Citation Nr: 1807940 Decision Date: 02/07/18 Archive Date: 02/20/18 DOCKET NO. 13-29 510 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to service connection for vertigo. 2. Entitlement to a rating in excess of 10 percent for hemorrhoids. 3. Entitlement to a rating in excess of 10 percent for allergic rhinitis. 4. Entitlement to a compensable rating for bilateral hearing loss before August 21, 2015, and a rating in excess of 10 percent thereafter. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD LM Stallings, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1972 to October 1992. These matters are before the Board of Veterans' Appeals (the Board) on appeal from August 2012 and November 2012 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In September 2015, the appeal was remanded for further evidentiary development. In a March 2017 rating decision, the Agency of Original Jurisdiction increased the Veteran's rating for bilateral hearing loss to 10 percent, effective August 21, 2015. As the Veteran has not expressed satisfaction with the increased rating and it is less than the maximum under the applicable criteria, the claims remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board has characterized the issue accordingly. The issue of service connection for vertigo is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's hemorrhoids disability has been manifested by mild to moderate bleeding, rectal discomfort, and external hemorrhoids, ranging in size from small to moderate to large, with no evidence of fissures or secondary anemia. 2. Throughout the appeal period, the Veteran's allergic rhinitis has been manifested by a greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side, with no evidence of polyps. 3. Prior to August 21, 2015, the Veteran's bilateral hearing loss was manifested by auditory acuity no worse than Level I in the left ear and Level I in the right ear. 4. From August 21, 2015, the Veteran's bilateral hearing loss has been manifested by auditory acuity no worse than Level II in the left ear and Level V in the right ear. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for a hemorrhoid disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.114, Diagnostic Code (DC) 7336 (2017). 2. The criteria for a rating in excess of 10 percent for allergic rhinitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.7, 4.97, DC 6522. 3. Prior to August 21, 2015, the criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.385, 4.1, 4.2, 4.7, 4.85, 4.86, DC 6100. 4. From August 21, 2015, the criteria for a rating in excess of 10 percent for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.385, 4.1, 4.2, 4.3, 4.7, 4.85, 4.86, DC 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board"); Regarding the duty to assist, in December 2017 written argument, the Veteran's representative indicated that remand for new audiometric testing for the claim for an increased rating for bilateral hearing loss was warranted as an examination had not been completed since August 2015. The representative generally indicated that the Veteran claimed his hearing loss disability was worse. The Board finds that remand for a new VA examination for bilateral hearing loss is not necessary. Audiometric testing was completed in May 2017, not in August 2015 and the Veteran has not made any specific allegations indicating a worsening of the condition since the recent May 2017 examination. The Veteran's representative has not raised any other issues with the duty to assist. Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Legal Standards and Analysis Disability evaluations are determined by comparing the manifestations of a particular disability with the criteria set forth in the DC of the VA Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The ratings represent, as far as can practicably be determined, the average impairment in earning capacity (in civilian occupations) resulting from a service-connected disability. 38 C.F.R. § 4.1. VA has a duty to consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has reviewed all evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence as appropriate and the analysis will focus on what the evidence shows, or fails to show, as to the claim. Increased Rating for Hemorrhoids The Veteran claims he is entitled to a rating in excess of 10 percent for his service-connected hemorrhoids. External or internal hemorrhoids are rated under 38 C.F.R. § 4.114, DC 7336, which provides that a 10 percent rating is warranted for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating is warranted for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114, DC 7336. The Veteran has had several VA examinations with regard to the nature and severity of hemorrhoids throughout the claims period, to include in July 2011, August 2015, and May 2017. A July 2011 VA examination for hemorrhoids reflected a diagnosis of external or internal hemorrhoids. The Veteran reported having anal itching, pain, and swelling. He reported that every time he has a bowel movement, he can feel the hemorrhoid protrude from the anus and that the hemorrhoid protrudes when he lifts weights. He did not have diarrhea, tenesmus, or perianal discharge. He did have leakage of stool. He reported having hemorrhoids that recur occasionally. Upon physical examination, the VA examiner noted the presence of large external hemorrhoids that were not reducible. There was no evidence of bleeding and thrombosis was absent. There was evidence of frequent recurrence, with excessive redundant tissue. There was no anemia and no malnutrition noted. An August 2014 VA Primary Care note reported a history of hemorrhoids. Rectal examination revealed extensive external hemorrhoids, with no thrombus noted. An August 2015 VA examination report shows a diagnosis of mild or moderate internal and external hemorrhoids. The Veteran reported intermittent rectal bleeding and anal itchiness. He further claimed a palpable anal mass after every bowel movement which needed manual reduction followed by anal pain. The Veteran denied abdominal pain, diarrhea, bowel incontinence, anorexia, or weight loss. He was taking Preparation-H suppository as needed. On rectal examination, the VA examiner noted small or moderate external hemorrhoids and excessive, redundant tissue. There were no scars related to the hemorrhoids. The examiner noted a 0.5 x 0.5 cm, non-tender, non-thrombosed, non-bleeding external hemorrhoid at the 12 o'clock position with redundant anal tissue. The Veteran underwent another VA examination in May 2017 for hemorrhoids. The Veteran reported that every time he had a bowel movement, the hemorrhoids protrude. He reported that he experienced frequent pain, bleeding, itching and burning. Upon rectal examination, the VA examiner noted large internal and external hemorrhoids that are large or thrombotic, with excessive redundant tissue, evidencing frequent recurrences. The examiner noted no bleeding, anemia, or fissures. After reviewing the evidence of record, the Board finds that a rating in excess of 10 percent for hemorrhoids is not warranted. The evidence does not indicate that the Veteran experienced persistent bleeding resulting in secondary anemia or fissures in association with the hemorrhoids. Although the Veteran has reported having bleeding, such has not been shown to be persistent, and there has been no indication that the Veteran has had secondary anemia. The record also does not indicate the Veteran has experienced fissures during the appeal period. The VA examination reports clearly indicate that the Veteran's condition did not include fissures or secondary anemia resulting from the hemorrhoids. Examinations of the Veteran's rectum and anus showed no prolapse, thrombosis, bleeding, fecal incontinences, fissures, or fistula. Therefore, the Board finds that the evidence shows that the Veteran's hemorrhoids most nearly approximated the criteria for the 10 percent rating, as the evidence does not more nearly approximate the criteria for the next highest rating of 20 percent, persistent bleeding with secondary anemia or fissures, are not met. His hemorrhoids have presented with generally the same symptoms throughout the claims period such that staged ratings are not appropriate. See Hart, 21 Vet. App. 505. Therefore, the Board finds that a rating in excess of 10 percent for a hemorrhoid disability is not warranted and the preponderance of the evidence is against the assignment of any higher rating. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. Increased Rating for Allergic Rhinitis The Veteran claims he is entitled to a rating in excess of 10 percent for allergic rhinitis. Of note, the Veteran was granted service connection for allergic rhinitis in an August 1993 rating decision, effective November 1992. The Veteran's allergic rhinitis has been rated under DC 6501. DC 6501, Rhinitis no longer exists and the most analogous rating is DC 6522, Allergic or Vasomotor Rhinitis, as that is the disability which has been diagnosed. He is currently receiving a 10 percent rating under this DC. The Board has also considered whether the selection of DC 6522 in place of DC 6501 is contrary to any regulatory prohibitions against changes in protected ratings or other reductions in ratings. See 38 C.F.R. § 3.951(b) ("A disability which has been continuously rated at or above any evaluation of disability for 20 or more years for compensation purposes . . . will not be reduced to less than such evaluation except upon a showing that such rating was based on fraud."). The Board finds that its decision is not contrary to any such regulations. Here, the Veteran's rating has not been reduced by rating it under DC 6522, so 38 C.F.R. § 3.951(b) is not for application. The same symptoms are being compensated under a substantially similar, but currently effective DC. See Murray v. Shinseki, 24 Vet. App. 420, 424 (2011). Under DC 6522, a 10 percent rating is appropriate for allergic or vasomotor rhinitis without polyps, but with greater than 50 percent obstruction of nasal passage on both sides, or complete obstruction on one side. 38 C.F.R. § 4.97. A 30 percent rating is appropriate for allergic or vasomotor rhinitis with polyps. Id. In July 2011, the Veteran underwent a VA examination in which he was diagnosed with chronic atrophic rhinitis. The Veteran reported that he had interference with breathing through the nose. He reported he did not have any purulent discharge from the nose, hoarseness of the voice, pain, or crusting. He reported he did not have any overall functional impairment from the condition. Physical examination revealed the mucosa of the throat was intact and there was no pharyngeal erythema or exudate. Examination of the nose revealed nasal obstruction of 90 percent in the right nostril and 0 percent in the left nostril. He did not have a deviated septum, loss of part of the nose, scarring, obvious disfigurement, or nasal polyps. Rhinitis was detected, but there was no sinusitis. The VA examiner noted his condition was active with nasal obstruction, sneezing, and coughing primarily in the morning. The Veteran underwent another VA examination in August 2015. The VA examiner diagnosed the Veteran with allergic rhinitis dating back to the 1990's based on medical history. The Veteran endorsed sneezing, watery eyes and rhinorrhea in the early morning, with recurrent coughing, daily. The Veteran used sprays and antihistamines to manage his symptoms. Upon physical examination, the VA examiner noted greater than 50 percent obstruction of the bilateral nasal passages. There was no complete obstruction to either side due to rhinitis, there was no permanent hypertrophy of the nasal turbinates, there were no nasal polyps, and there were no granulomatous conditions. The VA examiner noted there was no scarring or loss of the nose or part of the nose. The examiner opined that the Veteran had mild to moderate persistent allergic rhinitis. In an August 2015 VA Outpatient Treatment Note, the Veteran sought treatment for recurrent nasal congestion, frequent early morning sneezing, coughing, tearing, and itchiness usually triggered by strong irritant. After reviewing the evidence of record, the Board finds that a rating in excess of 10 percent for allergic rhinitis is not warranted. The medical evidence demonstrates that the Veteran has a greater than 50 percent obstruction of the nasal passages on both sides, with no polyps. In order to warrant a 30 percent rating the Veteran's allergic rhinitis would need to include polyps. VA examinations dated July 2011 and August 2015 both report that the Veteran does not have nasal polyps. VA treatment records also do not reflect any indication that the Veteran has had polyps during the appeal period. Therefore, the Board finds that the Veteran's allergic rhinitis is more nearly approximated by the criteria for the 10 percent rating, as a preponderance of the lay and medical evidence is against a finding that the criteria for the next higher rating of 30 percent are met. His allergic rhinitis has presented with generally the same symptoms throughout the claims period such that staged ratings are not appropriate. See Hart, 21 Vet. App. 505. Therefore, the Board finds that a rating in excess of 10 percent for allergic rhinitis is not warranted as the preponderance of the evidence is against the assignment of any higher rating. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. Increased Rating for Bilateral Hearing Loss The Veteran claims that he is entitled to a compensable rating for bilateral hearing loss before August 21, 2015, and a rating in excess of 10 percent thereafter. Ratings for hearing loss disability are derived from Table VII of 38 C.F.R. § 4.85 by a mechanical application of the rating schedule to numeric designations assigned after audiometric evaluations are performed. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The numeric designations correspond to eleven auditory acuity levels, indicated by Roman numerals, where Level I denotes essentially normal acuity and Level XI denotes profound deafness. The assignment of the appropriate numeric level is based on the results of controlled speech discrimination tests in combination with the claimant's average hearing threshold. The average threshold is obtained from pure tone audiometric tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz. 38 C.F.R. § 4.85. Rating specialists use either Table VI or VIA of 38 C.F.R. § 4.85 to determine the hearing acuity level. Table VIA is employed when the use of speech discrimination testing is inappropriate due to language difficulties, inconsistent speech discrimination scores, etc., or where there is an exceptional pattern of hearing loss (as defined in 38 C.F.R. § 4.86). One such pattern occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). Another occurs when the pure tone threshold at 1000 Hertz is 30 decibels or less and the pure tone threshold at 2000 Hertz is 70 decibels or more. 38 C.F.R. § 4.86(b). Prior to August 21, 2015 The Veteran had a VA audiology examination in July 2011 which revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 25 25 40 LEFT 20 20 25 30 55 The average pure tone thresholds were 27.5 for the right ear, and 32.5 for the left. Speech audiometry revealed speech recognition ability of 96 percent in both ears. The VA audiologist noted that the Veteran's bilateral hearing loss did cause difficulty communicating. The Veteran underwent a VA audiology evaluation in December 2014, which revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 35 45 40 40 50 LEFT 40 40 45 55 55 The average pure tone thresholds were 43.75 in the right ear and 48.75 in the left ear. The audiology evaluation report does not indicate that any speech discrimination testing was performed. The Veteran reported having difficulty understanding spoken words and phrases. Based on the foregoing, the Board concludes that a preponderance of the evidence is against a finding that the Veteran's bilateral hearing loss more nearly approximated the criteria for a compensable rating before August 21, 2015. Audiometry results and speech recognition scores from the July 2011 VA examination corresponds to Level I auditory acuity in the right ear and Level I auditory acuity in the left ear. 38 C.F.R. § 4.85, Table VI. These numeric designations in combination correspond to a zero percent, or noncompensable, rating under Table VII, DC 6100. As noted above, the December 2014 VA audiometry examination was not done using the Maryland CNC word list. As these results are not adequate for rating purposes they cannot be used to evaluate the severity of the Veteran's bilateral hearing loss under the rating criteria. The Board further finds that the record does not demonstrate an exceptional pattern of hearing impairment in either ear, including from December 2014 audiometry testing, of the type contemplated by 38 C.F.R. § 4.86, that is, pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz of 55 decibels or more or pure tone thresholds of 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. See 38 C.F.R. § 4.86(a) and (b). Therefore, evaluation using Table VIA is not appropriate. The Veteran is competent, as a layperson, to report on that as to which he has personal knowledge, such as difficulty hearing. 38 C.F.R. § 3.159(a)(2); see Jandreau v. Nicholson, 492 F.3d 1372, 1377; Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Nevertheless, as a layperson, without the appropriate medical training and expertise, he is not competent to provide a probative opinion on a medical matter, especially the severity of his bilateral hearing loss disability in terms of the applicable rating criteria. Rather, this necessarily requires appropriate medical findings regarding the extent and nature of his bilateral hearing loss, including pure tone audiometry testing. After a review of the evidence of record, there is no pure tone audiometry testing before August 21, 2015 that indicates a compensable rating for bilateral hearing loss is warranted. The record also does not reflect any exceptional patterns of hearing impairment for consideration of alternative rating under 38 C.F.R. § 4.86. Disability evaluations for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann, 3 Vet. App. 345. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim for entitlement to a compensable disability rating for bilateral hearing loss prior to August 21, 2015, is denied. 38 U.S.C. § 5107; 38 C.F.R. § 4.3; Gilbert, 1 Vet. App. at 55. After August 21, 2015 The Veteran is rated at 10 percent for bilateral hearing loss after August 21, 2015. The Veteran had another VA audiology examination in August 2015 which revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 30 35 30 45 LEFT 25 25 35 40 50 The average pure tone thresholds were 35 for the right ear, and 38 for the left. Speech audiometry revealed speech recognition ability of 60 percent in the right ear and 88 percent in the left ear. The Veteran reported difficulty understanding spoken words and phrases and that he often must ask for things to be repeated. The VA audiologist noted that the Veteran's bilateral hearing loss did cause occasional difficulty understanding spoken words and phrases and that he often must ask for things to be repeated. The Veteran had another VA audiology examination in May 2017 which revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 15 20 35 45 LEFT 20 20 35 45 50 The average pure tone thresholds were 28.75 for the right ear, and 37.5 for the left. Speech audiometry testing using the Maryland CNC word list was done, revealing 25 percent in the right ear and 30 percent in the left ear. However, the VA audiologist noted that word recognition readings were inconsistent and not reliable, potentially due to language barriers. Based on the foregoing, the Board concludes that a preponderance of the evidence is against a finding that the Veteran's bilateral hearing loss more nearly approximates the criteria for a 20 percent rating after August 21, 2015. Audiometry results and speech recognition scores from the August 2015 VA examination corresponds to Level V auditory acuity in the right ear and Level II auditory acuity in the left ear. 38 C.F.R. § 4.85, Table VI. These numeric designations in combination correspond to a 10 percent rating under Table VII, DC 6100. As noted above, the May 2017 VA examiner determined that the speech recognition scores were unreliable, potentially due to language barriers. Pursuant to 38 C.F.R. § 4.85(c), where speech discrimination testing is not appropriate because of language difficulties or inconsistent speech discrimination scores, Table VIA is used to determine the Roman numeral designation for hearing impairment based only on the pure tone threshold average. Therefore, as the May 2017 examiner determined the speech recognition scores were unreliable, in applying Table VIA, the Rating Schedule shows Level I hearing in the right ear and Level I hearing in the left ear. See 38 C.F.R. § 4.85, Table VIA, DC 6100. Applying these findings to 38 C.F.R. § 4.85, Table VII of the Rating Schedule, results in a noncompensable evaluation for bilateral hearing loss under DC 6100. The Veteran is competent, as a layperson, to report on that as to which he has personal knowledge, such as difficulty understanding spoken words and phrases and needing to have things repeated. 38 C.F.R. § 3.159(a)(2); see Jandreau, 492 F.3d at 1377; Barr, 21 Vet. App. at 310. Nevertheless, as a layperson, without the appropriate medical training and expertise, he is not competent to provide a probative opinion on a medical matter, especially the severity of his bilateral hearing loss disability in terms of the applicable rating criteria. Rather, this necessarily requires appropriate medical findings regarding the extent and nature of his bilateral hearing loss, including pure tone audiometry testing. Therefore, although the Board finds the Veteran's statements about his hearing loss to be credible, the VA audiological examination results are more probative for purposes of rating the disability. See Buchanan, 451 F.3d at 1331. After a review of the evidence of record, there is no pure tone audiometry testing at any point during the period on appeal that indicates a rating in excess of 10 percent for bilateral hearing loss after August 21, 2015, is warranted. Disability evaluations for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Lendenmann, 3 Vet. App. 345 (1992). Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim for entitlement to a rating in excess of 10 percent for bilateral hearing loss from August 21, 2015, is denied. 38 U.S.C. § 5107; 38 C.F.R. § 4.3; Gilbert, 1 Vet. App. at 55. ORDER A disability rating in excess of 10 percent for hemorrhoids is denied. A disability rating in excess of 10 percent for allergic rhinitis is denied. A compensable disability rating for bilateral hearing loss prior to August 21, 2015, is denied. A rating in excess of 10 percent for bilateral hearing loss from August 21, 2015, is denied. REMAND Although the Board regrets the additional delay, a remand for the claim of service connection for vertigo is necessary for additional development. The Board finds that there has not been substantial compliance with the mandates of the September 2015 remand order. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). In the September 2015 remand, the Board instructed that a VA examiner evaluate the Veteran's re-opened claim for service connection for vertigo and provide an etiology and nexus opinion, considering the reports of vertigo in service, reports of continuity of symptomatology, and diagnosis of benign paroxysmal positional vertigo in 2011. The Veteran underwent a VA examination in May 2017, in which the VA examiner reviewed the Veteran's claims file and performed a physical examination. The examiner noted a diagnosis of benign paroxysmal positional vertigo. The VA examiner then noted that the date of the onset of symptoms was in 1980, when the Veteran claims he would experience 5-10 minutes of vertigo with nausea and the feeling of being pulled in many directions when standing. The Veteran also claimed that his symptoms have been slowly worsening over the years. On physical examination, the VA examiner noted an abnormal Romberg test and abnormal limb coordination testing, especially poor coordination/missed finger to tip of nose. The examiner found that the Veteran also had tinnitus and hearing loss attributable to benign paroxysmal positional vertigo. The May 2017 VA examiner found that the Veteran's vertigo was less likely than not related to his military service and opined that the vertigo the Veteran experienced while in service was self-limited and resolved. Further, the VA examiner noted that the symptoms the Veteran describes presently cannot lead to a clear diagnosis without speculation. The VA examiner concluded that while the Veteran was seen for symptoms of dizziness and vertigo over the course of his service, they had various etiologies and were not related. The Board finds that the May 2017 VA examiner did not provide a clear rationale for his opinion as he did not explain how the Veteran's treatment in service and continuous symptoms of vertigo were not related to one another. Further, the VA examiner noted that the Veteran had a current diagnosis for benign paroxysmal positional vertigo but then later stated that based on the symptomatology, a clear diagnosis could not be made. The Board also notes that the September 2015 Board remand indicated specific dates on which the Veteran received treatment for vertigo in service which the VA examiner was to consider and discuss. While the May 2017 VA examiner noted review of some of the dates, the examination report does not indicate that they were all expressly considered. Additionally, the Veteran is service-connected for bilateral hearing loss and tinnitus, and the notation in the examination report indicating that tinnitus and hearing loss are related to a vertigo condition raises questions as to whether these service-connected disabilities have caused or aggravated any diagnosed vertigo condition. When VA undertakes to provide an examination, or obtain an opinion, it must ensure that the examination or opinion is adequate. Barr, 21 Vet. App. at 312. As it is not clear if there is a current diagnosis, nor is the VA examiner's rationale clear as to why or how the symptoms of vertigo in service are not the same as the symptoms of vertigo the Veteran experiences today, remand for another opinion is necessary. Where remand orders are not complied with, the Board errs as a matter of law when it fails to ensure compliance. See Stegall, 11 Vet. App. 268. As the May 2017 VA opinion failed to address or comply with the September 2015 remand instructions, the Board finds that the opinion is inadequate, and the claim must be remanded for a new examination and opinion. The most recent VA treatment records are from February 2016. As the record indicates the Veteran receives VA treatment, updated records should be obtained upon remand. Accordingly, the case is REMANDED for the following actions: 1. Contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim. Based on his response, attempt to procure copies of all records which have not previously been obtained from identified treatment sources. 2. Regardless of the Veteran's response, updated VA treatment records from February 2016 to the present must be obtained and associated with the claims file. 3. If any of the records requested in items 1 and 2 are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e). 4. After any records obtained have been associated with the electronic claims file, forward the claims file to a clinician with the appropriate expertise for an addendum medical opinion as to the etiology of the Veteran's current vertigo. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. After reviewing the claims file, the reviewing clinician should provide an opinion on the following questions: a) Has the Veteran had a diagnosis of chronic vertigo, or any diagnosed chronic disorder manifested by vertigo from 2011 to the present? b) If the Veteran has a current diagnosis of chronic vertigo or chronic disorder manifested by vertigo since from 2011 to the present, then is it at least as likely as not (50 percent probability or greater) that the Veteran's current diagnosis is related to or caused by his service? c) If the Veteran has a current diagnosis of chronic vertigo or chronic disorder manifested by vertigo since from 2011 to the present, then is it at least as likely as not (50 percent probability or greater) that the Veteran's current diagnosis is caused by service-connected tinnitus or bilateral hearing loss? d) If the Veteran has a current diagnosis of chronic vertigo or chronic disorder manifested by vertigo since from 2011 to the present, then is it at least as likely as not (50 percent probability or greater) that the Veteran's current diagnosis was aggravated beyond the natural progression of the disability by service-connected tinnitus or bilateral hearing loss? (Aggravation is any increase in severity beyond the natural progression of the disability.) The reviewing clinician should provide a complete rationale for any opinion provided. If the reviewing clinician cannot provide any requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 5. After completing the above actions, and any other development as may be indicated by any response received because of the actions taken above, readjudicate the Veteran's claims. If any benefit on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. ______________________________________________ M. Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs