Citation Nr: A19001560 Decision Date: 09/26/19 Archive Date: 09/25/19 DOCKET NO. 190301-2847 DATE: September 26, 2019 REMANDED Entitlement to service connection for a bilateral hearing loss disability is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1981 to July 1984. A March 2014 decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) denied service connection for a bilateral hearing loss disability. On August 23, 2017, the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (to be codified across 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA), was signed into law. This law creates a new framework for Veterans dissatisfied with VA’s decision on their claim to seek review. On January 4, 2018, VA received the Veteran’s request to opt into RAMP, the Rapid Appeals Modernization Program, in which he requested a higher-level review decision. The RO issued its higher-level review decision in March 2018, which considered the evidence of record as of the date VA received the RAMP election form. The Veteran appealed the RAMP decision to the Board, selecting direct review of the evidence considered by the Agency of Original Jurisdiction (AOJ).   Entitlement to service connection for a bilateral hearing loss disability is remanded. 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. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Veteran was afforded a VA audiological examination in February 2014. Puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 25 25 25 LEFT 15 25 35 35 30 Speech recognition scores using the Maryland CNC test were 80 percent in the right ear and 76 percent in the left ear. However, the examiner stated that the use of speech discrimination score was not appropriate for the Veteran because of language difficulties, cognitive problems, inconsistent speech discrimination scores, etc. The examiner opined that it was less likely than not that the Veteran’s left ear hearing loss disability was due to the Veteran’s service. The examiner’s rationale was that even though the Veteran was exposed to loud noises during service, the hearing loss “is contraindicative of noise damage based on [its] configuration.” The examiner indicated the Veteran did not meet VA standards for hearing impairment in the right ear, but also indicated that the mild hearing loss the Veteran had was less likely than not due to in-service noise exposure; no rationale was provided for this opinion. The Veteran was afforded a VA audiological examination in March 2016. Puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 25 20 20 LEFT 25 25 30 35 30 Speech recognition scores using the Maryland CNC test were 96 percent in the right ear and 94 percent in the left ear. The examiner indicated that the use of speech discrimination scores was appropriate for the Veteran. The examiner opined that it was less likely than not that the Veteran’s left ear hearing loss disability was due to the Veteran’s service. The examiner’s rationale was that the Veteran’s left ear hearing loss was inconsistent in degree and configuration for a noise-induced hearing loss that started during service. The examiner stated that while there were minimal permanent threshold shifts related to in-service noise exposure, there was no indication that the Veteran sustained any significant adverse changes in his hearing during service. The examiner added that the Veteran’s hearing was within normal limits at enlistment and separation. The Board finds both of the VA examiners’ opinions to be inadequate. The Veteran’s service treatment records (STRs) show that in June 1982 he repeatedly sought treatment for his ears. The STRs indicate that the Veteran complained of pain in the left ear, slight loss of hearing in both ears, and ear ache in both ears. Neither examiner considered these in-service occurrences, but rather focused their opinion on in-service noise exposure. Additionally, the February 2014 examiner’s opinion is conclusory and lacks a supporting rationale; thus, it is inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Also, the March 2016 examiner’s opinion was based on a premise that during the Veteran’s service, there were minimal permanent threshold shifts related to in-service noise exposure. However, the May 1984 separation audiogram appears to reflect a threshold shift in the left ear at 4000 Hertz when compared to the enlistment audiogram. The examiner did not clearly explain his conclusions regarding the lack of threshold shifts in the face of this evidence. Regarding the right ear, the February 2014 VA examination reflected that the results of speech discrimination testing would meet the criteria for VA hearing loss; however, the examiner indicated that use of such testing was inappropriate. On March 2016 VA examination, the examiner indicated the use of such testing was appropriate, but the results did not reflect hearing loss for VA purposes. These inconsistent results make it unclear regarding why speech discrimination testing was deemed inappropriate in 2014, but was not inappropriate in 2016. As such, the examination completed on remand should include audiometric testing for both ears, and a clear explanation should be given if it is determined that speech discrimination testing is inappropriate. The matter is REMANDED for the following action: Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of hearing loss disability in either ear. Audiometric testing must be completed (including puretone threshold testing and speech discrimination testing using the Maryland CNC word list). If it is determined that the use of speech discrimination testing is inappropriate, the examiner must provide a rationale as to why it is inappropriate that is particular to the Veteran’s situation. The examiner must opine whether it is at least as likely as not that any hearing loss for VA purposes in either ear is related to an in-service injury, event, or disease, including in-service noise exposure, complaints of pain in the left ear, slight loss of hearing in both ears, and/or ear ache in both ears.   In providing the above opinion, the examiner is asked to comment on the significance, if any, of the threshold shift in the left ear shown at 4000 Hertz from the April 1981 entrance examination to the May 1984 separation audiometry. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Patel, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.