Citation Nr: 21063520
Decision Date: 10/14/21	Archive Date: 10/14/21

DOCKET NO. 18-41 513
DATE: October 14, 2021

ORDER

Entitlement to service connection for bilateral hearing loss disability is granted.

Entitlement to service connection for Benign Paroxysmal Positional Vertigo (BPPV) is denied.

FINDINGS OF FACT

1. The Veteran's bilateral hearing loss disability is related to exposure to the sounds of mortar blasts, gunfire, and jet engines during service in Vietnam.

2. The Veteran's BPPV was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease.

3. The Veteran's BPPV (vertigo) is not secondary to service-connected Diabetes Mellitus (DM) II or bilateral peripheral neuropathy

CONCLUSIONS OF LAW

1. The criteria for service connection for bilateral hearing loss disability are met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for BPPV (vertigo) are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from February 1966 to December 1969.

These matters come to the Board of Veterans' Appeals (Board) from September and October 2016 rating decisions issued by the Agency of Original Jurisdiction (AOJ). In April 2020, the Board remanded the claims to the AOJ in order to provide VA disability examinations and get new medical opinions that were obtained in November 2020. The Board finds there has been substantial compliance with its directives and may now proceed with a decision. Stegall v. West, 11 Vet. App. 268, 271 (1998). 

1. Entitlement to service connection for bilateral hearing loss disability.

The Veteran contends his bilateral hearing loss disability is due to exposure to the sounds of mortar blasts, gunfire, and jet engines while serving in Vietnam. 

The question for the Board is whether there is sufficient evidence to find that Veteran's bilateral hearing loss disability is related to service in Vietnam. For the reasons discussed below, the Board concludes that the evidence supports a grant of service connection. 

Entitlement to service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (2007).  

VA regulations provide a specific definition for what constitutes a hearing disability for VA compensation purposes. Under 38 C.F.R. § 3.385, hearing loss is 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; (2) the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or (3) speech recognition scores using the Maryland CNC Test are less than 94 percent. So, it is possible for a Veteran to have a hearing impairment that does not rise to a level to become a disability for entitlement to VA compensation. Palczewski v. Nicholson, 21 Vet. App. 174, 178-80 (2007).  

Service connection may also be established for certain chronic diseases by satisfying the test for disability compensation for chronic diseases set forth in 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331, 1334 (2013). One method is to show the Veteran has (1) a current chronic disease listed under 3.309(a) and (2) that disease must have been "shown in service." Id. at 1335. As to (1), vertigo is an "organic disease of the nervous system," which is listed as a "chronic" disease under 38 C.F.R. § 3.309(a). As to (2), 38 C.F.R. § 3.303(b) equates "shown in service" with a reliable diagnosis of the chronic disease while in service. Walker, 708 F.3d at 1335.  

Another method is to show continuity of symptomatology. Continuity of symptomatology may be demonstrated if a claimant can show (1) a condition was "noted" during service; (2) postservice evidence of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the postservice symptomatology. Savage v. Gober, 10 Vet. App. 488, 495 (1997). Section 3.303(b) does not require medical evidence of an etiological link between service and a current disability.  Walker, 708 F.3d at 1338-40. 

Also, a Veteran may establish service connection on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Or for any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progression of the nonservice-connected disease. 38 C.F.R. § 3.310(b). Entitlement to service connection under 38 C.F.R. § 3.310(a) or (b) requires evidence of three elements: (1) evidence of a current disability that is not service-connected; (2) evidence of a service-connected disability; and (3) evidence of nexus establishing a connection between the service-connected disability and the current disability. 38 C.F.R. § 3.310.

In order to prevail on a claim for benefits, the Veteran need only demonstrate there is an approximate balance of positive and negative evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). 

Beginning with the Veteran's service, his entrance examination shows he reported observing "ear, nose, or throat trouble" and underlined nose. See January 1966 Report of Medical History. The clinical examination by a military doctor did not find any ear, nose, or throat problems at entrance. See January 1966 Report of Medical Examination. Audiometric testing was performed at entrance and revealed pure tone thresholds, in decibels, as follows: 

Hertz (Hz)	500	1000	2000	3000	4000	Average Hz (1000-4000 Hz)

Right Ear	 10(25)	-5(5)	-5(5)	-5(5)	5(10)	-2.5(6.25)

Left Ear	10(25)	10(20)	-5(5)	5(15)	15(20)	13.75(15)

(The Board notes the audiometric tests at entrance were conducted according to Acoustic Society of America (ASA) standards and not the currently used International Standard Organization (ISO) standard. The numbers in parenthesis represent the conversion of the audiometric test results from ASA to ISO units). Id. at 2. 

His service personnel records show he was trained to perform technical work on the egress systems of airplanes in June 1966.  Personnel records also show he performed those duties in Vietnam from December 12, 1966, through August 1968. See AF Form 7, Airman Military Record, Part 19, Chronological Listing of Service; April 2015 Statement. From July 1967 to July 1968, he performed his duties while exposed to hostile attacks. See September 1968 Narrative in Support of Air Force Commendation Medal. He returned to the U.S. in August 1968. 

Before the Veteran separated from service, he completed a questionnaire that asked if he observed signs or symptoms he believed were associated with a medical problem during service. He provided a history of medical problems, to include the removal of a cyst, stomach trouble, as well as pain and swelling at the right hand. See November 1969 Report of Medical History at 2. A military doctor performed a clinical examination and did not find an ear problem nor note reports of dizziness or difficulties maintaining balance. See November 1969, Report of Medical Examination at 2. Audiometric testing was conducted at separation and revealed pure tone thresholds, in decibels, as follows: 

Hertz (Hz)	500	1000	2000	3000	4000	Average Hz (1000-4000 Hz)

Right Ear	15(30)	10(20)	0(10)	0(10)	5(10)	3.75(12.5)

Left Ear	15(30)	15(25)	0(10)	0(10)	0(5)	3.75(12.5)

Id. at 2. The Board notes the audiometric test was conducted during a period when testing may have been conducted according to ISO or ASA standards. 

In September 2014, the Veteran underwent an Agent Orange Registry Exam at a VA Medical Center (VAMC). During the examination, he expressly denied dizziness, and balance problems. See September 4, 2014, Record by M.C., PA.  The following month, he visited a VAMC for an audiology consult. He reported he was exposed to loud noise during service. Also, he has been observing difficulties hearing people when there is background noise. An audiometric test was conducted that resulted in the diagnoses of mild to severe high frequency sensorineural hearing loss. See October 6, 2014, Record by S.B., AuD. The Board notes the audiogram showing threshold scores has not been incorporated into the record. 

During the same October 2014 audiology consult, the Veteran reported observing dizziness. He indicated he had not observed dizziness earlier than 2014. Also, he observed episodes of vertigo earlier in 2014 and they had subsided.  See Record by S.M.B. Later, in May 2016, the Veteran underwent a consult for exposure to environmental agents. During the consult the Veteran denied currently observing chronic headaches, dizziness, or balance problems but had observed three to four episodes of severe vertigo in the last few years. See May 20, 2016, Record by P.J.T., NP.

In February 2017, the VA received a medical opinion from G.U., NP, who asserted vertigo is due to his service-connected DM II. The opinion asserts that, even though the exact cause of vertigo is unknown, there is a relationship between vertigo and DM II. She cites to several studies, that collectively indicate a person's metabolism of certain nutrients, to include glucose, can lead to balance disorders and, therefore, DM II is a risk factor for vertigo. G.U., NP then indicates the theory supports a finding the DM II caused vertigo by emphasizing the Veteran's history of abnormal glucose levels (hyperglycemia) predated his diagnosed vertigo. See Medical Opinion for Vertigo by G.U., NP, at 3. 

In June 2017, the Veteran visited a VAMC and met with R.B.Y., AuD, to evaluate his hearing loss disability. The Veteran reported he was exposed to loud noise during service, to include jet engines, gunfire, mortars while he served in Vietnam. Dr. R.B.Y. conducted audiometric testing and noted thresholds for the right ear at 500, 1000, and 4000 Hz were poorer than the scores shown earlier, during the October 2014 audiometric test. He noted the diagnoses of sensorineural hearing loss at both ears. See Record by Dr. R.B.Y. Then, Dr. R.B.Y. opined the noises the Veteran was exposed to during service, to include jet engines, gunfire, mortars, at least as likely as not caused his bilateral hearing loss disability. Dr. R.B.Y. added that his opinion is "subject to" review of the Veteran's service treatment records (STRs). Id.

The following year, in February 2018, the Veteran visited a VAMC again and met with a physical therapist to evaluate his reports of balance problems. He reported he has observed balance problems from around 2016. He added that his current symptomatology is less severe than it was around 2016. His current symptoms included dizziness and impaired balance. When standing, he observed a spinning sensation, lightheadedness, imbalance. See February 8, 2018, Record by D.L.S, PT.

On examination, Veteran was able to stand independently for 2 minutes, sit safely, able to place feet together and stand for one minute with supervision, able to take small steps independently and hold for 30 seconds. The physical therapist noted Veteran demonstrated more problems than just maintaining balance when standing. Also, the Veteran's balance problems were enhanced by his diagnosed peripheral neuropathy. He was advised to use a cane; he indicated his balance problems are not so severe that he needs to use a cane. Id.

In November 2018, the Veteran visited a VAMC clinic and met with Dr. R.B.Y. again. Audiometric testing was conducted and revealed pure tone thresholds, in decibels, as follows:

Hertz (Hz)	500	1000	2000	3000	4000	Average Hz (1000-4000 Hz)

Right Ear	50	50	50	60	70	57.5

Left Ear	40	40	60	65	65	57.5

Dr. R.B.Y. did not use the Maryland CNC word list when he conducted speech discrimination testing. See November 2018 Audiological Evaluation. He noted the diagnoses of sensorineural hearing loss at 500 Hz and higher for both ears. See VAMC Record by R.B.Y, AuD.

Following an April 2020 Board remand, the Veteran underwent his first VA disability examination for hearing loss disabilities and vertigo for this appeal period. During the November 2020 examination for hearing loss disabilities, audiometric testing was conducted and revealed pure tone thresholds, in decibels, as follows: 

Hertz (Hz)	500	1000	2000	3000	4000	Average Hz (1000-4000 Hz)

Right Ear	45	55	60	60	60	59

Left Ear	35	35	75	70	75	64

The examiner used the Maryland CNC word list and found speech discrimination scores of 92 percent in the left ear; at the right ear, 76 percent. See VA Disability Benefits Questionnaire (DBQ) at 2. 

Then, the examiner opined that the Veteran's bilateral hearing loss disability is not related to service. The examiner explained that even if his combat service entitles him to the presumption that he suffered a noise induced injury in Vietnam, his separation examination showed normal hearing. The examiner expressed the separation examination provides clear and convincing evidence that no injury occurred while in service. In support of the opinion, the examiner referred to a 2005 Institute of Medicine (IOM) report titled Noise and Military Service, when asserting there is no scientific basis for the occurrence of delayed onset hearing loss. Essentially, the examiner concluded there is no delayed-onset hearing loss and because the Veteran's STRs show normal hearing at separation, it is unlikely the Veteran's disability is causally connected to his service. Id. at 5.

A different VA examiner conducted the Veteran's November 2020 disability examination for vertigo. The examiner found the earliest diagnosis of vertigo was rendered in 2014. See VA DQB at 2. As to the Veteran's symptoms, the examiner found the Veteran has more than one episode of vertigo a week, with each episode lasting less than an hour. Also, the Veteran's vertigo symptoms include moderate to persistent dizziness. Id. at 3. The examiner opined that the Veteran's vertigo is not due to his service. Neither was it proximately caused or aggravated by DM II or a left hip disability. The Board notes the examiner later indicated he interpreted "left hip disability" to mean bilateral lower extremity peripheral neuropathy.  Based on a reading of the examination as a whole, the examiner indicated the Veteran's service STRs do not show signs or symptoms that indicate vertigo existed during service. The examiner also indicated the long passage of time without medical complaints of symptoms was a factor that indicated vertigo did not exist during service. Altogether, the examiner indicated the evidence was not sufficient to support a diagnosis of vertigo during service or within a year of leaving service. The examiner concluded the evidence does not support finding the Veteran's vertigo was related to service. Id. at 4. 

As to a causal connection between vertigo and DM II or left hip disability the examiner noted the Veteran's diagnosed form of vertigo is attributable to calcium crystals that shift in the ear canal, which can become loose due to injury, age, or infection. She also noted her research did not show medical literature that supports finding DM II causes the calcium crystals that shift in the ear. Neither does the literature support finding hip conditions cause the physiological processes that lead to vertigo. Id. at 5.  The examiner then went through each of the articles referenced in the February 2017 medical opinion by G.U., NP, and determined they do not support finding a nexus. With regards to aggravation, the examiner indicated he reviewed the record and did not see evidence to support finding DM II or bilateral lower extremity peripheral neuropathy aggravated vertigo. Id. 

Turning to the Veteran's claim for disability compensation, the Board finds the Veteran has established entitlement to service connection for bilateral hearing loss disability. Given that the Veteran performed his duties in Vietnam while under hostile attack, it is likely he was exposed to the sounds of gunfire, mortar blasts, and jet engine noise as reported. So, his lay observations of loud noise exposure weigh strongly in favor of finding an injury in the form of acoustic trauma during the course of performing his duties in Vietnam. Layno v. Brown, 6 Vet. App. 465, 469 (1994).  

Despite the evidence weighing in favor of an in-service injury, his STRs did not show a left ear hearing loss "disability" was shown in service. The threshold range for normal hearing is 0 to 20 decibels, with higher threshold levels indicating some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Even though his separation examination shows a left ear threshold level of 30 decibels at 500 Hz, VA regulations prohibit a finding of a hearing loss "disability" if  thresholds scores are not 26 decibels or greater for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz, or 40 decibels or greater at any of those frequencies. So, the evidence does not show a left ear hearing loss "disability" under VA regulations. 

Even though the record does not support finding a hearing loss disability was shown in service, the VA audiologist who assessed the Veteran in June 2017 found exposure to the sounds of gunfire, mortar blasts, and jet engine noise led to the development of the Veteran's current bilateral hearing loss disability. See VAMC Record by R.B.Y., AuD. The Board recognizes the examiner indicated his opinion is "subject to" a review of the service medical records. This statement may be fairly read to assert that, if the Veteran's reports of noise exposure to mortar blasts, gunfire, and jet engines, is credible, there is a medical basis to link the Veteran's current hearing loss disability to service. Given the Board has found his statements credible, the Board finds the June 2017 opinion medical evidence that weighs in favor of finding a nexus.  

The Board recognizes the examiner who prepared the July 2015 VA DBQ did not find a nexus between the Veteran's service and current bilateral hearing loss disability; however, the Board found it to be of little to no probative value. The IOM report the VA examiner relied on has been found to contain contradictory aspects that, if not addressed, diminishes the opinion's probative value. McCray v. Wilkie, 31 Vet. App. 243, 257-59 (2019). Because the examiner did not address those contradictory aspects, it was assigned little to no probative value. As a result, it carries less probative weight than the June 2017 medical opinion that found a nexus; therefore, the Board finds the evidence weighs in favor of a nexus. 

In sum, the Veteran has shown his current bilateral hearing loss disability is directly related to service. Given that he was exposed to the sounds of mortar blasts, gunfire, and jet engine noise while under hostile attacks, his lay statements are sufficient to find an in-service injury. Reeves, 682 F.3d at 999. Because the record also includes medical evidence that links his in-service injury to his current hearing loss disability, he has established entitlement to service connection. Accordingly, service connection is granted for bilateral hearing loss disability. 38 C.F.R. § 3.303(a). 

2.  Entitlement to service connection for BPPV. 

The Veteran contends his diagnosed BPPV (vertigo) is related to service. See VA 21 526EZ. In the alternative, he contends his vertigo disorder is secondary to DM II. See February 2017 NOD at 2. 

The question for the Board is whether there is sufficient evidence to find the Veteran's vertigo is related to service. For the reasons discussed below, the Board concludes that the evidence does not support a grant of service connection.

A.	Entitlement to service connection on a direct basis. 

Turning to the Veteran's claim for disability compensation, the first questions is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.303(a). That is, on a direct basis. 

To answer that question, the first issue is whether the Veteran has a current disability. The Veteran has been diagnosed with BPPV (vertigo) during the appeal period, most recently during the November 2020 VA disability examination. See VA DBQ at 2.Thus, the record reflects a diagnosed ear disability. 

The next issue is whether the Veteran's ear disability was incurred during service. The Veteran's lay statements and observations weigh against finding an in-service incurrence. He has not expressly asserted symptoms of his vertigo disability were observed during service. Instead, he has consistently indicated symptoms of vertigo were observed following service. See October 6, 2014, Record by S.M.B. (noting Veteran reported symptoms of vertigo earlier in 2014); February 8, 2018, VAMC Record by D.L.S., PT (noting the Veteran reported observing symptoms of vertigo around 2016). 

The Board finds the lack of reference to observations of vertigo during service probative towards finding it did not manifest during service. This is because he has demonstrated he can recall the approximate time noticeable symptoms were first observed. For example, he was able to recall that his left hand started shaking in 2014; the right hand, in 2016. See August 2021 VA DBQ Parkinson's Disease at 3. Given that dizziness, like hand tremors, is a symptom that is apparent during the course of a person's daily activities, to include standing, walking, physical exercise; thus, the Board finds it is likely he would have been able to recall observing symptoms of vertigo during service, if observed.  Also, within the year of leaving service, if observed. Because he has not, the Board finds his omissions credible evidence that weigh against finding an in-service incurrence. 

While the Board recognizes the Veteran has not asserted his vertigo disability began during service or is due to any in-service injury, a search of his STRs did not reveal evidence that supports finding an in-service incurrence. His entrance and separation examinations do not reference symptoms he attributes to vertigo, like dizziness, imbalance. As noted above, those are symptoms that tend by be apparent during a person's daily activities, it is likely the symptoms would have been apparent, if observed. Considering he reported other symptoms that were readily apparent during his separation examination, like pain and swelling at his hands, the Board finds it is likely he would have reported symptoms of vertigo as well, if observed. So, the Board finds the lack of reference to symptoms of vertigo in his separation examination credible.  Considering they are contemporaneous medical evidence;  the Board assigned the STRs significant weight against finding an in-service incurrence.  

The November 2020 VA disability also weighs against finding vertigo began during service. The examiner based her opinion on the record, her personal examination of the Veteran, and consideration of his statements. So, the Board finds the examiner was informed of the relevant details of the Veteran's past medical history when rendering her opinion. Nievez-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2006).

The examiner indicated the record does not show signs or symptoms of vertigo during service. See November 2020 VA DBQ at 4. Given that the Veteran has not claimed vertigo was observed during service and the examiner has the medical knowledge to opine on the likelihood that vertigo existed during service, the Board finds the examiner's explanation sufficient to evaluate whether the data she relied on connects to her conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. So,  the Board assigned the opinion significant probative weight on whether vertigo was shown in service. 

Based on a reading of the opinion as a whole, it is apparent to the Board the examiner did not find a clear diagnosis of the Veteran's vertigo disability within a year of leaving service. After concluding the evidence does not support finding a medical diagnosis of vertigo during service. The examiner indicated the disability had not been diagnosed until 45 years after service, which indicates to the Board the examiner did not find signs or symptoms of vertigo that indicate a vertigo disability existed within the year the Veteran left service. 

The Board recognizes the examiner emphasized the passage of time without medical complaints, but considering she also referred to the lack of reference of symptoms of vertigo in the Veteran's STRs, the Board finds the passage of time was not the only factor the examiner considered when rendering her opinion. So, the Board finds the examiner's explanation sufficient to evaluate whether the data she relied on connects to her conclusion and assigned it significant probative weight. Nievez-Rodriguez, 22 Vet. App. at 301.

In this case, the Board finds the evidence is not approximately balanced on the issue of an in-service incurrence of vertigo. The Veteran has not asserted vertigo begin in or was observed during service. His STRs do not support finding an in-service incurrence. Also, the VA medical examiner who prepared the November 2020 opinion concluded the Veteran's vertigo was not shown in service or within a year of leaving service. So, doubt on this issue could not be resolved in the Veteran's favor. Gilbert, 1 Vet. App. at 54.

The next issue is whether there is a nexus between the Veteran's vertigo disability and service. The November 2020 VA disability examination weighed against finding a nexus. The examiner explained that the evidence available does not support finding his vertigo disability is directly related to service. As noted, the examiner indicated the record does not support finding vertigo existed during service. See November 2020 VA DBQ at 4. Given that the Veteran has not claimed it is due to any event during service, the Board is able to evaluate how she concluded there is no nexus. Nievez-Rodriguez, 22 Vet. App. at 301. Although her opinion is brief, it is apparent to the Board she did not see a medical basis to link the Veteran's vertigo disability to service. So, the Board assigned it significant probative weight. 

In this case the evidence weighs against finding a nexus. The November 2020 opinion is the only medical opinion of record that addressed a nexus between the Veteran's service and vertigo that has not been previously found to be inadequate or incomplete. As a result, it is the most probative evidence on the issue of a nexus. Because it weighed against the Veteran's claim, doubt could not be resolved in his favor. Gilbert, 1 Vet. App. at 54. So, a nexus has not been established. 

Even though the Veteran has a current disability, he has not established an in-service incurrence nor a nexus. Accordingly, the Veteran has not established entitlement to service connection on a direct basis. 38 C.F.R. § 3.303(a).

B.	Entitlement to service connection based on chronicity or continuity of symptomatology.

The next question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.303(b). That is, based on chronicity or continuity of symptomatology.

The first issue is whether the Veteran has a chronic disability listed under 38 C.F.R. § 3.309(a). Vertigo is a chronic disability under § 3.309(a). So, the record reflects a diagnosed chronic disability. 

The next issue is whether the Veteran's claimed vertigo was shown in or noted during service.  As noted above, the Veteran has not asserted vertigo was observed during service. Also noted above, the record does not reflect observations of symptoms during service that are sufficient to establish chronicity at the time of service. Walker, 708 F.3d at 1335-36. Neither has the Veteran alleged he observed manifestations of his chronic disability within a year of leaving service. 

The November 2020 VA DBQ is additional medical evidence that weighed against a finding of chronicity during service or within the year after leaving service. As discussed above, the examiner acknowledged and considered the Veteran's diagnosed chronic disability and indicated it is not related to his service. See VA DBQ at 4. The Board assigned the opinion significant weight against a finding of chronicity at the time of service or within a year of leaving service. 

In this case, the evidence is not approximately balanced in favor of finding the Veteran's chronic disability was shown in service. He has not asserted he observed manifestations of vertigo during service. Also, the VA examiner who evaluated the record did not find sufficient evidence of a reliable diagnosis of a chronic disability during service. Walker, 708 F.3d at 1335. Thus, doubt could not be resolved in the Veteran's favor. Gilbert, 1 Vet. App. at 54. Accordingly, he has not established entitlement to service connection based on chronicity. 

As to continuity of symptomatology, the Board has found a chronic disability was not shown during service or within one year after leaving service.  Neither has he asserted observing continuous symptoms of vertigo since leaving service. Also, a search of the record did not reveal continuous reference to symptoms of vertigo since leaving service.  Accordingly, consideration of entitlement to service connection based on continuity of symptomatology is not warranted. 38 C.F.R. § 3.303(b). 

C.	Entitlement to service connection on a secondary basis. 

The next question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.310(a). That is, on a secondary basis. 

The record reflects the Veteran currently has 10 service-connected disabilities; however, he has associated vertigo with DM II and a left hip disability that has been interpreted to mean complications associated with his bilateral lower extremity peripheral neuropathy. See November 2020 VA DBQ at 5. A search of the record did not raise the inference of a claim for service connection under 38 C.F.R. § 3.310 based on any other service-connected disability. So, the discussion of entitlement to service connection under 38 C.F.R. § 3.310(a) or (b) will be limited to his service-connected DMI II and bilateral lower extremity peripheral neuropathy. 

The next issue is whether the Veteran's vertigo was proximately caused by service-connected DM II or bilateral lower extremity peripheral neuropathy. Even though G.U., NP, opines there is a causal connection between DM II and vertigo, her opinion was of little to no probative value towards a finding of causation. 

The Board recognizes she referred to medical literature to support the proposition that DM II impacts a person's ability to process certain energy supplies which, in turn, affects the function of the ear; however, her rationale does not show how the theory applies to the particulars of this Veteran's case. Given that metabolism of energy supplies is medically complex, the Board is unable to evaluate how a history of abnormal glucose levels as likely as not led to his development of vertigo.  Nor is the Board qualified to determine if the metabolic processes referenced in the abstracts are directly applicable to the Veteran's claim. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Without more, the Board is unable to evaluate how she connected the data she relied on to her conclusion. So, it was of little probative value towards evaluating the issue. Nievez-Rodriguez, 22 Vet. App. at 301.

The examiner who prepared the November 2020 VA DBQ can interpret complex medical literature and explained how the abstracts G.U., NP, relied on do not apply to the Veteran's claim. The examiner noted that none of the medical abstracts referenced in G.U., NP's opinion link DM II to his diagnosed BPPV. See VA DBQ at 5. The examiner added that, based on her current medical knowledge, understanding, and research, there is not enough medical evidence to support finding DM II influences the known causes of vertigo. Given that the examiner has the medical knowledge to opine that there is a lack of medical data to support a causal connection between DM II and vertigo, the Board is able to connect the data she relied on to her conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. Considering the examiner also conducted her own research on the matter, the Board assigned it great weight against a finding of causation.

Moving to a causal connection between vertigo and a left hip imbalance, the examiner properly noted the Veteran is not service-connected for a left hip disability. In any event, the examiner considered the service-connected disabilities that closely approximate the effects described (bilateral lower extremity peripheral neuropathy) and explained the medical literature does not support finding a link between hip problems and the physiological changes that cause vertigo. See November 2020 VA DQB at 5. Given that the examiner has the medical knowledge to opine if two separate conditions impact another, the Board is able to connect the data she relied on to her conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. Considering the examiner also conducted her own research on the matter, the Board assigned it great weight against a finding of causation.

As to causation, the Board finds the evidence is not approximately balanced. Although the Veteran has provided a February 2017 opinion that weighs in his favor, it is outweighed by the more probative November 2020 opinion. The examiner who prepared the opinion concluded vertigo is not caused by DM II or the service-connected disabilities that most likely cause a left hip imbalance (bilateral lower extremity peripheral neuropathy). So, doubt cannot be resolved in his favor. Gilbert, 1 Vet. App. at 54. Accordingly, he is not entitled to service connection under 38 C.F.R. § 3.310(a). 

The next issue is whether the Veteran's vertigo is aggravated by his service-connected DM II. The February 2017 medical opinion did not address the issue of aggravation; therefore, it was not probative towards evaluating the issue.  

The November 2020 VA DBQ weighs against a finding of aggravation. Although the portion of the opinion discussing aggravation is brief, it is apparent to the Board the examiner did not see a medical basis to find DM II or bilateral lower extremity peripheral neuropathy aggravated the Veteran's vertigo disability. Considering the examiner did not find a medical link between DM II, bilateral lower extremity peripheral neuropathy, and the processes associated with the development of vertigo, the Board is able to evaluate whether the data she relied on connects to her conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. So, the Board assigned it significant weight.

With regards to aggravation, the Board finds the evidence is not approximately balanced. The November 2020 VA medical opinion is the only item of medical evidence that addressed the issue of aggravation; it weighed against finding aggravation. So, doubt could not be resolved in the Veteran's favor. Gilbert, 1 Vet. App. at 54. Accordingly, he is not entitled to service connection under 38 C.F.R. § 3.310(b). 

In sum, the Veteran has not established entitlement to service connection for vertigo under 38 C.F.R. §§ 3.303 or 3.310. The Board regrets a more favorable decision could not be reached in the Veteran's case.

 

DAVID L. WIGHT

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Dean, Michael S.

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.