Citation Nr: 21004443 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 14-15 528 DATE: January 27, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. FINDINGS OF FACT 1. The most probative evidence of record weighs against a conclusion that bilateral hearing loss was incurred in service; sensorineural hearing loss was not demonstrated within one year of service. 2. The evidence weighs against a finding that the Veteran’s recurrent tinnitus was incurred in-service or within one year of service. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2018). 2. The criteria for service connection for tinnitus are not met. 38 U.S.C. §§ 1110, 1112, 1113, 5100, 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.326, 4.87. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Army from February 1966 to January 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2012 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In his April 2014 VA Form 9, the Veteran indicated, “I want a BVA hearing by live videoconference.” See April 2014 VA Form 9, Substantive Appeal. A hearing was scheduled for December 2016 in the Waco, Texas Regional Benefits Office. See November and December 2016 notification letters. The Veteran failed to report for the December 2016 hearing, without good cause, and did not request to reschedule the hearing. As such, the April 2014 hearing request is considered withdrawn. The Board denied the Veteran service connection for bilateral hearing loss and tinnitus in a February 2018 decision. Following the denial, the Veteran appealed to the United States Court of Appeals for Veterans Claims (CAVC). In December 2018, CAVC vacated the February 2018 Board decision and granted a Joint Motion for Remand (JMR) of these issues for further development. The matter was returned to the Board for actions consistent with the December 2018 JMR in May 2019. The Board remanded the matter in May 2019 and again in September 2020 for further development. The appeal is returned to the Board for further consideration. This case has been advanced on the docket pursuant to 38 U.S.C. § 7107(b) and 38 C.F.R. § 20.902(c). Duty to Notify and Assist VA must notify the claimant of any information, including any medical or lay evidence, not previously provided to VA, that is necessary to substantiate the claim. See 38 U.S.C. § 5103 (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA has satisfied its duties to inform and assist the Veteran in this case. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 21.1032(a). The duty to notify was satisfied by VA Veterans Claims Assistance Act correspondence dated July 2011. See also June 2012 Acknowledgment Letter, April 2014 Statement of the Case, January 2015 and October 2016 Supplemental Statements of the Case (SSOC), March 2019 Appeal Notification Letter, November 2019 and November 2020 SSOC, and December 2020 Board letter. The RO’s efforts have substantially complied with the instructions contained in the December 2018 CAVC and May and September 2019 Board remands. See Stegall v. West, 11 Vet. App. 268 (1998). The entire record was available to the March 2012 and November 2019 and 2020 examiners, hearing loss and tinnitus examinations were performed, and the testing was sufficient to adequately address all potential rating criteria. See March 2012, November 2019, and November 2020 VA examination reports. Further development and further assistance by VA is not warranted. VA’s duty to assist functions to assist a claimant in obtaining evidence necessary to substantiate a claim, but VA is not required to provide assistance to a claimant when there is no reasonable possibility that assistance would aid in substantiating the claim. See 38 U.S.C. § 5103A (2012). As for VA’s duty to assist the Veteran, medical examinations and medical opinions have been obtained, sufficient to apply the applicable rating criteria and to make a decision on the claim. See 38 U.S.C. § 7104(d)(1); 38 C.F.R. §§ 3.385, 4.87. The Board finds that VA has done everything reasonably possible under 38 C.F.R. § 21.1032(a) to assist the Veteran. A remand or further development of this claim would serve no useful purpose. Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claims in this Board decision. The Veteran has not identified any available, outstanding records that are relevant to the claim decided herein, nor is there an indication that any outstanding evidence, relevant to the claim, needs to be obtained. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2017). Service Connection In order to prove service connection, there must be competent and credible evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the in-service disease or injury. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. After the evidence is assembled, it is the Board’s responsibility to evaluate the entire record. See 38 U.S.C. § 7104 (a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2017). 1. Entitlement to service connection for bilateral hearing loss For the purpose of applying the laws administered by the VA, impaired hearing will be considered a disability when: (1) the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; or (2) the auditory thresholds for at least three of those frequencies are 26 decibels or greater; or (3) speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2017). Prior to January 1967, all VA audiograms were conducted under an old standard. From January 1967 through December 1970, VA audiograms were conducted under either the old standard or the current standard. The Board considers these results under both standards. After December 1970, all VA audiograms were conducted under the current standard. Because the statute regulating VA hearing loss determinations is written under the current standard, the auditory threshold readings of examinations conducted under the old standard are adjusted to align with the current standard. When considering the auditory threshold levels under the old standard, the decibel reading is adjusted as follows: (Hz) 500 1000 2000 3000 4000 Threshold Increase 15 10 10 10 5 Hearing loss is a chronic disease that is found to occur in service if it manifested to a compensable degree in active service or, for hearing loss, within one year of separation. 38 C.F.R. §§ 3.307, 3.309. When a chronic disease is shown in service, “subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes.” 38 C.F.R. § 3.303(b). Analysis The Veteran contends that his bilateral hearing loss is the result of noise exposure during service, more specifically, “I was sent to the weapons range several times during the years I was in-service. I was never given ear plugs to protect my hearing.” See August 2011 VA Form 21-4138, Statement in Support of Claim. Medical evidence of record establishes that the Veteran has a current disability of bilateral hearing loss for VA purposes. As such, the Board concedes that the Veteran has a current diagnosis of bilateral hearing loss in order to satisfy the first element of service connection. In December 1965, the Veteran was provided with a physical examination upon his entry into active duty service. His clinical evaluation was “Normal” for “Ears – general…Drums,” and his self-evaluation reflected “No Ear, Nose or Throat Trouble.” At that time, the Veteran indicated that his “usual occupation” was “Steel worker.” See December 1965 Reports of Medical Examination and Medical History. At the time of his entry into active duty, the Veteran was administered an audiogram. The test results, adjusted to the current standards, are as follows: (Hz) 250 500 1000 2000 3000 4000 6000 8000 Right X -5 -10 -5 -10 -5 X X Left X 0 -5 -5 -5 -5 X X In October 1967, the Veteran received a physical examination before separating from active duty service. His clinical evaluation was “Normal” for “Ears – general…Drums,” and his self-evaluation reflected “No Ear, Nose or Throat Trouble.” In addition, the Veteran described his “present health” with the following statement, “I am in good health.” See October 1967 Reports of Medical Examination and Medical History. At the time of his separation from active duty, the Veteran was given an audiogram. The results are as follows: (Hz) 250 500 1000 2000 3000 4000 6000 8000 Right 5 0 -10 -5 X 0 X 10 Left 5 0 -5 -5 X 5 X 5 Before he left active duty service, the Veteran executed the following statement, “There has been no change in my medical condition since my last medical examination 14 October (19)67 with the following exception(s): To the best of my knowledge and belief [sic] there has been no change in my medical condition subsequent to the last examination which I took in conjunction with my appointment in the regular Army [sic] and I am not now suffering from any defect or deformity not then recorded.” See service medical records, p.14. The first indication of hearing loss for the Veteran was his statement regarding service connection in June 2011. See June 2011 VA Form 21-4138, Statement in Support of Claim. Prior to the June 2011 claim, a January 2005 “Complete Physical” recorded no “decreased hearing.” See January 2005 Tiena Health Review of Systems. In addition, physical examinations at Baylor University were “Negative” for ear conditions. See April and July 2006 Baylor Medical Center Physical Examinations. A September 2009 head CT and related examination was “Negative for hearing loss.” See September 2009 State of the Heart Cardiology Medical Record. At an October 2008 physical therapy evaluation, the Veteran’s hearing was determined to be “intact.” See October 2008 VA Physical Therapy Consult. During an October 2013 pre-operative consult, the Veteran denied hearing loss. See October 2013 VA Pre-Operative E & M Consult. The Veteran was provided with a VA examination in March 2012, where he stated that he experienced an episode of complete left ear hearing loss for approximately 3 days, about six years prior to the examination. The examiner diagnosed the Veteran with bilateral hearing loss under 38 C.F.R. § 3.385 but concluded that the Veteran’s bilateral hearing loss was not related to service. See March 2012 VA examination report. The March 2012 examiner pointed to the Veteran’s active duty service as a cook and noted that the MOS had a “low probability” of hazardous noise exposure. The examiner also noted that the Veteran’s post-military occupations were in mass transit and factories, although the Veteran reported wearing hearing protection in his civilian occupations. The examiner also noted that service treatment records indicated “hearing within normal limits” from entry to separation. Further, the examiner found no evidence of “noise trauma” in the Veteran’s service records. The examiner opined that hearing loss was more likely due to the hazardous noise exposure at the Veteran’s post-service occupations. See March 2012 VA examination report. An audiology examination in January 2013 found, “Type A tympanogram consistent with normal tympanic membrane mobility” after acoustic-immittance testing. For the Veteran’s right ear, the audiologist found “hearing within normal limits” and “excellent” word recognition ability. For the left ear, word recognition ability was also “excellent,” but Pure-tone test results reflected “mild sensorineural hearing loss” from 250 – 8000 Hz. The diagnosis confirmed, “asymmetrical hearing loss in the left ear and tinnitus.” See January 2013 VA Audiology Consult. In September of that same year, an emergency department physician determined, “hearing appears normal.” See September 2013 VA Physician Emergency Department Note. An additional VA examination was completed for the Veteran in November 2019. Pure-tone threshold testing yielded the following results: Right Ear A B C D E F G 500 Hz* 1000 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz 8000 Hz 15 15 30 30 40 25 50 Left Ear A B C D E F G 500 Hz* 1000 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz 8000 Hz 40 40 45 50 55 50 60 The Pure-tone threshold at 500 Hz is not used in calculating the Pure-tone threshold average for evaluation purposes but is used in determining whether or not hearing impairment reaches the level of a disability for VA purposes. The Pure-tone threshold average requires the decibel (dB) levels at each of the required frequencies (1000 Hz, 2000 Hz, 3000 Hz, and 4000 Hz) to be recorded for the test to be valid for determination of hearing impairment. There were no frequencies that could not be tested for either ear, and the test results were valid for rating purposes. The average Pure-tone threshold for the right ear, columns B – E, was 28.75 dB. The average Pure-tone threshold for the left ear, columns B – E, was 47.50 dB. The Maryland CNC word list speech discrimination scores, appropriate for use with this Veteran, were 100 percent for the right ear and 94 percent for the left ear. Immittance (tympanometry) testing was not obtained for the Veteran due to the inability to obtain or maintain a seal. See November 2019 VA examination report. The diagnosis was sensorineural hearing loss across all frequencies (500 – 6000 Hz or higher) in both the right and left ears. There was no permanent positive threshold shift (worse than reference threshold) greater than normal measurement variability at any frequency between 500 and 6000 Hz for either the right or left ears. The November 2019 examiner opined that the Veteran’s right and left ear hearing loss was less likely than not caused by or a result of an event in military service. See November 2019 VA examination report. The rationale for the November 2019 examiner included “no significant permanent shifts in hearing thresholds between entrance and separation,” despite “slight changes in hearing” noted at the October 1967 separation examination. Specifically, hearing at 4 kHz was measured at -5 dB hearing loss in December 1965 and 0 dB hearing loss in October 1967, “which is not considered to be a clinically significant shift in hearing.” The lack of “significant permanent shifts in hearing thresholds between entrance and separation” was considered “objective evidence of no permanent auditory damage on active duty” by the examiner. Further, the examiner pointed to the lack of reported hearing loss by the Veteran in service records, including separation, civilian occupations in factories, and the “low probability of noise exposure” as a cook in-service. See November 2019 VA examination report. The Veteran was provided with another VA examination in November 2020. Pure-tone threshold testing yielded the following results: Right Ear A B C D E F G 500 Hz* 1000 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz 8000 Hz 15 20 25 20 25 25 40 Left Ear A B C D E F G 500 Hz* 1000 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz 8000 Hz 50 45 40 40 45 35 50 There were no frequencies that could not be tested for either ear, and the test results were valid for rating purposes. The average Pure-tone threshold for the right ear, columns B – E, was 22.5 dB. The average Pure-tone threshold for the left ear, columns B – E, was 42.5 dB. The Maryland CNC word list speech discrimination scores, appropriate for use with this Veteran, were 100 percent for the right ear and 94 percent for the left ear. Immittance (tympanometry) testing was obtained for the Veteran, with acoustic immittance, ipsilateral acoustic reflexes, and contralateral acoustic reflexes “Normal” for both the right and left ears. See November 2020 VA examination report. The diagnosis was sensorineural hearing loss (in the frequency range of 6000 Hz or higher frequencies) in the right ear, and sensorineural hearing loss across all frequencies (500 – 6000 Hz or higher) in the left ear. There was no permanent positive threshold shift (worse than reference threshold) greater than normal measurement variability at any frequency between 500 and 6000 Hz for either the right or left ears. The November 2020 examiner opined that the Veteran’s right and left ear hearing loss was less likely than not caused by or a result of an event in military service. See November 2020 VA examination report. Rationale for the November 2020 examiner included the “low probability of hazardous noise exposure” as a cook, civilian work in factories, which “are consistent with hazardous noise exposure,” and the lack of a “significant dip” in Pure-tone thresholds between 2000 – 6000 Hz. The examiner explained that, “Hearing loss which is a result of exposure to loud noise is characterized by a significant dip in thresholds between 2000 Hz and 6000 Hz,” contrasting the Veteran’s hearing loss, “(significant dip) present only at 8000 Hz, more than 50 years after military service.” The lack of “significant shifts in hearing thresholds during military service” were noted by the examiner. See November 2020 VA examination report. While the November 2020 examiner acknowledged “a shift of 10 dB…at 4000 Hz in the right ear (-10 dB HL to 0 dB HL),” from entry to separation in the Veteran’s service records, she pointed out that the Department of Defense only classifies Pure-tone threshold shifts of 15 dB or greater as “significant.” Further, the examiner explained that, “Any shift within 5 to 10 dB is considered test-retest variability and is not indicative of any organic (hearing) loss but of factors due to testing differences which cannot be eliminated.” See The Handbook of Standard Procedures and Best Practices for Audiology Compensation and Pension Examinations (2004). Because the Veteran’s recorded threshold shift is less than 15 dB when compared at entry and separation, “A nexus cannot be established between hazardous noise exposure during military service and…hearing loss.” See November 2020 VA examination report. Moreover, the November 2020 examiner quoted an Institute of Medicine study from 2006 titled, “Noise and Military Service – Implications for Hearing Loss and Tinnitus.” The conclusion of the study was that there was no “scientific basis” for the concept that hearing loss that develops many years after exposure (to hazardous noise) is causally related to that exposure. Quoting from the findings, “There 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. Although the definitive studies to address this issue have not been performed, based on the anatomical and physiological data available on the recovery process following noise exposure, it is unlikely that such delayed effects occur.” Id at 47. Based on this research, the examiner opined, “[T]he hearing loss primarily in the left ear documented in the current evaluation is less likely than not the result of hazardous noise exposure or other events during military service.” See November 2020 VA examination report. Regarding the Veteran’s lay statements about the lack of hearing protection in-service, the November 2020 examiner again pointed to the lack of “significant shifts” in Pure-tone threshold measurements between December 1965 and October 1967. Addressing the Veteran’s lay statements related to the lack of recorded 3000 Hz Pure-tone threshold data in October 1967, the November 2020 examiner reasoned that, “All (Pure-tone) thresholds in both ears (in October 1967) are well within normal limits.” Pure-tone thresholds at the November 2020 examination “are the same or less than thresholds at 2000 Hz and 4000 Hz, bilaterally.” By analogy, October 1967 Pure-tone threshold measurements that were “well within normal limits” at 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz, 6000 Hz, and 8000 Hz would also be “well within normal limits” at 3000 Hz, including data analogous with similarly recorded, 2000 Hz and 4000 Hz, frequencies. See November 2020 VA examination report. The Veteran contends that his October 1967 audiometry examination is inadequate, because the report does not include Pure-tone threshold measurements at 3000 Hz. See March 2019 Memorandum, p.2. While the Veteran relies upon the non-precedential opinion of Schmoker v. Wilkie, 2018 U.S. App. Vet. Claims LEXIS 605, to support this assertion, the facts of his case are vastly different. First, the appellant had an MOS as “field artillery man.” Second, the appellant had demonstrated asymmetrical hearing loss in his separation examination, with hearing in his right ear worse than his left ear. Third, the appellant had partial deafness documented in his service treatment records. Fourth, the Board found that the appellant had normal hearing at separation. Fifth, the Board conceded in-service acoustic trauma for the appellant. Sixth, service records for the appellant were inconsistent with the interpretation of a normal audiometry examination at separation. Seventh, the Court found that the Board provided an inadequate statement of reasons or bases for relying on VA medical opinions to support its finding of no hearing loss disability for the appellant. Eighth, the appellant was able to demonstrate continuity of symptomatology of hearing loss from service. These facts do not exist in this case. A more appropriate case for reference is Porter v. Wilkie, 2020 U.S. App. Vet. Claims LEXIS 2400, another non-precedential decision regarding hearing loss, because the facts more closely align with the present case. The appellant demonstrated a change in Pure-tone threshold measurements of 10 dB from entry to separation. A VA examiner determined that the appellant’s hearing was within normal limits at separation from service, noted the absence of a significant shift in measured Pure-tone thresholds from entry to separation, explained that a 10 dB shift in Pure-tone measurements is within acceptable testing variability, found no objective evidence of permanent auditory damage on active duty, pointed to the lack of in-service complaints or treatment for hearing problems, including the denial of ear, nose or throat trouble at separation, and relied upon normal audiologic examinations that occurred may years post-service. Two notable differences in the appellant’s case are: 1) that he was a mortarman with conceded exposure to hazardous noise; and 2) he served for 4 years in his MOS. Notwithstanding the fact that the October 1967 audiometry examination did not record the Pure-tone threshold for 3000 Hz or that VA examinations discussed herein used the terms “normal, within normal limits,” and “no significant shift” to describe Pure-tone threshold results as they relate to hearing loss for VA disability purposes, the Board finds that the examinations nevertheless are adequate for VA rating purposes. The rationale for the medical opinions is based on the Veteran’s prior medical history, including prior VA examinations, Stefl v. Nicholson, 21 Vet. App. 120 (2007), “describes the disability…in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one,” Ardison v. Brown, 6 Vet. App. 405 (1994), and “sufficiently inform(ed) the Board of a medical expert’s judgment on a medical question and the essential rationale for that opinion,” Monzingo v. Shinseki, 26 Vet. App. 97 (2012). Moreover, the opinions did not rely exclusively on the fact that the Veteran’s hearing was within normal limits at his separation from service. See Hensley v. Brown, 5 Vet. App. 155 (1993). Any failure to record Pure-tone threshold at the 3000 Hz frequency during the October 1967 audiometry examination is harmless and not prejudicial to the Veteran. The November 2020 VA examiner opined that no significant shift in Pure-tone threshold measurements, nor a finding of hearing loss, can be assumed based on the absent 3000 Hz data in the October 1967 examination. She based her opinion on the consistency of recorded data during the October 1967 examination and on the consistency of the data in the November 2020 examination. Extrapolating the data from each examination, the examiner determined that no outlier data, indicating a “significant shift” or hearing loss, would have existed, as an exclusive exception, at the 3000 Hz frequency threshold in October 1967. In summary, a review of the Veteran’s service treatment records do not contain any complaints, treatment, or diagnosis of hearing loss or trauma, and the Veteran’s clinical and self-evaluations at separation do not reflect any findings or complaints for hearing conditions. The absence of in-service evidence of hearing loss is not fatal to a claim for service connection. See Ledford v. Derwinski, 3 Vet. App. 87 (1992). However, the Veteran was examined numerous times after service, including VA and non-VA treatment, and he either denied hearing loss or was determined not to have hearing loss. The Veteran first reported hearing loss in June 2011, and the first medical documentation of hearing loss is March 2012. The greater weight of the evidence is against a finding of elements two and three for service connection, an in-service event or aggravation and a nexus to military service. The Veteran alleges injury to his hearing while in-service. The Board notes that the Veteran is competent to report the onset and continuity of hearing loss symptoms. However, the question of whether the Veteran’s hearing loss is related to his active service falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Opining on the etiology of hearing loss requires the expertise of a medical professional, particularly when there has been a significant passage of time without any documentation of symptomatology. While the Veteran can report symptoms that he experiences, he does not have the necessary training to offer medical opinions. There is no evidence in the record of a hearing condition or of hearing trauma, which was adequately addressed in the VA examinations. Hearing loss is a chronic disease that is found to occur in service if it manifested to a compensable degree in active service or within one year of separation. 38 C.F.R. §§ 3.307, 3.309 (2017). When a chronic disease is shown in service, “subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes.” 38 C.F.R. § 3.303(b) (2017). Assuming arguendo that the Board interpreted the Veteran’s statements to indicate that his hearing loss has continued since service, an actual diagnosis of sensorineural hearing loss requires objective, medical testing to determine whether it is severe enough to be considered a disability for VA compensation purposes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376, 1377 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). To the extent the Veteran may be competent to opine as to medical etiology, the Board finds that the Veteran’s lay assertions in the present case are outweighed by the medical evidence of record, including the March 2012, November 2019, and November 2020 VA examinations. The examiners have the training, knowledge, and medical expertise on which to rely in order to form an opinion. The Board has considered the statements of the Veteran and finds the medical evidence more probative. Factors for assessing the probative value of a medical opinion are the examiner’s access to the claims file and the thoroughness and detail of the opinion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The guiding factors in evaluating the probative value of a medical opinion are whether the opinion was based on sufficient facts or data, whether the opinion was the product of reliable principles and methods, and whether the medical professional applied the principles and methods reliably to the facts of the case. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). These standards are met in the VA examinations. The March 2012, November 2019, and November 2020 VA opinions are the most probative evidence of record on the question of diagnosis and nexus to service. The opinions were based on an extensive review of all of the evidence, including statements from the Veteran, the December 1965 and October 1967 audiometric tests, the Veteran’s treatment records, and the Veteran’s in-service MOS and civilian occupations, were supported by a detailed rationale, provided data to support any conclusions, and provided a clear and reasoned analysis, the source of the most probative value in a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The March 2012, November 2019, and November 2020 VA examiner opinions are consistent with one another and the evidence of record, including the Veteran’s private treatment. The VA examiner opinions provide compelling evidence against the Veteran’s claim for service connection. The Veteran contends that his claimed disability exists and is related to his active service. This opinion is of no probative value, because he lacks the medical expertise needed to diagnose a hearing condition or to attribute it to active military service. There is no competent, credible evidence to refute the VA examiner opinions. The weight of the probative evidence of record is against a finding that the Veteran’s hearing condition is causally or etiologically related to any disease, injury, or incident, in service. Consequently, service connection is not warranted. Finally, a clear preponderance of the evidence of record indicates the Veteran does not meet the criteria under 38 C.F.R. § 4.87, DC 6100, for entitlement to service connection for a hearing condition. Therefore, his claim must be denied. In reaching the conclusions stated above, the Board has considered the applicability of the benefit of the doubt doctrine. The rule does not apply when the Board finds that a preponderance of the evidence is against the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (2018); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 2. Entitlement to service connection for tinnitus The Veteran asserts that his tinnitus is a result of noise exposure during service, including training at “the weapons range several times during the years I was in Service.” See August 2011 VA Form 21-4138, Statement in Support of Claim. Medical evidence of record establishes that the Veteran is diagnosed with tinnitus for VA disability purposes. As such, the Board concedes that the Veteran has a current diagnosis in order to satisfy the first element of service connection. Because tinnitus is “subjective” and cannot be tested, its existence is generally determined by whether the veteran claims to experience it. For VA purposes, tinnitus diagnosis is determined to be a disorder with symptoms that can be identified through lay observation alone. See Charles v. Principi, 16 Vet. App. 370 (2002). Although the credibility of lay evidence may not be refuted solely by the absence of corroborating medical evidence, it is a factor. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay evidence concerning continuity of symptoms after service, if credible, may be competent, regardless of the lack of contemporaneous medical evidence). Other factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). Analysis The reported history of the Veteran’s claimed tinnitus is inconsistent. Clinical and self-evaluations upon entry into service were negative for tinnitus, including “Normal Ears – General…Drums,” and “No Ear, Nose or Throat Trouble.” At that time, the Veteran indicated that his “usual occupation” was “Steel worker.” See December 1965 Reports of Medical Examination and Medical History. Likewise, clinical and self-evaluations upon separation from service were negative for tinnitus, including “Normal Ears – General, Normal Drums,” and “No Ear, Nose or Throat Trouble.” In addition, the Veteran described his “present health” with the following statement, “I am in good health.” See October 1967 Reports of Medical Examination and Medical History. At his March 2012 VA examination, the Veteran stated, “I have always had (tinnitus).” See March 2012 VA examination report. In November 2019, the Veteran stated that his tinnitus began “about 4 – 5 years ago.” See November 2019 VA examination report. At his November 2020 VA examination, the Veteran reported that his tinnitus “started during training in 1967.” See November 2020 VA examination report. During an October 2013 pre-operative consult, the Veteran denied tinnitus. See October 2013 VA Pre-Operative E & M Consult. Further, the Veteran denied tinnitus symptoms during private treatment evaluations. See January 2005 Tiena Health Review of Symptoms, April and July 2006 Baylor Medical Center History and Physical Examinations, and September 2009 State of the Heart Cardiology Examination. The first medical documentation of the Veteran’s tinnitus occurred at the March 2012 VA examination, at which point the Veteran stated that he was “unsure” when his tinnitus began. See March 2012 VA examination report. The Veteran was provided with a VA examination in March 2012. The examiner considered the Veteran’s statements: 1) “I have always had it;” and 2) that his recurrent tinnitus became “constant” about six years prior to the examination. In conclusion, the examiner opined that the Veteran’s tinnitus was less likely than not related to service. Rationale for the opinion included no reports of tinnitus by the Veteran in-service, the low probability of hazardous noise exposure as a cook, and the lack of acoustic trauma documented in-service. See March 2012 VA examination report. A second VA examination was performed in November 2019. The Veteran reported “recurrent” tinnitus that began “4 – 5 years ago (Circa 2014 to 2015).” The examiner considered the Veteran’s statement that, prior to 2014 or 2015, he “did not notice any (emphasis added) tinnitus.” The Veteran described his tinnitus as “buzzing / roaring, with fluctuations in loudness.” The examiner opined that the Veteran’s tinnitus was less likely than not caused by or a result of military noise exposure. Rationale included the absence of a “significant permanent shift” in Pure-tone thresholds from entry to separation, the “low probability of noise exposure” as a cook in-service, the lack of complaints, treatment, or diagnosis for tinnitus in-service, including separation clinical and self-evaluations, and the statement by the Veteran that he didn’t notice any tinnitus before 2014 or 2015. The examiner pointed out that medical literature “does not support late onset (45+ years) noise-induced tinnitus.” See November 2019 VA examination report. An additional VA examination was afforded to the Veteran in November 2020. The Veteran reported “recurrent” tinnitus but was again unable to recall the date or circumstances of onset, nor could he state in which ear the symptoms manifest. The examiner noted statements by the Veteran that his tinnitus may have began in 1967, while in-service, which conflicted with previous Veteran statements in the record. It was conceded by the examiner that tinnitus is commonly unreported “until it progresses into a more persistent condition,” but the examiner also pointed to the 40 plus year delay in the Veteran’s report of tinnitus after service. See November 2020 VA examination report. The November 2020 examiner concluded that it was less likely than not that the Veteran’s tinnitus was caused by or a result of military service. Rationale included the conflicting information with regard to onset, the lack of “significant shifts in (Pure-tone) hearing thresholds” from entry to separation, the “low probability of hazardous noise exposure” in-service as a cook, the exposure to “hazardous noise areas” in civilian occupations, and the 2006 Institute of Medicine study “Noise and Military Service – Implications for Hearing Loss and Tinnitus,” which stated, “[I]t is unlikely that such delayed effects (between hazardous noise exposure and symptoms) occur.” Id at 47. See November 2020 VA examination report.   In summary, a review of the evidence indicates that the preponderance of the evidence is against the claim for service connection for tinnitus. The Veteran’s service treatment records are negative for complaints, treatment, or diagnoses of tinnitus. The first complaint of tinnitus was in the Veteran’s June 2011 claim, more than 40 years after service. The Veteran’s statements at VA examinations range from, “I have always had it” to onset “4 – 5 years ago (Circa 2014 to 2015).” It is worth noting that the Veteran denied tinnitus at October 2013 VA treatment, which corroborates the November 2019 VA examination statement that his tinnitus began in 2014 or 2015. To that end, the Board finds that there is no credible evidence supporting a finding of continuity of symptomatology since service. To the extent the Veteran may be competent, or credible, to opine as to medical etiology, the Board finds that the Veteran’s lay assertions in the present case are outweighed by the medical evidence of record, including the March 2012, November 2019, and November 2020 VA examinations. The examiners have the training, knowledge, and medical expertise on which to rely in order to form an opinion. The Veteran first reported hearing loss in June 2011, and the first medical documentation of hearing loss is March 2012. The Board has considered the statements of the Veteran and finds the medical evidence more probative. The greater weight of the evidence is against a finding of elements two and three for service connection, an in-service event or aggravation and a nexus to military service. Factors for assessing the probative value of a medical opinion are the examiner’s access to the claims file and the thoroughness and detail of the opinion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The guiding factors in evaluating the probative value of a medical opinion are whether the opinion was based on sufficient facts or data, whether the opinion was the product of reliable principles and methods, and whether the medical professional applied the principles and methods reliably to the facts of the case. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). These standards are met in the VA examinations.   The March 2012, November 2019, and November 2020 VA opinions are the most probative evidence of record on the question of diagnosis and nexus to service. The opinions were based on an extensive review of all of the evidence, including statements from the Veteran, the Veteran’s treatment records, and the Veteran’s in-service MOS and civilian occupations, were supported by a detailed rationale, provided data to support any conclusions, and provided a clear and reasoned analysis, the source of the most probative value in a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The March 2012, November 2019, and November 2020 VA examiner opinions are consistent with one another and the evidence of record, including the Veteran’s private treatment. The VA examiner opinions provide compelling evidence against the Veteran’s claim for service connection. The Veteran contends that his claimed disability exists and is related to his active service. This opinion is of no probative value, and while the Veteran is competent to report on symptoms of “buzzing,” he lacks the medical expertise needed to diagnose a tinnitus condition or to attribute it to active military service. There is no competent, credible evidence to refute the VA examiner opinions. The weight of the probative evidence of record is against a finding that the Veteran’s tinnitus condition is causally or etiologically related to any disease, injury, or incident, in service. Consequently, service connection is not warranted. Finally, a clear preponderance of the evidence of record indicates the Veteran does not meet the criteria under 38 C.F.R. § 4.87, DC 6260, for entitlement to service connection for a tinnitus condition. Therefore, his claim must be denied.   In reaching the conclusions stated above, the Board has considered the applicability of the benefit of the doubt doctrine. The rule does not apply when the Board finds that a preponderance of the evidence is against the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (2018); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Small, Attorney Advisor 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.