Citation Nr: 21001380 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 14-34 880A DATE: January 7, 2021 REMANDED The issue of entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1967 to January 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) in June 2018. A transcript of the hearing has been associated with the claims file. This matter was previously before the Board in August 2018 at which time it was remanded for further development. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran seeks service connection for bilateral hearing loss. Specifically, he contends that he has bilateral hearing loss as a result of acoustic trauma related to basic training; constant noise on the gun range, throwing grenades, and firing weapons. In this regard, the evidence of record includes an August 2013 VA examination report in which the examiner opined that it was less likely as not that the Veteran's hearing loss was caused by or a result of an event in military service. The examiner reasoned that the Veteran's military audiograms documented normal hearing at entrance and at separation. Therefore, his current hearing loss had to have begun after he was discharged from service. The examiner further reasoned that an Institute of Medicine 2005 report concluded that based on current knowledge, noise-induced hearing loss occurs immediately. There is no scientific support for delayed onset noise induced hearing loss, weeks, months, or years after the exposure event. In August 2018 the Board remanded the Veteran’s claim to obtain an addendum opinion. In a September 2019 addendum an examiner opined that the Veteran’s bilateral hearing loss was less likely than not related to service, to include noise exposure. The examiner reasoned that there was no evidence that in-service noise exposure caused hearing loss in either ear during service, within one year of discharge from the service, or that it was causally or etiologically related to noise exposure during service. No evidence of hearing loss occurring during the Veteran’s service was found in review of the Veteran’s medical record. No medical records documenting complaint of hearing loss or showing hearing status from the Veteran’s ETS examination in 1969 until 2010 were found in review of the Veteran’s file. The first evidence of hearing loss was not found in the Veteran’s medical record until an examination completed in 2010, 40 years after service exit. Citing to the Institute of Medicine (IOM), the examiner further reasoned that based on the anatomical and physiological data available on the recovery process following noise exposure, it was unlikely that delayed effects occurred. In light of a recent decision of the United States Court of Appeals for Veterans Claims (Court), the Board finds that remand is necessary. See McCray v. Wilkie, 31 Vet. App. 243 (2019). This Court decision highlighted the contradictory findings regarding delayed onset hearing loss in the IOM report. Specifically, the VA medical opinion noted that the IOM report concluded, in part, that based on the anatomical and physiological data available on the recovery process following noise exposure, it was unlikely that delayed effects occurred. However, the IOM report also indicates that "[t]here is not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one's lifetime, long after the cessation of that noise exposure" and that "definitive studies to address this issue have not been performed." Any future opinion predicated on the IOM reports' findings regarding delayed onset hearing loss must address these inconsistencies. As the September 2019 VA examiner relied on this IOM study without addressing these inconsistencies, the Board finds the opinion inadequate and a remand for an addendum opinion is necessary. In addition, the Veteran’s representative submitted additional argument in support of the Veteran’s claim in a December 2020 Informal Hearing Presentation. Specifically, the representative cited evidence suggesting that noise induced hearing loss can take a long time to be noticeable and evidence suggesting that a single synaptopathic exposure (traumatic event) can accelerate cochlear aging. The addendum opinion provided on remand must also address this additional evidence. The matters are REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of his relevant treatment that have not yet been associated with the claims file, and associate with the claims file any outstanding VA treatment records. 2. Return the claims file to the audiologist who provided the September 2019 addendum opinion, if available. If that audiologist is not available, send the claims file to another audiologist. The claims file and this remand should be made available to the examiner and review of the file should be noted in the requested report. After reviewing the claims file the audiologist should respond to the following: (a.) Is it at least as likely as not (50 percent probability or greater) that any current hearing loss disability had its onset in, or is related to any in-service disease, event, or injury, including noise exposure, including on a delayed onset theory of causation? The audiologist should review the September 2019 VA examination report, August 2013 VA examination report, July 2013 audiogram, June 2018 audiogram, and the June 2018 hearing testimony. The audiologist should specifically address the Veteran's contention that he was exposed to acoustic trauma in relation to his military basic training (firing weapons and launching grenades). The audiologist should also address the Veteran's contention that he first noticed hearing loss during service and the lay statements from his family and friends related to his hearing loss. (b.) Please discuss the National Institute on Deafness and Other Communication Disorders and the Journal of Neuroscience evidence cited in the December 2020 Informal Hearing Presentation, specifically addressing evidence suggesting that noise induced hearing loss can take a long time to be noticeable and evidence suggesting that a single synaptopathic exposure (traumatic event) can accelerate cochlear aging. The audiologist is advised the lack of a diagnosis of hearing loss in service is not, by itself, a sufficient reason to find there is no nexus to service. The salient question is whether any incident of service, including noise exposure, caused a current hearing loss disability even though it may have been initially diagnosed years after the Veteran's discharge from service (delayed on-set hearing loss). In formulating a medical opinion, if relying to any extent upon the IOM study noted above, the examiner must (a) identify the medical text's qualifying or contradictory aspects; and (b) explain why the examiner found the contradictory aspects or conclusions in the IOM study to be less persuasive in this Veteran's case as to the question of whether delayed onset hearing loss is as likely as not etiologically related to in-service noise exposure. All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should be explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. S.C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith-Jennings, 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.