Citation Nr: 1824366 Decision Date: 04/24/18 Archive Date: 05/03/18 DOCKET NO. 14-41 811 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial compensable rating for service-connected bilateral hearing loss. 2. Entitlement to service connection for a small bowel carcinoid with mesentric lymphadenopathy (small bowel carcinoid), claimed as secondary to a service-connected duodenal ulcer. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Teague, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1967 to September 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision of the St. Petersburg, Florida, Regional Office (RO). In August 2017, the Veteran testified at a Videoconference hearing held in St. Petersburg, Florida, before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the Veteran's electronic claims file. The appeals are REMANDED to the Agency of Original Jurisdiction (AOJ). REMAND Hearing Loss In April 2012, the AOJ granted service-connection for bilateral hearing loss and assigned a noncompensable rating. The Veteran filed a timely notice of disagreement with the assigned rating and this appeal followed. A July 2015 VA treatment note indicated the Veteran brought in a hearing evaluation conducted by an audiologist outside the VA that showed a significant decline in the Veteran's hearing. The VA physician reported that a hearing test conducted by the VA during the same appointment did not show a significant change in the Veteran's hearing since his 2012 VA examination. Significantly, the results of the examination were noted to be available on CPRS but were not provided in a form the Board could view. At his August 2017 Board hearing, the Veteran submitted a private audiological report that contains speech audiometry and word recognition tests. However, it is unclear whether it was the Maryland CNC word test that was administered. The Veteran last underwent a VA audiology examination for rating purposes in January 2012. In light of the specific assertions of worsening since the last VA examination, a VA audiology examination should be obtained to assist in determining the severity of the service-connected bilateral hearing loss. See Snuffer v. Gober, 10 Vet. App. 400 (1997) (finding a veteran is entitled to a new examination where the veteran specifically alleged the disability had increased in severity since the last examination two years earlier); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). Small Bowel Carcinoid The Veteran contends his recurrent small bowel carcinoid with mesentric lymphadenopathy was caused by his service-connected duodenal ulcer. VA treatment records show diagnosis of a small bowel carcinoid with mesentric lymphadenopathy in July 2009. The Veteran underwent a resection of 30cm of bowel and monthly octreotoid shots. In August 2010, the Veteran underwent a second surgery to remove a small mesenteric mass. In September 2011, the Veteran discussed with his treating physician the possibility of relationship of his neuroendocrine tumor to his service-connected ulcer. The treating physician indicated that he found no evidence of a gastrin measurement in the record nor had there been an ulcer diathesis in the last several years suggesting a gastrin producing tumor. The treating physician indicated: [A]ccompanying documentation for service-connected disability asked for probability of relationship to time in service. Choices are arbitrary. 50-50% is as good as any estimate. See September 2011 General Surgery Attending Note. An August 2012 VA CT scan indicated there was no evidence of the disease after octreotide treatment. A December 2014 VA general surgery note indicated that the Veteran had a recurrent mass in the same area of the bowel resection that was previously removed in 2010. The Veteran was again placed on octreotide injections and in January 2015 underwent a right axillary dissection with tumor excision. At his August 2017 Board hearing, the Veteran submitted medical treatise evidence on links between carcinoid tumors and peptic ulcers. The Veteran testified he received treatment for the small bowel carcinoid through the VA. Under applicable law, VA will provide a medical examination or obtain a medical opinion where there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service, or within a qualifying presumptive period; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). The third prong of this criteria, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. See McClendon v. Nicholson, 20 Vet. App. 79, 83 (2006). To date, a medical opinion on the etiology between the Veteran's small bowel carcinoid and service-connected duodenal ulcer has not been obtained. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and ask him to provide sufficient information and necessary authorization in order to obtain copies of any outstanding records of treatment by non-VA health care providers for hearing loss treatment. The letter should invite the Veteran to submit any pertinent medical evidence in support of his claim, including the January 2015 private audiology examination. If the Veteran provides the necessary information and authorizations, obtain any outstanding clinical records and incorporate them into the electronic claims file. 2. Associate all VA treatment records since July 2015 with the electronic claims file. Additionally, attempts to obtain the audiometric testing results, if available, from the July 2015 VA audiological treatment at the Gainesville VAMC should be made. 3. After completion of the above development. Schedule the Veteran for a VA audiology examination to determine the severity of the service-connected hearing loss disability. 4. Obtain a medical opinion as to the etiology of the Veteran's small bowel carcinoid. Following reviewing the claims file, the medical professional is first asked to determine whether the Veteran has a current diagnosis of small bowel carcinoid. If the Veteran does have a current diagnosis of small bowel carcinoid, the oncologist is asked to provide the following opinions: a) Is it at least as likely as not (50 percent probability or greater) that the Veteran's small bowel carcinoid began in or is etiologically related to service? b) Is it at least as likely as not (50 percent probability or greater) that Veteran's small bowel carcinoid is caused by any of the Veteran's service-connected duodenal ulcer? c) If not caused by the duodenal ulcer, is it at least as likely as not (50 percent probability or greater) that the small bowel carcinoid is aggravated (worsened in severity beyond the natural progression of the disease) by the service-connected duodenal ulcer? In addressing the above-requested opinions, the examiner should specifically comment on the September 2011 General Surgery Attending Note and the August 2017 article submitted by the Veteran. A complete rationale for any opinion provided is requested. If the medical professional is unable to provide an opinion without resort to speculation, an explanation as to why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered should be provided. 5. Then, the Veteran's claim should be readjudicated. If the benefits sought on appeal are not granted to the Veteran's satisfaction, the Veteran and his representative must be provided a Supplemental Statement of the Case and be given an adequate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. The appellant has the right to submit additional evidence and argument on the matter or matters 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 of Veterans' Appeals 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.A. §§ 5109B, 7112 (West 2014). _________________________________________________ H. SEESEL Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).