Citation Nr: A20008646 Decision Date: 05/15/20 Archive Date: 05/15/20 DOCKET NO. 200203-63675 DATE: May 15, 2020 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to service-connected bilateral hearing loss and tinnitus, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1954 to July 1957. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2019 rating decision by the Department of Veterans Affairs (VA) under its modernized review system. See Veterans Appeals Improvement and Modernization Act (AMA), Pub. L. No. 115-55, 131 Stat. 1105 (2017); VA Claims and Appeals Modernization, 84 Fed. Reg. 138 (Jan. 18, 2019) with applicability provisions under 38 C.F.R. §§ 3.2400 and 19.2. The Veteran timely appealed the that decision to the Board in a February 2020 VA Form 10182 and selected the evidence submission review lane. Upon review, the Board finds that a remand is required to correct a duty to assist error that occurred prior to the October 2019 rating decision. The Veteran was afforded a VA examination in October 2019 in connection with his claim. The examiner diagnosed him with major depressive disorder and unspecified dementia and opined that the disorder was less likely than not proximately due or the result of his service-connected bilateral hearing loss and tinnitus. However, the examiner did not address the aggravation prong of secondary service connection. See 38 C.F.R. § 3.310; El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). Therefore, an additional VA medical opinion is needed. The matters are REMANDED for the following action: The Veteran should be afforded a VA examination to determine the nature and etiology of any acquired psychiatric disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should state whether it is at least as likely as not that any current disorder manifested in service or is otherwise causally or etiologically related to his military service. The examiner should also opine as to whether it is at least as likely as not that any current psychiatric disorder was either caused by or aggravated by his service-connected bilateral hearing loss and tinnitus. In rendering his or her opinion, the examiner should address both the causation and aggravation questions in his or her rationale. In other words, even if the Veteran’s hearing loss and tinnitus did not cause a current psychiatric disorder, the examiner should still address whether those service-connected disabilities could have worsened any current psychiatric disorder. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. J. Williams, 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.