Citation Nr: 21063881 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 16-53 977 DATE: October 18, 2021 ORDER The application to reopen the claim for service connection for hearing loss is granted. Service connection for chronic sinusitis, to include as due to the service-connected allergic rhinitis, is granted. Service connection for dizziness is denied. REMANDED Entitlement to service connection for hearing loss is remanded. Entitlement to service connection for hypertension, to include as secondary to the now service-connected OSA disability, is remanded. Entitlement to service connection for a right shoulder disorder (characterized as upper extremity disorders) is remanded. FINDINGS OF FACT 1. In an unappealed April 1990 rating decision, the Department of Veterans Affairs last denied service connection for hearing loss. 2. Evidence received since the April 1990 rating decision is new and material and relates to an unestablished fact necessary to substantiate the claim of service connection for hearing loss. 3. The Veteran's chronic sinusitis is caused by his service-connected allergic rhinitis. 4. Dizziness is a vestibular symptom of the already service-connected headache disability, and the Veteran is not shown to have a separately diagnosable disability productive of dizziness. CONCLUSIONS OF LAW 1. The April 1990 rating decision that last denied service connection for a hearing loss is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.104, 20.1103 (2020). 2. New and material evidence has been received sufficient to reopen the claim of service connection for hearing loss. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2020). 3. The criteria for entitlement to service connection for chronic sinusitis as secondary to service-connected allergic rhinitis are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.310 (2020). 4. The criteria for entitlement to service connection for dizziness are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from November 1967 to January 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision of a Department of Veterans' Affairs (VA) Regional Office, the agency of original jurisdiction (AOJ). In April 2019, the Veteran testified during a Travel Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record and has been reviewed. The Board is aware of the U.S. Court of Appeals for Veterans Claims (Court) decision in Quinn v. Wilkie, 31 Vet. App. 284, 292 (2019), which held that each time a legacy appeal (an appeal adjudicated prior to enactment of the Appeals Modernization Act) is returned to the Board the claimant is entitled to a Board hearing, even if a hearing was held previously. In this case, the Veteran appeared at a Board hearing before the undersigned in April 2019. To date, the Veteran has not requested another hearing. Procedural History In October 2019, the Board determined that there was a basis for reopening the Veteran's service connection claims for headaches, rhinitis, sinusitis, low back disorder, right and left knee disorders; right and left shoulder disorders, right elbow disorder, and chest pain. Additionally, the Board granted service connection for allergic rhinitis and obstructive sleep apnea, denied service connection for hyperlipidemia, cardiac catheterization, a right eye disorder, and a lung disorder, and, pursuant to the Veteran's request during the April 2019 Board hearing, dismissed the claim for service connection for a skin rash. See Board Decision and Remand dated October 3, 2019. The Board's decision as to these claims are final. See 38 U.S.C. §§ 7103(a), 7104 (2012); 38 C.F.R. § 20.1100(a) (2020). The Board also remanded the Veteran's service connection claims for dizziness, headaches, sinusitis, gastroesophageal reflux disease (GERD), hypertension, diabetes mellitus Type II, and disorders of the cervical spine, low back, bilateral knees, and bilateral shoulders, as well as the Veteran's petition to reopen his service connection claim for hearing loss for further development. See Board Decision and Remand dated October 3, 2019. In a May 2021 rating decision, the AOJ, in part, granted service connection for diabetes mellitus Type II, headaches, GERD, and disorders of the cervical spine, lumbar spine, right and left knees, left shoulder, and right elbow, which is considered a full grant of the benefits for these claims. As such, the claims granted in the May 2021 rating decision are no longer before the Board for appellate consideration. A.B. v. Brown, 6 Vet. App. 35 (1993). In the May 2021 Supplemental Statement of the Case (SSOC), the AOJ denied service connection for sinusitis, hypertension, dizziness, and a right shoulder disorder, and denied the Veteran's petition to reopen his claim for service connection for hearing loss. See SSOC dated May 27, 2021. As such, the denied claims now return to the Board for further appellate consideration. As detailed in the remand section below, the Board finds there has not been substantial compliance with its October 2019 remand directives regarding VA etiology opinions for the Veteran's hypertension and a right shoulder disorder. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand); Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). Additionally, further development is needed prior to Board review of the Veteran's claim for entitlement to service connection for hearing loss. Preliminary Matters As phrased on the title page herein, the Board has recharacterized the issue of entitlement to service connection for sinusitis, to include the word "chronic" and to reflect consideration of the claim on a secondary basis so as to better reflect the information contained in the evidence of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that the scope of a claim is determined by the claimant's description of the claim, the symptoms described, and the information submitted or developed in support of the claim). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). New and Material Evidence Rating decisions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of a AOJ decision to initiate an appeal by filing a Notice of Disagreement (NOD) with the decision or submitting new and material evidence, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.160, 20.201, 20.302. In a legacy claim, such as this one (a claim not appealed under the new Appeals Modernization Act), an exception to the finality rule is found in 38 U.S.C. § 5108, which provides that, if new and material evidence is received with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held, however, that evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented. Anglin v. West, 203 F.3d 1343, 1347 (2000). In deciding whether new and material evidence has been received, the Board looks to the evidence submitted since the last final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Here, in an April 1990 rating decision, the AOJ denied service connection for hearing loss, concluding that his service treatment records reflected that his hearing acuity was normal throughout service. The Veteran did not appeal the May 1990 rating decision, nor was new and material evidence received within a year of issuance of the May 1990 notification letter; the rating decision therefore became final. 38 C.F.R. § 20.1103. In February 2014, the Veteran sought to reopen his service connection claim for hearing loss, indicating that he had experienced hearing loss since 1967. In a September 2014 rating decision, the RO denied the Veteran's petition to reopen the claim, finding that the Veteran had not submitted new and material evidence to support the claim. See Rating Decision dated September 8, 2014 at pg. 9. The Veteran submitted a timely NOD and timely perfected an appeal to the Board, and the instant appeal ensued. Based on the procedural history of the case, the last final decision pertinent to the Veteran's claims of service connection for hearing loss is the April 1990 rating decision. The evidence of record at the time of the April 1990 rating decision consisted of the Veteran's service treatment and service personnel records, post-service VA and non-VA treatment records, and a March 1990 VA hearing loss examination reflecting normal hearing. Subsequent to the April 1990 rating decision, evidence added to the claims file includes the Veteran's non-VA treatment records and a May 2021 VA examination report in which the VA examiner noted that the Veteran had an audiogram in 2008 that was "abnormal." See VA ear conditions examination dated May 19, 2021 at pg. 8. The additional evidence received since the April 1990 prior final denial, particularly the May 2021 VA examination noting an abnormal 2008 audiogram, speaks to the question of a nexus and is therefore new and material. Accordingly, new and material evidence has been received, and to this extent only, the claim of service connection for hearing loss is reopened. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.310(b); Allen v. Brown, 8 Vet. App. 374 (1995). An alternative means of establishing service connection is showing continuity of symptomatology under 38 C.F.R. § 3.303(b); however, this alternative means is only available for certain "chronic disease" specifically enumerated under 38 C.F.R. § 3.309(a), and the record here does not reflect that the disorders that gave rise to this appeal, adjudicated herein, are among the listed diseases. Therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) do not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A lay person is competent to report on the onset and reoccurrence of current symptomatology. See Layno, 6 Vet. App. at 470 (a veteran is competent to report on that of which he or she has personal knowledge). The Board must determine, on a case by case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Generally, the degree of probative value which may be attributed to a medical opinion takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107(b)). A veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Sinusitis The Veteran asserts that his chronic sinusitis is related to service or his service-connected allergic rhinitis. See Board hearing transcript dated April 1, 2019 (Hearing Transcript) at pg. 8. Initially, the Board recognizes that the Veteran is currently diagnosed with chronic sinusitis. See VA Orbits CT Scan dated April 15, 2015; VA Sinusitis/Rhinitis examination dated May 20, 2021. The Veteran's service treatment records (STRs) reflect that during his September 1967 enlistment examination, the Veteran denied sinusitis symptoms and clinical examination revealed that his nose, ears, and sinuses were normal. The STRs do reflect that the Veteran complained of sinus symptoms, including nasal drainage and headaches during service. See, e.g., Chronological Record of Medical Care entries dated September 4, 1974 and August 8, 1975. Mild nasal congestion was noted during a 1983 examination. However, during his November 1988 separation examination, the Veteran denied sinusitis and no abnormalities of the Veteran's nose or sinuses were noted upon clinical evaluation. See Report of Medical Examination dated November 2, 1988. Post-service treatment records reflect that the Veteran complained of sinus congestion. See, e.g., Private treatment record dated November 7, 2013 and December 6, 2013; VA Orbits CT scan report dated April 15, 2015. The Veteran underwent a VA Sinusitis/Rhinitis examination in May 2021, during which the examiner noted diagnoses of chronic sinusitis and allergic rhinitis. During the examination, the Veteran said his sinusitis symptoms started in the late 1970s, he described problems breathing through the right side of his nose, shortness of breath, headaches, and nasal pain, and he endorsed ongoing symptoms since service. See VA Sinusitis/Rhinitis examination dated May 20, 2021. Although the VA examiner concluded that the Veteran's chronic sinusitis is not related to service, she opined that it is proximately due to the Veteran's service-connected allergic rhinitis, explaining that allergic rhinitis can cause sinusitis, that the Veteran's allergic rhinitis was diagnosed in 1979, and his chronic sinusitis was diagnosed thereafter by CT scan in 2015. See VA medical opinion dated May 20, 2021. The May 2021 VA medical opinion is competent, credible and probative: It was authored by a medical clinician who reviewed the Veteran's claims file and was therefore familiar with the Veteran's symptoms, diagnoses, and treatment of his sinusitis; the opinion was based on examination and interview of the Veteran and review of the evidence of record as well as the Veteran's lay statements. The opinion is consistent with the medical evidence of record and contains clear conclusions with supporting data connected by a reasoned medical explanation. See Nieves-Rodriguez, 22 Vet. App. at 301-02. Notably, there are no medical opinions or other competent medical evidence of record that weighs against the May 2021 VA opinion. Accordingly, the Board finds the May 2021 VA medical opinion highly probative, competent and persuasive medical evidence in this case. Accordingly, the Board concludes that the competent and probative evidence supports a finding that the Veteran's chronic sinusitis is etiologically related to his service-connected allergic rhinitis. See Gilbert, supra. The grant of service connection on a secondary basis moots all other theories of entitlement. Dizziness The Veteran asserts that he has dizziness that is related to service. At the outset, the Board must determine whether the Veteran meets the criteria for the threshold element of a current disability. In other words, the Board must determine if the Veteran has been diagnosed with dizziness since the date of claim. See Shedden, 381 F.3d at 1167. There is no indication in the STRs or elsewhere in the record that the Veteran has been diagnosed with dizziness and the Veteran consistently denied dizziness during examinations throughout his military career. See, e.g., Reports of Medical History dated September 11, 1967 (enlistment), July 31, 1973, March 15, 1979, July 27, 1983, and November 2, 1985 (retirement). Post-service treatment notes relevant to the claim period are negative for reports or diagnosis of dizziness. Indeed, the Veteran has consistently denied dizziness during outpatient treatment appointments. See, e.g., Private treatment notes dated September 29, 2020, October 27, 2020, November 5, 2020, November 13, 2020, April 6, 2021, and May 13, 2021. During a May 2021 VA ear conditions examination, the examiner noted that the Veteran reported that he experienced dizziness that onset in service in the 1980s and has been ongoing. However, the VA examiner rendered no diagnosis, explaining that the "Veteran's dizziness is more than likely a symptom of his diagnosed chronic tension and migraine headaches." The examiner further noted that an abnormal Romberg test during the examination indicated that the Veteran's dizziness is a vestibular feature of his headaches, and not a separately diagnosable condition. See VA Ear Conditions examination at pg. 9. This is also reflected in the May 2021 VA headaches examination report, which reflects that the VA examiner found symptoms of the Veteran's service-connected headaches include lightheadedness and dizziness. See VA Headaches examination dated May 20, 2021 at pg. 5. Notably, the examiner opined that the Veteran's headache symptoms do not impact the Veteran's ability to work. See Saunders v. Wilkie, 886 F.3d 1356, 1363 (Fed. Cir. 2018) (finding that a disability for VA purposes, as defined by statute, refers to the functional impairment of earning capacity, not the underlying cause of the disability). While the Veteran has endorsed dizziness during VA compensation and pension examinations and during the April 2019 Board hearing, the Board assigns more probative value to the Veteran's treatment records that reflect his consistent denials of dizziness during the claim period. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (Board decision properly assigned more probative value to a private hospital record that included lay history that was made for treatment purposes than to subsequent statements made for compensation purposes). In the absence of a diagnosed current disability, it follows that service connection for dizziness cannot be granted as the threshold element of the claim has not been met. Shedden, supra. In analyzing this claim, the Board also considered the Veteran's assertions as to a current disability. While the Veteran may genuinely believe that he has separately diagnosable dizziness, the Board finds that the question as to whether the Veteran has such a disorder requires substantiation through medical findings, requiring specialized training for a determination, and is not susceptible of lay opinion. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). There being no competent evidence that the Veteran has been diagnosed with the claimed disability, analysis of the remaining elements of a service connection claim is unnecessary. Based on this body of evidence, the appeal must be denied. In reaching this determination, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application here. See Gilbert, supra. REASONS FOR REMAND Hearing Loss VA is obligated to provide an examination and obtain a medical opinion in a claim of service connection 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). Here, as discussed above, a VA examiner noted during the May 2021 ears examination that the Veteran had an audiogram in 2008 that was "abnormal." See VA Ear Conditions examination dated May 19, 2021 at pg. 8. However, the 2008 audiogram does not appear to be of record. The Veteran's Certificate of Release or Discharge from Active Duty (DD Form 214) indicates that while in the Navy, his military occupational specialty (MOS) was that of System Organizational Maintenance Technician and that his duties included pneumatic systems maintenance, naval aircraft rework, corrosion control, RADOME and fiberglass repair, and aircraft painting and finishing. The Department of Defense's Duty MOS Noise Exposure Listing indicates that MOSs of aircraft structural repair are accompanied by a "high" probability of hazardous noise exposure. During the April 2019 Board hearing, the Veteran described working with sheet metal and around riveting guns and aircraft during service aboard an aircraft carrier. See Hearing Transcript at pg. 31. Accordingly, the Board finds the Veteran was routinely exposed to hazardous loud noises during his active-duty service. Considering that the Veteran was exposed to hazardous noise in-service and that the May 2021 VA ears examination indicates the Veteran had an abnormal audiogram in 2008, a remand to obtain a medical examination and opinion addressing the nature, severity, and, if appropriate the etiology of the Veteran's hearing loss, is warranted. McLendon, supra. Additionally, on remand the AOJ must attempt to obtain outstanding treatment records, to include the 2008 audiogram. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Hypertension Once VA undertakes the effort to provide an examination or medical opinion when developing a service-connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr, 21 Vet. App. at 312. Additionally, as noted above, a Board remand confers on the claimant, as a matter of law, the right to compliance with the remand order. See Stegall, supra. Here, a May 2021 VA medical opinion reflects the examiner's conclusion that the Veteran's hypertension was not proximately caused by his service-connected obstructive sleep apnea (OSA) because the examiner was "[u]nable to confirm permanent aggravation beyond natural progression of Veteran's hypertension due to service connected OSA[.]" See VA medical opinion dated May 20, 2021 at pg. 3. However, in 2019, the Court issued a precedential decision holding that a "permanent worsening" of a non-service-connected disability is not required to establish secondary service connection on the basis of aggravation (i.e., aggravation may include temporary worsening of a disability). See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). Thus, the VA examiner used the pre-Ward definition of "aggravation," which required a permanent, rather than temporary, worsening, which renders the May 2021 opinion regarding secondary service connection inadequate. Accordingly, based on this evidence, the Board must remand to obtain an addendum opinion regarding secondary service connection consistent with the Court's holding in Ward. See Barr, supra; Stegall, supra. Right Shoulder Disorders The May 2021 VA examiner acknowledged the Veteran's statements that he began experiencing right shoulder pain during service while working with sheet metal and playing tennis. However, in opining that the Veteran's right shoulder disorders are not related to service, the examiner concluded that there is no evidence of right shoulder symptoms during service, or in close proximity to service, and discussed only the Veteran's post-service complaints of right shoulder pain. In this regard, the examiner failed to adequately consider the lay statements of record regarding the onset and continuity of the Veteran's symptoms of a right shoulder disability during service and the possible causes thereof. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). The Veteran is competent to give testimony concerning the onset and recurrence of his right shoulder symptoms. See Layno v. Brown, 6 Vet. App. 465 (1994). Moreover, the examiner relied heavily on the absence of complaints in the Veteran's STRs as the rationale for the negative nexus opinion. As the opinion is not adequate, it is not sufficient to serve as the basis of denial of entitlement to service connection and is of limited probative value. Therefore, the Board finds that an addendum opinion addressing the nature and etiology of the Veteran's right shoulder disorders is needed. Accordingly, a remand to obtain an addendum opinion addressing the etiology of the Veteran's right shoulder disorder is necessary to ensure that the Board's evaluation of the Veteran's claim is a fully informed one. See Barr, supra; Stegall, supra. The matters are REMANDED for the following action: 1. Implement the Board's decision herein granting service connection for sinusitis. 2. Ensure that all outstanding VA treatment records are associated with the claims file. 3. Contact the Veteran, and, with his assistance, identify any outstanding records of pertinent medical treatment from VA or non-VA health care providers, to include a 2008 audiogram characterized by the May 2021 VA examiner as "abnormal" (see VBMS entry with document type "C&P Exam," receipt date 05/20/2021, at pg. 8 (Section 9B)). Provide the Veteran with the appropriate VA consent and release forms. If VA attempts to obtain any outstanding records that are unavailable, the Veteran and his representative should be notified pursuant to 38 C.F.R. § 3.159(e). 4. Then, schedule the Veteran for a VA examination to determine the nature and current severity of his hearing loss, if any. The entire claims file, including a copy of this Remand, should be made available to, and be reviewed by, the VA examiner. All necessary tests should be conducted. After a complete review of the claims file, the examiner is asked to respond to the following: (a) Provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that currently diagnosed hearing loss, if any, onset during service, manifested within one year after service separation, or is otherwise etiologically related to service, to include exposure to in-service acoustic trauma associated with the Veteran's military occupational specialty (MOS), which has been conceded herein. The examiner must provide a complete rationale for all opinions proffered. 5. Obtain an addendum opinion from the same VA examiner who conducted the May 2021 VA hypertension examination, if available, as to the etiology of the Veteran's currently diagnosed hypertension. If the same examiner is unavailable, request an addendum opinion from an appropriately qualified VA clinician. *The need for another examination(s) is left to the discretion of the medical professional offering the addendum opinion. Should an examination(s) be necessary, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. *Review of the body of this Remand is recommended to assist in avoiding deficiencies the Board identified in the May 2021 hypertension opinion regarding secondary service connection. After a complete review of the claims file, the examiner is asked to respond to the following: (a) State whether it is at least as likely as not that the Veteran's currently diagnosed hypertension was CAUSED or AGGRAVATED by his service-connected obstructive sleep apnea. Here, "aggravated" means worsened beyond the natural progression of the condition. The examiner's opinion should reflect consideration of the holding of the U.S. Court of Appeals for Veterans Claims that aggravation need NOT be permanent in nature. See Ward v. Wilkie, 31 Vet. App. 233 (2019); see also 38 C.F.R. § 3.310(b). *Note to examiner: To ensure that the correct legal standard is applied, which is essential for adjudication of this claim, the opinion MUST BE STATED IN TERMS OF whether the disorder was CAUSED or AGGRAVATED by the service-connected disorder. The examiner must provide a complete rationale for all opinions proffered. 6. Obtain an addendum opinion from the same VA examiner who conducted the May 2021 shoulder examination, if available, as to the etiology of the Veteran's currently diagnosed right shoulder disorders. If the same examiner is unavailable, request an addendum opinion from an appropriately qualified VA clinician. *The need for another examination(s) is left to the discretion of the medical professional offering the addendum opinion. Should an examination(s) be necessary, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. *Review of the body of this Remand is recommended to assist in avoiding deficiencies the Board identified in the May 2021 opinion regarding the etiology of the Veteran's right shoulder disorders. After a complete review of the claims file, the examiner is asked to respond to the following: (a) Provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the currently diagnosed right shoulder disorders, to include the diagnosed disorders reflected in the May 2021 VA Shoulder and Arm Conditions Disability Benefits Questionnaire, onset during service, manifested within one year after service separation, or are otherwise etiologically related to service, to include as due to the Veteran's work with sheet metal as part of his Navy duties and playing tennis during service. *Note: The Veteran's service personnel records reflect that his military occupational specialty (MOS) was that of "System Organizational Maintenance Technician" and that his duties included pneumatic systems maintenance, naval aircraft rework, corrosion control, RADOME and fiberglass repair, and aircraft painting and finishing. The examiner must provide a complete rationale for all opinions proffered. 7. Thereafter, ensure that the examiner(s) has substantially responded to the questions posed by the Board, and if not, take corrective action. Then, readjudicate the remanded claims. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.