSD had not been met. However, the examiner also indicated that the stressors reported by the Veteran, including being constantly under attack by the enemy and walking through body parts of dead American as well as Vietnamese soldiers were adequate to support a diagnosis of PTSD. The examiner also noted that the Veteran persistently experienced recurrent distressing dreams of the events. A review of the Veteran's VA treatment record reflects a diagnosis of, and treatment for, PTSD, that have been rendered by a VA psychiatrist. Moreover, the record contains numerous private hospital reports showing that the Veteran has been diagnosed with and received treatment for PTSD. A private hospital report dated in January 2017 indicates that the Veteran presented with depressive symptomatology with suicidal ideas, hallucinations, poor insight and judgment; his final diagnoses were major depressive disorder, severe, recurrent with psychotic features, and PTSD. In light of the foregoing, the evidence supporting the issue as to whether the Veteran has a current diagnosis of PTSD is, at the very least, as probative (meaning as competent and credible) as the evidence against the claim. Therefore, the Board believes the point of equipoise has been reached in this appeal. While the April 2015 DBQ/VA examiner's concluded that the Veteran met most of the criteria for a diagnosis of PTSD, but nonetheless failed to provide a diagnosis of PTSD. the records reflect that the Veteran’s treating physicians have found that he has met the DSM-IV/V criteria for PTSD. Thus, the record shows medical evidence diagnosing PTSD based on the DSM-5 criteria, a link, established by medical evidence, between current symptoms and a stressor event in service, and credible supporting evidence that the claimed stressor event in service occurred. These findings are adequate to warrant service connection for PTSD under 38 C.F.R. § 3.304 (f). While there are contrary opinions of record, the Board finds that the positive medical evidence is sufficient to place the evidence in relative equipoise. Therefore, resolving reasonable doubt in favor of the Veteran, service connection for PTSD is granted. The Veteran's in-service stressors have been corroborated. The Veteran has a PTSD diagnosis, which has been linked to his in-service stressors. Thus, the Board finds that service connection for PTSD is warranted and the appeal is granted. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for alcohol dependence with alcohol induced mood disorder The Veteran seeks service connection for alcoholism, which he claims developed as a result of the stressors he experienced in service. He maintains that he used alcohol to erase the memories of the horrified events he witnessed in Vietnam. After weighing the evidence, the Board finds in favor of the Veteran's claim of service connection for alcohol dependence with alcohol induced mood disorder. To that end, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). Although service connection is not possible for primary drug or alcohol abuse; service connection is possible for such abuse if it is secondary to a service-connected disability. See 38 U.S.C. § 105; Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001); 38 C.F.R. §§ 3.1 (m), 3.301(d). As noted above, the Board has determined that the Veteran’s PTSD is related to stressors experienced during his period of active duty in Vietnam. Here, the evidence regarding whether the Veteran's alcohol dependence and alcohol induced mood disorder is related to his PTSD supports the claim. Significantly, following a DBQ examination in April 2015, the examiner reported a diagnosis of alcohol dependence and alcohol induced mood disorder with psychotic features. The examiner also stated that the Veteran’s claimed auditory and visual hallucinations which were most probably due to his alcohol abuse/dependence. The examiner explained that alcohol a potent psychoactive substance and alcohol abuse/dependence increases risk for depressive disorders and can exacerbate a depressive disorder. In an assessment, printed in December 2016, it was noted that the Veteran was seen for an evaluation following a recent hospital admission in January 2015. The Veteran presented with maintained major depressive disorder, recurrent and severe psychotic symptoms, alcohol use disorder and PTSD, delayed onset. It was noted that the Veteran was forthcoming about his alcohol use as a means to manage distress associated to trauma from Vietnam and Maritime Police. The diagnoses were major depressive disorder, recurrent and severe without psychotic symptoms; alcohol use disorder, and PTSD with delayed onset. Of record is a treatment note, dated in May 2018, which indicates that he had a history of depression, PTSD and alcohol use disorder who continues with chronic and bothersome PTSD symptoms despite compliance with psychotropics and minimal alcohol use since he joined our clinic. He said had never try CPT nor prolonged exposure and is willing to try those treatment options, if recommended. Moreover, a July 2018 hospital summary noted that the Veteran was admitted for symptoms of depression, anxiety, and use of alcohol, all of which were trauma related. The pertinent diagnoses were PTSD and alcohol use disorder. The medical evidence of record makes clear that the Veteran’s alcohol abuse is a symptom of his psychiatric disorder, including his PTSD. The Veteran's statements and the examiners’ acknowledgement that he coped with his PTSD through substance abuse, place the evidence at least in equipoise. After resolving all reasonable doubt in the Veteran's favor, the evidence supports a finding that his alcohol dependence and alcohol induced mood disorder are related to his PTSD. Consequently, the Board finds that the Veteran’s alcohol abuse was not the result of willful misconduct, but was a symptom of his service-connected PTSD. Accordingly, the Board finds that service connection for alcohol dependence and alcohol induced mood disorder is warranted as secondary to the service connected PTSD. REASONS FOR REMAND After a thorough review of the Veteran’s claims file, the Board has determined that additional evidentiary development is necessary prior to the adjudication of the issues on appeal. 1. Entitlement to service connection for bilateral hearing loss disability is remanded. The Veteran contends that his bilateral hearing loss was incurred as a result of his exposure to loud noise from gunfire and mortars while on active duty. He related that, while in active duty serving in Vietnam, he had to cross-train with an artillery unit due to a short of personnel. The Veteran further reported that they were constantly receiving fire trying to support the troops and the loud noise damaged his hearing. The record reflects diagnoses of bilateral hearing loss and tinnitus and the severity of his hearing loss in each ear meets the criteria for a disability as defined by 38 C.F.R. § 3.385. See April 2015 VA Examination Report. Also, the Veteran's service records indicate that he served as a Field Radio Mechanic. The RO has determined that the Veteran’s military occupational specialty (MOS) involve hazardous noise exposure; thus, in-service noise exposure is conceded. Following a VA audiological examination in April 2015, the examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event or illness, explaining that it is well known that prolonged exposure to high intensity noise levels like the military type can cause damage to auditory structures resulting in hearing loss. The examiner noted that the Veteran was exposed to military noise including helicopters, fire range and cannons for one year in Vietnam. However, he noted that the separation examination in 1969 indicated bilateral normal hearing even after being exposed to hazardous noise known to result in hearing loss. Therefore, it is his opinion that the Veteran's bilateral hearing loss is less likely than not incurred in or caused by (the) acoustic trauma during service. The Board finds the April 2015 opinion insufficient to determine whether the Veteran is entitled to service connection for bilateral hearing loss. As an initial matter, the opinion appears to be based on an inaccurate factual premise and reflects a less than thorough review of the evidence. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based on an inaccurate factual premise has no probative value). In this regard, while the examiner reported that the separation examination was normal, the record reflects that the June 1968 audiogram at separation shows some threshold shifts when compared to the Veteran’s September 1965 entrance examination. It is not clear whether the examiner considered this evidence in rendering the negative nexus opinion. Further, the VA examiner based the negative nexus opinions on a finding that the Veteran’s hearing at separation was within normal limits. Relying on the absence of evidence in medical records without regard for lay statement to provide a negative opinion is contrary to established case law, and such opinions are therefore inadequate. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Moreover, hearing acuity within normal limits on separation does not preclude service connection for a current hearing loss disability. See Hensley v. Brown, 5 Vet. App. 155 (1993); Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). In Hensley v. Brown, 5 Vet. App. 155 (1993), the United States Court of Appeals for Veterans Claims (Court) held that even though a hearing disorder may not have been demonstrated at separation, a veteran may still establish service connection for a current hearing disorder by showing he now has a hearing disorder and by submitting evidence that his current hearing disability is related to his active military service. See also Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). In Hensley, there was an upward shift in threshold levels at some frequencies on an examination for separation and in-service audiometric testing yielded elevated thresholds at some frequencies. Thus, the Court found that the claim could not be denied solely because the hearing loss did not meet the criteria for 38 C.F.R. § 3.385 at separation. Rather, if there were any current hearing loss (by VA standards) it had to be determined whether shifts in auditory thresholds during service represented the onset of any current hearing loss (even if first diagnosed a number of years after service). Thus, a claimant who seeks to establish service connection for a current hearing disability must show, as is required in a claim for service connection for any disability, that a current hearing disability is the result of an injury or disease incurred in service, the determination of which depends on a review of all the evidence of record including that pertinent to service. See 38 U.S.C. §§ 1110; C.F.R. §§ 3.303 and 3.304; Hensley, 5 Vet. App. at 159-60. Here, as noted above, the audiogram dated in June 1968 appears to show significant threshold shifts at multiple frequencies when compared to the Veteran’s September 1965 entrance examination. However, the examiner did not address this evidence in rendering the negative nexus opinion. In light of the foregoing, the claim must be remanded for an opinion with an adequate rationale regarding the etiology of the Veteran’s diagnosed bilateral hearing loss. See 38 C.F.R. § 3.159 (c)(4); Barr v. Nicholson, 21 Vet. App. 303 (2007) (Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place); Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board’s duty to return an inadequate examination report “if further evidence or clarification of the evidence...is essential for a proper appellate decision”). 2. Entitlement to a total disability rating based on individual unemployability (TDIU) by reason of service connected disabilities is remanded. The Veteran maintains that he is unable to secure or follow a substantially gainful occupation as a result of the conditions that he acquired while on active duty in Vietnam. In light of the grant of service connection for PTSD and alcohol dependence, a remand is necessary in order for the AOJ to implement the Board's grant and assign an initial rating prior to consideration of the TDIU claim, as the award of service connection may impact outcome of the TDIU claim. Therefore, the claims are inextricably intertwined and, before the issue of entitlement to TDIU can be addressed on appeal, the grant of service connection for PTSD and alcohol dependence must be implemented. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following actions: 1. Implement the Board's grant of service connection for PTSD. 2. Schedule the Veteran for a VA medical examination with the appropriate physician regarding entitlement to service connection for bilateral hearing loss. The examiner should opine whether it is at least as likely as not (50 percent or greater degree of probability) that the Veteran’s hearing loss is related to military service, to include in-service noise exposure. In providing the requested opinion, the examiner should address the Veteran’s in-service and post-service noise exposure. In doing so, the examiner should presume a layperson is competent to report matters within his personal knowledge, including exposure to loud noise and diminished hearing. The examiner should note that the absence of in-service evidence of a hearing disability during service is not always fatal to a service connection claim. The examiner should not rely solely on the absence of hearing loss in service as a basis for any opinion. Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service. In providing the opinion, the examiner must provide a full and complete rationale explaining the reasoning for all opinions given. If the examiner is unable to provide the opinion requested, then he or she must state so and provide an explanation as to why an opinion cannot be given. 3. After completion of the above requested development, and any other development deemed necessary, readjudicate the claims on appeal. If the benefits sought on appeal remain denied, furnish the Veteran a supplemental statement of the case, and afford him the opportunity to respond before the claims file is returned to the Board for further appellate consideration. ERIC S. LEBOFF Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Suzie Gaston, Counsel