Citation Nr: 20065645 Decision Date: 10/08/20 Archive Date: 10/08/20 DOCKET NO. 14-17 040 DATE: October 8, 2020 ORDER New and material evidence having been received, the petition to reopen a claim for VA disability compensation under 38 U.S.C. § 1153, for a bilateral foot disability, manifested by pes planus is granted. Entitlement to service connection for bilateral pes planus, on the basis of in-service aggravation, is granted. REMANDED Entitlement to service connection for a bilateral hip disability, to include as secondary to a bilateral foot disability, is remanded. Entitlement to service connection for a bilateral knee disability, to include as secondary to a bilateral foot disability, is remanded. Entitlement to service connection for left ear hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. FINDINGS OF FACT 1. VA disability compensation 38 U.S.C. § 1153 for a pre-service bilateral foot disability manifested by pes planus was denied in a July 1981 rating decision. The Veteran did not appeal this decision or submit evidence relating to a previously unestablished fact necessary to substantiate the claim within a year of being notified of the denial. Evidence received since that decision relates to a previously unestablished element of the claim. 2. The Veteran’s pre-existing pes planus was noted upon induction but was asymptomatic. The circumstances of his military service to include his service in a combat capacity aggravated the disability. CONCLUSIONS OF LAW 1. The July 1981 rating decision denying service connection for a bilateral foot disability is final, but new and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5108; 38 C.F.R. §§ 3.104(a), 3.156, 3.160(d). 2. The criteria for entitlement to service connection for a bilateral foot disability manifested by pes planus, on the basis of aggravation have been met. 38 U.S.C. §§ 1110, 1153, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1968 to February 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa, which denied service connection for left ear hearing loss, tinnitus, and bilateral hip, knee, and feet disabilities. At the outset, the Board notes that the procedural history of this case is somewhat complex. This matter was first certified to the Board in July 2015 after the RO issued a March 2014 Statement of the Case and the Veteran timely appealed that decision in May 2014. In doing so, he declined a Board hearing. While this appeal was pending, however, he filed a separate claim for service connection for shin splints secondary to a bilateral foot disability, which was denied in a June 2015 rating decision. The claim for shin splints was eventually certified to the Board in March 2016, and the Veteran requested a Board hearing. A hearing was scheduled for September 25, 2018. Thereafter, in a September 2018 VA Form 21-4138, the Veteran indicated he wished to “withdrawn his appeal with the Board” without specifying which appeal he wished to withdraw. Although the Board subsequently sent a September 2018 letter reflecting that his appeal for shin splints had been withdrawn, it was somewhat unclear whether the Veteran had intended to instead withdraw his other appeal. Subsequently, the Board sent the Veteran a letter in August 2020 asking for him to clarify whether he intended to withdraw the current appeal or any of the issues on appeal in the instant matter when he submitted the September 2018 VA Form 21-4138. The correspondence indicated that if the Veteran did not respond to the letter in 30 days, the Board would assume that no argument was forthcoming and review all issues on appeal. To date, the claims file contains no response from either the Veteran or his representative. As such, the Board will assume that he did not intend to withdraw his current claim or any of the issues on appeal. New and Material Evidence Historically, the Veteran filed a claim for service connection for a bilateral foot disability that was denied in a July 1981 rating decision. More specifically, the July 1981 rating decision found that at induction to active duty, bilateral asymptomatic pes planus had been noted and that he was given a prescription for molded inserts during service but that nothing in his records indicated that his pre-existing foot condition was aggravated by service. The Veteran did not appeal this rating decision, and new and material evidence was not submitted within one year of the rating decision. The rating decision thus became final. The Board has considered whether the provisions of 38 C.F.R. § 3.156(c), regarding newly received official service department records, apply. Pursuant to these rules, if VA receives or associates with a claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided a claim, VA will reconsider the claim. The Board acknowledges that service personnel records were added to the claims file after the July 1981 rating decision was issued. Although these records existed at the time of the previous rating decision but had not yet been associated with the claims file, these records are nonetheless unrelated to the Veteran’s claim for a bilateral foot disability. Indeed, the records include documents such as enlistment contracts and clothing and equipment records, and not the matter in dispute here (i.e., whether a pre-existing foot disability was aggravated by his service). See Kisor v. Wilkie, 969 F.3d 1333 (Fed. Cir. 2020). As such, the records have no impact on the outcome of the case, and the July 1981 rating decision became final. Generally, a claim that has been denied by an unappealed decision may not thereafter be reopened. 38 U.S.C. § 7105(c). An exception to this rule exists for cases in which new and material evidence is presented or secured with respect to a claim that has been disallowed, in which case the claim must be reopened and the former disposition reviewed. 38 U.S.C. § 5108. “New” evidence means evidence not previously submitted to agency decisionmakers, and “material” evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). This is a “low threshold” in which the phrase “raises a reasonable possibility” should be interpreted as “enabling rather than precluding reopening.” Shade v. Shinseki, 24 Vet. App. 110, 121 (2010). The credibility of the newly-submitted evidence is presumed, though not blindly accepted as true if patently incredible. Justus v. Principi, 3 Vet. App. 510 (1992). Here, additional evidence has been associated with the claims file that suggests that the Veteran’s pre-existing pes planus disability was aggravated by his service. For instance, the Veteran submitted a July 2014 private medical opinion from Dr. J.L. that indicated that the Veteran’s pes planus was likely aggravated by his service. This evidence is new, as it was not previously of record at the time of the July 1981 rating decision. It is also material, as it relates to a previously unestablished element of his claim. As new and material evidence suggesting that his bilateral foot disability was aggravated by his service has been received, the claim is reopened. Service Connection Here, the Veteran asserts that although pre-existing pes planus was noted on his induction examination, his foot condition was aggravated by his service. More specifically, he has argued that his pes planus was asymptomatic when he entered service, but that it became symptomatic during basic training. As a result of increased foot pain, he argues that he was ultimately given premade cork inserts for his boots to relieve foot pain and that he often had to be driven to training exercises because he could not run. He has also stated that he has continued to use orthotic inserts for his pes planus since leaving service and also that his pes planus caused him to develop shin splints. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In determining whether service connection is warranted for a disability, 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 preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Every veteran shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Here, however, the Veteran’s March 1968 report of medical examination indicates that he was diagnosed with bilateral asymptomatic pes planus at induction. As such, pre-existing pes planus was noted at induction, and the presumption of soundness does not attach. See 38 U.S.C. § 1153; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). As such, the chief question for the Board is whether the evidence demonstrates that his pre-existing pes planus was aggravated by his active service. A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable (that is, obvious or manifest) evidence is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered “aggravation in service” unless the underlying condition, as contrasted with symptoms, has worsened. See Davis v. Principi, 276 F.3d. 1341, 1346-46 (Fed. Cir. 2002) (“[E]vidence of temporary flare-ups symptomatic of an underlying preexisting condition, alone, is not sufficient for a non-combat veteran to show increased disability under 38 U.S.C. § 1153 unless the underlying condition is worsened”); Maxson v. West, 12 Vet. App. 453, 458 (1999) (citing Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991)), aff’d 230 F.3d 1330 (Fed. Cir. 2000)). Here, the evidence indicates that the Veteran’s pes planus was aggravated by service. In various lay statements submitted by the Veteran, he states that he had never used orthotic inserts prior to his service, but that his condition worsened almost immediately after beginning boot camp. He also indicated that he went to sick call for his severe foot pain because it prevented him from walking. His service treatment records confirm that there is evidence that his foot pain worsened during service. To that end, although the Veteran was diagnosed with pes planus at his induction to service, it was asymptomatic. He did not report a history of foot trouble on his accompanying report of medical history, and he was deemed qualified for enlistment into the Army in July 1968. Shortly thereafter, however, his service treatment records reflect that he was referred to the base podiatry clinic during basic training. A November 1968 podiatry clinic note indicates that he complained that his boots were too small and that his feet hurt. He was given correctly sized boots, as well as pre-molded cork inserts for his bilateral feet to offer him additional support. Additionally, the Veteran submitted a July 2014 opinion from Dr. J.L. indicating that his bilateral pes planus had “beyond a reasonable doubt” become symptomatic during service due to the conditions of his service, such as wearing boots that were too small, and that the Veteran must still wear custom orthotics on a regular basis to reduce chronic foot pain. The Board finds this opinion to be consistent with and supported by other competent, credible medical and lay evidence in the record. As such, the Board finds that the presumption of aggravation has attached. As set forth above, the presumption of aggravation can be rebutted, and service connection denied, if there is a specific finding that the increase in disability is due to the natural progress of the disease. Here, the Veteran underwent a December 2012 VA examination with respect to his claim for a bilateral foot disability. The VA examiner ultimately opined that the Veteran’s claimed condition was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. As rationale, the examiner reasoned that his service treatment records indicated recurrent foot pain due to ingrown toenails or wearing a suboptimal boot size, but never due to pes planus. The Board acknowledges that the examiner is competent to opine as to such a matter but finds that his opinion is nevertheless entitled to little probative weight. First, the examiner’s opinion does not adequately address the Veteran’s lay statements regarding the onset and severity of his pes planus symptoms. Second, the examiner states, without explaining why, the Veteran’s cork inserts were provided to accommodate ingrown toenails. However, the service treatment records do not in fact state that his cork inserts were provided to treat ingrown toenails instead of pes planus. Third, the examiner does not appear to have considered whether the continuous use of the cork supports was indeed evidence of aggravation of his pes planus. For combat veterans, as defined under 38 U.S.C. § 1154(b), lay evidence alone can establish the in-service element of service connection, if consistent with the circumstances, conditions, or hardships of such service, even if there is no official record. 38 C.F.R. § 3.304(d). This is commonly referred to as the “combat presumption.” 38 U.S.C. § 1154(b) does not establish service connection for a combat veteran, but rather aids him in relaxing the adjudicative evidentiary requirements for determining what happened in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999). When a veteran has not received a medal indicative of combat, the Board must determine on a case by case basis whether he participated in combat with the enemy. VAOPGCPREC 12-99 (October 18, 1999) (combat determination should be made on a case by case basis where there is no medal specifically indicating combat service). Evidence submitted to support a claim that a veteran engaged in combat may include the veteran’s own statements and an “almost unlimited” variety of other types of evidence. Gaines v. West, 11 Vet. App. 353, 359 (1998). The Court of Appeals for Veterans Claims has held that receiving enemy fire or firing on an enemy can constitute participation in combat. Sizemore v. Principi, 18 Vet. App. 264 (2004). Here, although the Veteran’s Form DD-214 does not indicate that he has received a medal indicative of combat service, the record nevertheless indicates that the Veteran engaged in combat. For instance, the Veteran is currently service connected for post-traumatic stress disorder (PTSD). In a July 2014 VA examination, the examiner opined that the Veteran’s PTSD was at least as likely as not a result of his combat experiences in Vietnam. Other evidence of record indicates that the Veteran worked as a door gunner in helicopters while stationed in Vietnam, and that his helicopter was fired on several times. See June 2017 VA Form 21-4138; March 1970 Aerial Gunner Medical Clearance Statement. As part of his duties as a gunner, the Veteran indicated that he would frequently jump out of helicopters in full combat gear. See January 2011 Correspondence. The above evidence reflects that the Veteran engaged in combat while deployed in the Republic of Vietnam. This finding that he engaged in combat is significant because it allows him to use “satisfactory lay or other evidence” to establish that he was injured or incurred or aggravated a disability while in combat on active duty, even in cases where there is no official record that such injury or disability occurred. Reeves v. Shinseki, 682 F.3d 988, 998 (Fed. Cir. 2012) (citing 38 U.S.C. § 1154(b)). In this regard, the Board finds that the circumstances, conditions, and hardships of his service, that required him to participate in activities such as jumping out of helicopters while in combat gear, are consistent with aggravation of the Veteran’s bilateral pes planus, regardless of whether there are contemporaneous service treatment records that affirmatively document aggravation of his pes planus. Ultimately, because an increase in the Veteran’s preexisting disability has been determined, the Board further findings that the evidence does not clearly and unmistakably establish that the worsening of his preexisting pes planus was due to the natural progression of the disability. As the presumption of aggravation has not been rebutted, service connection based on aggravation of a preexisting disability is warranted. REASONS FOR REMAND 1. Hips, knees, and tinnitus The Veteran also alleges that he is entitled to service connection for bilateral hip and knee disabilities. To that end, he has argued that he frequently jumped out of helicopters in heavy gear through his work as a door gunner during service, as set forth above, and that he now experiences pain in his knees and hips as a result. The record also indicates that he has reported that the pain in his knees and hips is secondary to the pain in his feet that began during service. As such, the issue of secondary service connection has been reasonably raised by the record. Additionally, the Veteran has claimed entitlement to tinnitus. As part of its duties to assist claimants, VA may be required to provide a medical examination. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). If an examination report is inadequate or does not contain sufficient detail, the Board is required to return the report. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001). The record reflects that the Veteran was afforded VA examinations in connection with his knees and hips in February 2014. The Veteran informed the VA examiner that the pain in his feet began during service and worsened over time until eventually his knees and hips were involved. The VA examiner diagnosed bilateral knee and hip pain, although made no other diagnoses. Ultimately, the VA examiner opined that the Veteran’s knee and hip conditions were less likely as not incurred in or caused by an in-service injury, event, or illness, as he had made no clinical complaints and recent radiological findings in his hips and knees were negative. The Board finds that the February 2014 VA examination report is lacking in several respects. First, the VA examiner did not consider all theories of entitlement raised by the record. Indeed, the examiner focused only on whether service connection was warranted on a direct basis, but not on a secondary basis. Second, the examiner’s opinion is conclusory and fails to adequately consider all relevant evidence of record, including the Veteran’s lay statements that describe jumping out of helicopters in combat gear in Vietnam. Third, although the VA examiner diagnosed only hip and knee pain, the Veteran’s VA treatment records reflect current diagnoses of degenerative joint disease in the knees and hips. An examination that does not consider all relevant evidence of record is inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In the interest of assembling clear and reliable findings, remand is warranted to obtain an addendum VA opinion that considers all relevant evidence of record, including lay statements, and all raised theories of entitlement. With respect to the Veteran’s tinnitus, he was last afforded a VA examination on the etiology of his tinnitus in April 2012. The VA examiner noted that he reported “humming” or “whistling” in both ears several times a day for several minutes. Although the Veteran did not recall the onset of his tinnitus, he stated that it was “probably” not over 10 years ago. The VA examiner ultimately opined that his tinnitus was less likely as not caused by or a result of military noise exposure and explained that the onset was relatively recent and unlikely to be related to noise exposure over 40 years ago. The Board finds that remand is also necessary with respect to the claim for tinnitus. As with the February 2014 VA examiner’s medical opinions, the April 2012 VA examiner’s rationale is conclusory and fails to provide a sufficiently detailed rationale supported by evidence of record or medical literature. An opinion that is conclusory is inadequate. Stefl v. Nicholson, 21 Vet. App. 120 (2007). As such, remand is warranted to obtain an addendum medical opinion that provides an adequately detailed rationale. 2. Left ear hearing loss The Veteran also claims that he is entitled to service connection for hearing loss in his left ear. Under 38 C.F.R. § 3.385, hearing loss is considered a disability for VA purposes when pure tone thresholds in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC test are less than 94 percent. Most recently, the Veteran was afforded a VA audiological examination in April 2012. At the time of his audiology examination, pure tone thresholds, in decibels, were as follows in the left ear at the following frequencies: 500 Hertz 1000 Hertz 2000 Hertz 3000 Hertz 4000 Hertz 30 25 10 20 30 Additionally, speech audiometry revealed speech recognition ability of 98 percent on the Maryland CNC test in the left ear. These results indicated that the Veteran did not have a current diagnosis of left ear hearing loss for VA purposes, as the pure tone thresholds at 500, 1000, 2000, 3000, and 4000 Hertz were all below 40 decibels, and only two of the auditory thresholds for these frequencies were above 26 decibels in the left ear. Last, the speech recognition scores were greater than 94 percent. A comparison between these findings indicated that in April 2012 a current left ear hearing loss disability was not present. Likewise, at a private audiology examination in June 2013, pure tone thresholds, in decibels, were as follows in the left ear: 500 Hertz 1000 Hertz 2000 Hertz 3000 Hertz 4000 Hertz 25 20 10 15 30 Speech audiometry revealed speech recognition scores of 92 percent but did not indicate which test was used to obtain his speech discrimination scores. As with the April 2012 VA examination, the results did not suggest a current diagnosis of left ear hearing loss for VA purposes. To that end, pure tone threshold results did not indicate any pure tone thresholds over 40 decibels, and only one of the auditory thresholds in the left ear was above 25 decibels. Although the speech recognition score was 92 percent in the left ear, the audiologist did not indicate whether the Maryland CNC test was used. As such, the June 2013 test data does not support a finding of left ear hearing loss for VA purposes. Nevertheless, subsequent VA treatment records from November 2017 indicate that the Veteran has “mildly impaired” hearing. These treatment records are not detailed enough to support a finding that the Veteran has hearing loss in his left ear under 38 C.F.R. § 3.385. In the interest of obtaining clear and reliable findings, however, the Board finds that a contemporaneous audiological evaluation is warranted to determine whether the Veteran currently has left ear hearing loss for VA purposes. Accordingly, the matters are REMANDED for the following action: 1. After obtaining proper authorization, obtain and associate with the claims file all outstanding VA treatment records and any outstanding, relevant private treatment records. 2. Following completion of the above, obtain an addendum medical opinion from an appropriate VA examiner in connection with the Veteran’s claim for a bilateral knee disability. The entire claims file, including a copy of this Remand, must be made available to the examiner for review, and the examiner must acknowledge such review in the addendum opinion. If additional VA examination is necessary, a new VA examination shall be obtained. After reviewing the claims file in its entirety, the VA examiner is asked to do the following: (a.) Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral knee disability had its onset during or is otherwise related to active service, to include the Veteran’s combat service in Vietnam. (b.) Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral knee disability is (1) caused by, or (2) aggravated by his bilateral foot disability. Aggravation is defined as a worsening beyond the natural progression of a disease. The examiner must note that an opinion to the effect that one disability is not “caused by or a result of” another disability does not answer the question of aggravation and will necessitate obtaining another opinion. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). (c.) If the examiner finds that aggravation is found, the examiner is asked to address the following issues to the extent feasible: i. The baseline manifestations of the bilateral knee disability, and ii. The increased manifestations which, in the examiner’s opinion, are proximately due to the Veteran’s service-connected disability. A complete rationale for these opinions must be provided. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. The examiner is specifically reminded to consider the Veteran’s lay statements regarding his work as a door gunner in Vietnam, as well as VA treatment records indicating that he has a current diagnosis of degenerative joint disease in his knees. If the examiner is unable to provide any requested opinion without resorting to speculation, he or she must indicate why this is so. Specifically, the examiner must indicate whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). If the reason for speculation is that the particular examiner does not possess the expertise, another examiner who does must provide the opinion in question. 3. Obtain an addendum medical opinion from an appropriate VA examiner in connection with the Veteran’s claim for a bilateral hip disability. The entire claims file, including a copy of this Remand, must be made available to the examiner for review, and the examiner must acknowledge such review in the addendum opinion. If additional VA examination is necessary, a new VA examination shall be obtained. After reviewing the claims file in its entirety, the VA examiner is asked to do the following: (a.) Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral hip disability had its onset during or is otherwise related to active service, to include the Veteran’s combat service in Vietnam. (b.) Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral hip disability is (1) caused by, or (2) aggravated by his bilateral foot disability. Aggravation is defined as a worsening beyond the natural progression of a disease. The examiner must note that an opinion to the effect that one disability is not “caused by or a result of” another disability does not answer the question of aggravation and will necessitate obtaining another opinion. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). (c.) If the examiner finds that aggravation is found, the examiner is asked to address the following issues to the extent feasible: i. The baseline manifestations of the bilateral knee disability, and ii. The increased manifestations which, in the examiner’s opinion, are proximately due to the Veteran’s service-connected disability. A complete rationale for these opinions must be provided. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. The examiner is specifically reminded to consider the Veteran’s lay statements regarding his work as a door gunner in Vietnam, as well as VA treatment records indicating that he has a current diagnosis of degenerative joint disease in his hips. If the examiner is unable to provide any requested opinion without resorting to speculation, he or she must indicate why this is so. Specifically, the examiner must indicate whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). If the reason for speculation is that the particular examiner does not possess the expertise, another examiner who does must provide the opinion in question. 4. Obtain an addendum medical opinion from an appropriate VA examiner in connection with the Veteran’s claim for tinnitus. The entire claims file, including a copy of this Remand, must be made available to the examiner for review, and the examiner must acknowledge such review in the addendum opinion. If additional VA examination is necessary, a new VA examination shall be obtained. After reviewing the claims file in its entirety, the VA examiner is asked to opine as to whether the Veteran’s tinnitus is at least as likely as not (50 percent or greater probability) related to his active service, to include the Veteran’s combat service in Vietnam. A complete rationale for these opinions must be provided. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. If the examiner is unable to provide any requested opinion without resorting to speculation, he or she must indicate why this is so. Specifically, the examiner must indicate whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). If the reason for speculation is that the particular examiner does not possess the expertise, another examiner who does must provide the opinion in question. 5. Arrange for the Veteran to undergo a new VA examination on the nature and etiology of the Veteran’s claimed left ear hearing loss. After reviewing the claims file in its entirety and examining the Veteran, the VA examiner is asked to do the following: (a.) Identify any currently diagnosable hearing loss disabilities in the Veteran’s left ear that have been present during the period on appeal. (b.) If a hearing loss disability is identified, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it had its onset during or is otherwise related to active service, to include the Veteran’s combat service in Vietnam. A complete rationale for these opinions must be provided. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. If the examiner is unable to provide any requested opinion without resorting to speculation, he or she must indicate why this is so. Specifically, the examiner must indicate whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). If the reason for speculation is that the particular examiner does not possess the expertise, another examiner who does must provide the opinion in question. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Rademacher, 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.