Citation Nr: 21001522 Decision Date: 01/08/21 Archive Date: 01/08/21 DOCKET NO. 20-04 601 DATE: January 8, 2021 ORDER Entitlement to service connection for a left arm disability, claimed as carpal tunnel syndrome (CTS) is denied. Entitlement to service connection for a right arm disability, claimed as CTS is denied. Entitlement to an effective date prior to August 22, 2017 for the grant of an increased rating for epilepsy is denied. Entitlement to an effective date prior to August 22, 2017 for the grant of service connection for tinnitus is denied. Entitlement to an effective date prior to August 22, 2017 for the grant of service connection for status-post right great toe is denied. REMANDED Entitlement to service connection for a head injury, claimed as traumatic brain injury (TBI) is remanded. Entitlement to service connection for a respiratory condition is remanded. Entitlement to service connection for a sinus condition is remanded. Entitlement to service connection for a right eye disability is remanded. Entitlement to service connection for migraine headaches is remanded. Entitlement to service connection for stuttering is remanded. Entitlement to service connection for vertigo is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for chronic nose bleeds is remanded. Entitlement to an initial 10 percent disability rating, but no higher, for status-post right great toe fracture is remanded. Entitlement to a rating in excess of 20 percent for epilepsy is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran’s left CTS began during active service, or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against a finding that the Veteran’s right CTS began during active service, or is otherwise related to an in-service injury or disease. 3. On August 22, 2017, the Veteran filed an increased rating claim for service-connected epilepsy. 4. On August 22, 2017, the Veteran filed service connection claims for tinnitus and right foot injury; the record does not include any communication or other action that indicate an intent to apply for VA benefits for these disabilities prior to that date. CONCLUSIONS OF LAW 1. The criteria for service connection for left CTS have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for right CTS have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for an effective date earlier than August 22, 2017 for the grant of an increased rating for epilepsy have not been met. 38 U.S.C. §§ 5110, 7104; 38 C.F.R. §§ 3.102, 3.400. 4. The criteria for an effective date prior to August 22, 2017 for the grant of service connection for tinnitus have not been met. 38 U.S.C. §§ 5110, 7104; 38 C.F.R. §§ 3.151, 3.155, 3.400. 5. The criteria for an effective date earlier than August 22, 2017 for the grant of service connection for status-post right great toe have not been met. 38 U.S.C. §§ 5110, 7104; 38 C.F.R. §§ 3.151, 3.155, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1990 to May 1992. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2018 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). In his August 2017 application for compensation, in pertinent part, the Veteran requested service connection for respiratory and sinus conditions. See VA 21-526EZ, Fully Developed Claim (Compensation). In a March 2018 rating decision, the RO characterized the request as service connection for respiratory condition (also claimed as sinus condition). However, during a February 2018 VA examination the Veteran asserted that his symptoms are related to a sinus, not respiratory, condition. Therefore, the Board has bifurcated the issues as listed in the remanded section. In September 2020, the Veteran submitted evidence stating that he could not work due to his service-connected epilepsy disability. See September 2020 Psychological evaluation. As entitlement to a TDIU has been raised as part and parcel of the increased rating claims on appeal, the Board has assumed jurisdiction of this issue. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 1. Entitlement to service connection for left CTS 2. Entitlement to service connection for right CTS The Veteran contends that he has CTS in both upper extremities due to service. In an August 2017 statement the Veteran wrote: “Carpal tunnel – machinist in military.” Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. For the reasons set forth below, the Board concludes that an in service injury, disease, or event did not occur. Service treatment records (STRs) contain no complaints of or treatment for symptoms related to CTS. These records document that the Veteran fainted and lost consciousness in January 1992. He denied numbness and tingling in his extremities. His cranial nerves were intact but the reflexes in his ankles, knees, and elbows appear to have been diminished (+1), however a medical review Board stated that a detailed neurological exam was normal. The Veteran denied having painful joints in a November 1990 and May 1992 dental questionnaire while identifying other health concerns. The STRs contain no complaints of or treatment for symptoms related to CTS and the Veteran has not identified any event, injury, or disease during service to which his claimed disability may be related. To the extent the Veteran’s August 2017 statement suggests that he injured his wrists as a machinist in service, the records do not indicate that such an injury occurred. As noted above, following the Veteran’s in-service seizure, he was given a neurological examination and carpal tunnel of either extremity was not noted. A post-service, August 25, 2010 VA treatment record documented that “for several years and particularly over the past year” the Veteran experienced progressive numbness, tingling, and discomfort in the right hand. A month later the Veteran’s symptoms were noted to have onset one year prior and he denied similar symptoms in his left hand. He complained of bilateral wrist pain that had existed for over four years in September 2012 and was diagnosed with Cubital tunnel syndrome. Although the Veteran complained of numbness and tingling for “several years” when he sought treatment for wrist pain in August 2010, there is no evidence of onset within one year of separation from service. An April 1994 VA examination conducted a neurological evaluation and did not identify any neurologic abnormalities. If the Veteran had been experiencing ongoing numbness and tingling in his extremities, it is reasonable to conclude that such complaints or findings would have been noted following the neurological examination that was conducted shortly after his separation from service. The Board has considered the arguments submitted by the Veteran’s attorney, however the brief does not suggest, and the record does not otherwise indicate, that the Veteran’s CTS had its onset during service or within one year thereafter. The brief and the record also do not indicate that the disability is related to an in-service injury or disease or to another service-connected disability. While the Veteran believes that he has CTS due to his active duty service, the preponderance of the evidence weighs against findings that an in-service injury, event, or disease occurred. Without such evidence, VA’s duty to provide the Veteran with a VA examination or opinion is not triggered. As noted below, the evidence is missing post-service medical records, however the Veteran has not been prejudiced by an adjudication of these issues at this time as the claims are being denied based on the absence of an in-service injury or disease. The contemporaneous service treatment records that document that the Veteran was examined and bilateral CTS was not identified during service and he did not complain of joint pain or neurological abnormalities of the upper extremities during service. Given the foregoing, the Board finds the preponderance of the evidence is against a finding that the Veteran currently has a right or left arm disability, claimed as CTS, that was incurred during or as a result of his military service. Accordingly, the Veteran’s claim is denied. Effective Date Except as otherwise provided, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. An exception to that rule provides that the effective date of an award of an increase shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if the application is received within one year from such date. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). VA amended its adjudication regulations on March 24, 2015, to require that all claims governed by VA’s adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57,660 (Sept. 25, 2014). Under the old regulations, any communication or action, indicating an intent to apply for one or more benefits under laws administered by VA, from a claimant or the claimant’s representative, may be considered an informal claim. Such informal claims must identify the benefit sought. 3. Entitlement to an effective date earlier than August 22, 2017 for the grant of an increased rating for epilepsy In a December 1992 rating decision, the AOJ granted service connection for a seizure disorder and assigned a 20 percent rating, effective May 9, 1992. The Veteran did not appeal this decision nor was new and material evidence associated with the record within one year. The December 1992 rating decision therefore became final. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. In a May 1994 rating decision, the AOJ proposed to reduce the disability rating assigned to the Veteran’s epilepsy from 20 percent to 10 percent. In a July 1994 rating decision, the AOJ reduced the rating to 10 percent, effective October 1, 1994. The Veteran did not appeal this decision and new and material evidence was not associated with the file within one year of the July 1994 rating decision. Instead, on August 22, 2017, the Veteran filed an application requesting an increased rating for his service-connected seizure disorder. In a March 2018 rating decision, the AOJ increased the assigned rating for epilepsy, previously rated as a history of seizure disorder, to 20 percent, effective August 22, 2017 date of claim. In his December 2018 NOD, the Veteran, through his attorney, indicated disagreement with the effective date and assigned rating. He requested the earliest possible effective date for the increased 20 percent rating but did not identify any error in the assigned date. As noted, the Veteran filed a VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits in August 2017. Among other disabilities, this application listed an increased rating for epilepsy, claimed as seizures. No prior claim, formal or informal, for this disability is of record, and the Veteran and his attorney has not pointed to any specific communication prior to that date as a pending claim. Thus, based on these facts, the Board finds an effective date prior to August 22, 2017 is not warranted. Having determined that the Veteran’s claim was filed on August 22, 2017, the Board must now determine when entitlement arose. Upon review, the record reflects entitlement arose subsequent to August 22, 2017, receipt of the Veteran’s claim. Specifically, the award of a 20 percent rating was predicated upon a September 2017 VA examination which noted that the Veteran had at least one major seizure in the last two years, and at least two minor seizures in the last six months. As entitlement arose subsequent to the date of the claim, an earlier effective date is not warranted on this basis. In conclusion, based on review of the record, an earlier effective date is not assignable by law; thus, the claim for an effective date prior to August 22, 2017 for the award of an increased rating for epilepsy must be denied. As a preponderance of the evidence is against the award of an earlier effective date, the benefit of the doubt doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). 4. Entitlement to an effective date prior to August 22, 2017 for the grant of service connection for tinnitus 5. Entitlement to an effective date earlier than August 22, 2017 for the grant of service connection for status-post right great toe On August 22, 2017, the Veteran filed an application requesting service connection for tinnitus and a right foot injury. See August 2017 VA 21-526EZ. In a March 2018 rating decision, the AOJ granted service connection for tinnitus, evaluated as 10 percent disabling; and status-post right great toe fracture (claimed as right foot injury), evaluated as noncompensable. Both disabilities were assigned an effective date of August 22, 2017. In his December 2018 NOD, the Veteran, through his attorney indicated disagreement with the effective date assigned for these disabilities, generally stating that he was seeking the earliest effective date possible. A specific error was not identified in the NOD, substantive appeal or the September 2020 brief. As stated above, relevant law states that, unless specifically provided otherwise, the effective date for a grant of service connection is the day after separation from service or day entitlement arose, if a claim is received within one year of separation from service; otherwise, the date of receipt of claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(b)(2)(i). In addition to the foregoing, the relevant regulations state that the effective date of an award based on an original claim, a claim reopened after final adjudication, dependency and indemnity compensation, or pension shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of the application. 38 U.S.C. § 5110(a). The Court of Appeals for Veterans Claims (Court) has further explained that, in an original claim for service connection, the date entitlement arouse is governed by the date the claim is received, not the date of the medical evidence submitted to support a particular claim. See McGrath v. Gober, 14 Vet. App. 28 (2000). Because service connection claims for tinnitus and a right foot injury were received more than one year after the Veteran’s May 1992 separation from service, the effective date for the grant of service connection for these conditions may not be earlier than the date of receipt of the claim. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i); McGrath v. Gober, 14 Vet. App. 28 (2000). The Board acknowledges that 38 C.F.R. § 3.400(b)(2)(i) includes consideration of the date entitlement arouse and that it appears the Veteran’s argument is based, at least partially, on the concept that the entitlement to service connection for his tinnitus and right foot injury disabilities arose prior to the current date assigned. There is no dispute that the Veteran’s tinnitus and status-post right great toe (claimed as right foot injury) were incurred during and as a result of his active duty service. Indeed, the current grant of service connection for tinnitus and status-post right great toe represents an acknowledgement that the Veteran has these disabilities as a result of service. While the Veteran’s tinnitus and status-post right great toe disabilities began or arose during service, the law explicitly states that an effective date for a service connection claim received more than one year after separation from service will be the date of receipt of claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(b)(2)(i). Therefore, while the Veteran’s disabilities arose during service, his claim for benefits for these disabilities was received after the disabilities arose. As noted, the law relevant to this case provides that the effective date of a compensation award based on an original claim will be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(b)(2)(i). The evidence reflects that the first time the Veteran indicated an intent to seek entitlement to benefits for tinnitus and status-post right great toe was when he submitted an August 2017 application for benefits. Prior to this date, the Veteran submitted a September 1992 application for benefits limited to a request for service connection for seizure disorder. See September 1992 VA Form 21-526. There is no communication or action by the Veteran or his representative that indicates an intent to apply for VA benefits for tinnitus and status-post right great toe disabilities prior to the August 2017 application for benefits. The Board is sympathetic to the Veteran’s claims; however, it is bound by the law and is without authority to grant benefits on an equitable basis. See 38 U.S.C. §§ 503, 7104. The Board notes that the Court of Appeals for Veterans claims has stated that “no equities, no matter how compelling, can create a right to payment out of the United States Treasury which has not been provided for by Congress.” See Smith v. Derwinski, 2 Vet. App. 429, 432-33 (1992). As such, the Board is unable to waive the earlier effective date regulations and assign a date prior to the date of receipt of his initial claim for tinnitus and status-post right great toe disabilities. Accordingly, the earliest possible date for the grant of service connection for tinnitus and status-post right great toe disabilities is August 22, 2017, the date currently assigned. REASONS FOR REMAND 1. Entitlement to service connection for head injury, claimed as TBI, is remanded The Veteran claims that he has a TBI due to a head injury during service. The Board acknowledges that the claims file contains competing medical opinions on whether the Veteran has a current TBI disability. However, the claims file is missing evidence cited by a November 2017 examiner. In a November 2017 report, an examiner found that the Veteran did not have a TBI. In formulating this opinion, the examiner referenced an August 31, 2017 VA treatment record noting magnetic resonance imaging (MRI) tests of the brain were normal, however, the examiner also indicated that the report itself was not available for review. In contrast, the Veteran submitted a private medical opinion dated in September 2020. In this report, a psychologist found that the Veteran had a current diagnosis of TBI and that STRs document that the Veteran and hit his head while on active duty. The psychologist noted disagreement with a November 2017 VA examiner’s finding that the Veteran did not have a TBI. A review of the claims file indicates that the August 31, 2017 MRI report noted by the November 2017 examiner is not of record. Instead, the claims file contains VA treatment records dated in November 1998, from November 2009 to July 2017, and from September 2017 to February 2018. Because VA treatment records dated in August 2017 are not of record, the Board is unable to render a fully informed decision with respect to this issue. Therefore, a remand is necessary to obtain all relevant, outstanding VA treatment records. 38 U.S.C. § 5103A(c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if pertinent). 2. Entitlement to service connection for a respiratory condition is remanded 3. Entitlement to service connection for a sinus condition is remanded As outstanding VA treatment records obtained on remand may be relevant to service connection claims on appeal, the claims are remanded pending such development. The Board recognizes that the Veteran has been afforded a VA examination for his respiratory condition, but not sinus condition. As noted in the Introduction, the Veteran reported during a February 2018 examination that he does not have a respiratory disability, but a sinus disability. VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low for the purposes of obtaining a medical opinion. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. Because VA treatment records list a current diagnosis of chronic rhinitis and December 1990 STRs document inhalation of chemicals with subsequent symptoms, the sinus claim is remanded for a VA examination to determine the nature and etiology of his claimed condition. 4. Entitlement to service connection for a right eye disability is remanded 5. Entitlement to service connection for migraine headaches is remanded 6. Entitlement to service connection for stuttering is remanded 7. Entitlement to service connection for vertigo is remanded The Veteran claims to have right eye, migraine headaches, stuttering, and vertigo disabilities are being claimed as secondary to his head injury. See December 2018 NOD. Adjudication of these claims must be deferred, as these issues are inextricably-intertwined with the TBI issue being remanded herein. See Harris v. Derwinski, 1 Vet. App. 180. 8. Entitlement to service connection for left ear hearing loss is remanded The Board notes that for VA compensation purposes, hearing impairment is considered a disability when: (1) the auditory threshold in any of the frequencies 500, 1000, 2000, 3000 or 4000 Hertz (Hz) is 40 decibels (dB) or greater; (2) the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000 or 4000 Hz are 26 dB or greater; or (3) the speech recognition scores using the Maryland CNC test are less than 94 percent. 38 C.F.R. § 3.385. A veteran is presumed to have been in sound condition when “examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service.” 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). This presumption of soundness applies only when a disease or injury not noted upon entry to service manifests in service, and a question arises as to whether it preexisted service. Gilbert v. Shinseki, 26 Vet. App. 48, 55 (2012), aff’d 749 F.3d 1370 (Fed. Cir. 2014). Pursuant to 38 C.F.R. § 3.304(b), only those conditions recorded in examination reports can be considered as “noted,” and a history of pre-service existence of conditions recorded at the time of examination does not constitute notation of such conditions. On February 2018 VA audiological examination, an audiologist provided a negative nexus opinion on the relationship between the Veteran’s current bilateral hearing loss and service. For the left ear, the audiologist referenced a November 1990 entrance examination showing a threshold of 50 dB at 6000 Hz in the left ear and concluded that the Veteran had a pre-existing left ear hearing loss disability. The audiologist opined that the Veteran’s pre-existing left ear hearing loss was not aggravated beyond normal progression during service. A review of STRs reveals that at the time of the Veteran’s November 1990 enlistment, an audiometer revealed auditory thresholds of 10, 0, 0, 5, 0 dB at frequencies of 500, 1,000, 2,000, 3,000, and 4,000 Hz in the left ear. Auditory thresholds were 5, 0, 5, 5, and 0 dB at applicable frequencies in the right ear. Under VA regulations, the Veteran did not have a hearing loss disability at entrance, nor was a hearing loss condition noted. Because the February 2018 VA audiologist inaccurately found that the Veteran had a pre-existing left ear hearing loss disability, the opinion is inadequate to decide the claim on appeal. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (holding that once VA has provided a VA examination or obtained a medical opinion, it is required to provide or obtain one that is adequate for the purpose sought). Therefore, a remand is needed to obtain a VA opinion. 9. Entitlement to service connection for chronic nose bleeds is remanded The Veteran asserts that he has a chronic disability resulting from nose bleeds due to inhaling cleaning chemicals during service. See December 2018 NOD. The Board acknowledges that a current diagnosis related to nose bleeds is not of record. However, STRs document inhalation of chemicals in December 1990 and post-service VA treatment records document complaints of nose bleeds. In September 2010, the Veteran reported having nose bleeds during severe headaches. In April 2014, he reported having a lot of nose bleeds related to rubbing. During both visits, a diagnosis for reported symptoms was not provided. However, because evidence of functional impairment of earning capacity can meet the criteria for a current disability, a remand is warranted to consider whether the Veteran’s reported symptoms result in such functional impairment. See Saunders v. Wilkie, 886 F.3d 1356, 1363 (Fed. Cir. 2018); Wait v. Wilkie, No. 18-4349 (Vet. App. August 26, 2020). 10. Entitlement to an initial 10 percent disability rating, but no higher, for status-post right great toe fracture is remanded 11. Entitlement to a rating in excess of 20 percent for epilepsy is remanded As outstanding VA and private treatment records obtained on remand may be relevant to the increased rating claims on appeal, the claims are remanded pending such development. 12. Entitlement to a TDIU is remanded The Veteran claims he is unable to work due to his service-connected epilepsy disability. See September 2020 Medical Treatment Non-Government Facility. As such, the Board has assumed jurisdiction of this issue. See Rice v. Shinseki, 22 Vet. App. 447 (2009). However, the TDIU claim is inextricably intertwined with the epilepsy increased rating claim being remanded herein, as the outcome of this claim may impact the TDIU claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a Veteran’s claim for the second issue). Therefore, adjudication of the TDIU claim must be deferred. The matters are REMANDED for the following action: 1. Contact the Veteran in order to have him identify the names and addresses of all health care providers who have treated him for the issues on appeal. The Veteran should also be notified that he may submit evidence or treatment records to support his claim. The Veteran should be asked to submit, or authorize VA to obtain, imaging studies of the brain reported in January 2010 and November 2014 VA treatment records. VA treatment records from August 2017, to include the MRI report noted in an August 31, 2017 treatment note must be obtained. All outstanding records of VA medical treatment (generated after the last treatment notes of record) should also be obtained. The AOJ should attempt to obtain the records identified above as well as any records identified by the Veteran. All efforts to obtain such records should be documented in the claims folder. All available records should be associated with the Veteran’s VA claims folder. 2. After completing the action requested in item 1, obtain an etiology opinion from an appropriate examiner to determine the nature and etiology of the Veteran’s sinus condition, to include chronic rhinitis. The need for a physical examination is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review. Based on the review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s sinus condition, to include chronic rhinitis, had its clinical onset during service or is due to an event or incident of the Veteran’s period of active service. In rendering an opinion, the examiner should consider the Veteran’s relevant STRs, to include December 1990 records documenting inhalation of chemicals. The examiner is reminded that the lack of evidence in the Veteran’s STRs regarding complaints of or treatment for a sinus condition, standing alone, cannot be a sufficient basis to form a negative nexus opinion. If the examiner finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. A complete rationale should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. 3. After completing the action requested in item 1, obtain an etiology opinion from an appropriate examiner, other than the February 2018 VA examiner, to determine the nature and etiology of the Veteran’s bilateral hearing loss. The need for a physical examination is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review. Based on the review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present bilateral hearing loss had its onset during active service, or is otherwise etiologically related to such service, to include in-service noise exposure. In rendering an opinion, the examiner should consider the Veteran’s relevant STRs, to include November 1990 entrance examination. The examiner is reminded that the lack of evidence in the Veteran’s STRs regarding complaints of or treatment for hearing loss, standing alone, cannot be a sufficient basis to form a negative nexus opinion. If the reviewing examiner finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. A complete rationale should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered in formulating the requested opinion. However, if there is a medical reason to doubt its veracity, the examiner should explain why the Veteran’s statements or recollection are inconsistent with the evidence in this case, medical principles relating to the onset and progress of the disease, the specific findings in the record, and/or your professional judgment. 4. After completing the action requested in item 1, obtain an etiology opinion from an appropriate examiner to determine the nature and etiology of the Veteran’s nose bleeds. The need for a physical examination is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review. Based on the review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s nose bleeds had its clinical onset during service or is due to an event or incident of the Veteran’s period of active service. If the examiner concludes that the Veteran does not have a chronic nose bleed disability, the examiner is asked to describe the Veteran’s symptoms and provide an opinion as to whether the Veteran’s symptoms (nose bleeds during severe headaches, or nose bleeds related to rubbing) cause functional impairment of his earning capacity. In rendering an opinion, the examiner should consider the Veteran’s relevant STRs, to include December 1990 records documenting inhalation of chemicals. The examiner is reminded that the lack of evidence in the Veteran’s STRs regarding complaints of or treatment for nose bleeds, standing alone, cannot be a sufficient basis to form a negative nexus opinion. If the examiner finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. A complete rationale should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. 6. After completing the action requested in item 1, arrange for an appropriate health care provider to review the Veteran’s claims file and provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran has a TBI or TBI residuals that had their clinical onset during service or are due to an event or incident of the Veteran’s period of active service. In rendering the opinion, the examiner’s attention is drawn to the conflicting November 2017 examiner and September 2020 medical opinions of record. If the examiner determines that a TBI is at least as likely as not related to the Veteran’s active duty service, the examiner is asked to provide an additional opinion as to whether it is at least as likely as not, (50 percent probability or greater), that the claimed right eye disability, migraine headaches, stuttering, and vertigo are (A) caused or (B) aggravated beyond its normal progression by the TBI. Aggravation means an increase in disability – any additional impairment of earning capacity – of the nonservice-connected disability. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. 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. 5. Readjudicate the issues remaining on appeal. If any benefit sought is not granted, then the Veteran and his representative should be furnished with a Supplemental Statement of the Case and afforded an opportunity to respond before the record is returned to the Board for further review. M. Donohue Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Amanda Baker, 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.