Citation Nr: 21068251 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 19-18 118 DATE: November 9, 2021 ORDER New and material evidence sufficient to reopen a previously denied claim for service connection for bilateral hearing loss has been received. New and material evidence sufficient to reopen a previously denied claim for service connection for tinnitus has been received. Service connection for tinnitus is granted. An effective date of November 29, 2016, but not earlier, for the award of a total disability rating based on individual unemployability due to service-connected disability (TDIU) is granted. REMANDED The issue of entitlement to service connection for bilateral hearing loss is remanded. The issue of entitlement to rating greater than 70 percent for service-connected posttraumatic stress disorder (PTSD) is remanded. The issue of entitlement to an initial compensable rating residuals of a shrapnel injury to the jaw is remanded. FINDINGS OF FACT 1. In an August 2010 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) denied service connection for bilateral hearing loss and tinnitus; the Veteran did not appeal that decision and it became final. 2. Since the August 2010 final rating decision, evidence has been associated with the claims file that is not duplicative or cumulative of evidence previously of record, and that relates to unestablished facts necessary to substantiate the claims for service connection for hearing loss and tinnitus. 3. The Veteran has conceded in-service noise exposure which likely resulted in some acoustic trauma. 4. The evidence demonstrates that the Veteran had a current diagnosis of tinnitus, and based on the competent, credible and, hence, probative lay statements concerning the onset and continuity of tinnitus, in-service incurrence is established. 5. On November 29, 2016, the RO received the Veteran's claim for an increased evaluation for his service-connected PTSD. 6. The Veteran filed a formal application for a TDIU on June 17, 2019. 7. The Veteran met the threshold percentage requirements for an award of TDIU under 38 C.F.R. § 4.16(a) as of November 29, 2016, and there is no reason to conclude that the Veteran could engage in substantially gainful employment at any point during the period from November 29, 2016, to June 17, 2019. 8. As of November 29, 2016, the Veteran was rendered permanently unable to follow substantially gainful employment by his service-connected PTSD. CONCLUSIONS OF LAW 1. The August 2010 rating decision, in which the RO denied service connection for bilateral hearing loss and tinnitus is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.1103. 2. As evidence received since the August 2010 rating decision is new and material, the criteria for reopening the claim for service connection for bilateral hearing loss have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 3. As evidence received since the August 2010 rating decision is new and material, the criteria for reopening the claim for service connection for tinnitus have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 4. The criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1110, 1131, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for entitlement to an effective date of November 29, 2016, but no earlier, for the award of a TDIU have been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.151, 3.155, 3.157, 3.400; see Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 2000 to December 2003. His DD Form 214 reflects that he received, among other decorations, the Combat Infantry Badge and the Bronze Star Medal with "V" Device. This appeal to the Board arose from a November 2017 rating decision in which the RO granted service connection for residuals of a shrapnel injury to the jaw, evaluated as noncompensably disabling, effective from November 29, 2016; denied a rating greater than 70 percent for service-connected PTSD; and determined that new and material evidence sufficient to reopen previously denied claims for service connection for bilateral hearing loss and tinnitus had not been submitted. The Veteran disagreed with that decision, to include with the disability rating assigned in connection with the grant of service connection for residuals of a shrapnel injury to the jaw, and subsequently perfected an appeal to the Board. In May 2020, the Veteran and his fiancée testified at a Board hearing before the undersigned Veterans Law Judge; a transcript of the hearing has been associated with the claims file. Regarding the claims involving hearing loss and tinnitus, as discussed below, the Board must first decide whether new and material evidence to reopen the claims for service connection for a skin condition and a low back disability has been received See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). Given the favorable disposition, below, on the requests to reopen, the Board has characterized the appeal as encompassing both the requests to reopen and the underlying service connection claims, as set forth above. As to the issue of entitlement to an earlier effective date for the award of a TDIU, the Board notes that the RO awarded a TDIU, effective June 17, 2019, via rating decision dated in December 2019. Although the Veteran did not file a notice of disagreement as to the effective date assigned therein, because entitlement to a TDIU was raised during the course of the Veteran's appeal for a higher rating for his service-connected PTSD, entitlement to an earlier effective date for the grant of TDIU is properly on appeal as part of that claim. Harper v. Wilkie, 30 Vet. App. 356 (2018). Requests to Reopen The record reflects that the RO previously denied the Veteran's claims for service connection for bilateral hearing loss and tinnitus in August 2010. The RO notified the Veteran of the denials that same month; however, the Veteran did not initiate an appeal by filing a notice of disagreement within one year. See 38 C.F.R. §§ 20.200, 20.201. Also, no new and material evidence for either claim was associated with the claims file within one of year the denials, and no additional service records have been associated with the claims file at any time, warranting readjudication of the claim. See 38 C.F.R. §§ 3.165(b), (c). Therefore, the August 2010 rating decision is final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Thus, as a result of the finality of the August 2010 rating decision, the Veteran's claims for service connection for bilateral hearing loss and/or tinnitus may now be considered on the merits only if new and material evidence has been received since the time of the last final denial. 38 U.S.C. §§ 5108, 7104; Evans v. Brown, 9 Vet. App. 273 (1996); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); 38 C.F.R. § 3.156. Section 3.156(a) of title 38, Code of Federal Regulations provides the following definitions of new and material evidence: New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing 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 of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In making the determination of materiality, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). To determine whether new and material evidence has in fact been submitted, the Board first must compare the evidence submitted since the previous final denial with evidence previously of record. If the newly submitted evidence is that which was not of record at the time of the last final disallowance (on any basis) of the claim, and is not merely cumulative of other evidence that was then of record, it will be considered new evidence under 38 C.F.R. § 3.156(a). If the evidence is in fact new, the Board will then consider whether it is also material. In this regard, the Board notes that 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. When evaluating the materiality of newly submitted evidence, the focus must not be solely on whether the evidence remedies the principal reason for denial in the last prior decision; rather the determination of materiality should focus on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement. See id. at 118, 124 (Lance, J. concurring). Notably, the evidence of record at the time of the August 2010 final rating decision failed to suggest that the Veteran had bilateral hearing loss and/or tinnitus that was incurred in or otherwise caused by service. Indeed, the record contained no documented diagnosis of bilateral hearing loss and/or tinnitus, and the Veteran had failed to report for a scheduled VA examination intended to determine whether he im fact had hearing loss and/or tinnitus that was related to service. During his May 2020 hearing, the Veteran testified regarding his claims for service connection for hearing loss and tinnitus. Specifically, the Veteran reported that while stationed in Iraq, he was in close proximity to artillery fire and several improvised explosive device (IED) attacks. The Veteran reported that he began to experience ringing in his ears after the IED attack and after firing two anti-tank weapons, and that he has experienced such symptom since. Additionally, a review of the Veteran's VA treatment records shows that he has been issued hearing aids for both ears, which suggests to the Board that the Veteran is experiencing some level of hearing loss, bilaterally. The Board finds that the lay testimony, which is presumed credible for purposes of determining if it is material, see Justus, supra, as well as the evidence demonstrating that the Veteran has been issued hearing aids, is new in that it was not previously before VA adjudicators, and is not cumulative or duplicative of other evidence. The evidence is also material, in that it is relevant to the question of the whether the Veteran has a current diagnosis of hearing loss or tinnitus that is attributable to service. As such, this evidence is new and material within the meaning of 38 C.F.R. § 3.156 (a). Under these circumstances, the Board concludes that the criteria for reopening the previously denied claims for service connection for bilateral hearing loss and tinnitus are met. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303. In addition, certain chronic diseases, including organic disease of the nervous system, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. 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). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Alternatively, for chronic diseases, as defined by regulation, shown in service, the second and third elements of service connection may be established through demonstrating chronicity or continuity of symptomatology in accordance with 38 C.F.R. § 3.303(b). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also Fountain v. McDonald, 27 Vet. App. 258, 271 (2015) (holding the 38 C.F.R. "§ 3.309(a) includes tinnitus, at a minimum where there is evidence of acoustic trauma, as an 'organic disease[] of the nervous system'"). Regarding the claim for service connection for tinnitus, the Board notes that the Veteran has not been afforded a VA audiological examination, as he failed to report for a scheduled examination in July 2010. His VA treatment records, however, note as an active problem "tinnitus." Further, during his May 2020 hearing, the Veteran reported experiencing ringing in his ears. The Board finds this evidence is sufficient to support a finding that the Veteran currently has tinnitus. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (stating that "[l]ay testimony is competent... to establish the presence of observable symptomatology"); Charles v. Principi, 16 Vet. App. 370 (2002) (stating that "ringing in the ears is capable of lay observation and, as such, a veteran is competent to testify as to that symptom"). The Board also points out that in the 2010 examination request, the RO noted that the Veteran had received the Combat Infantryman Badge and indicated acoustic trauma related to combat experiences. The Board also points out the Veteran had served as an infantryman in combat and that it is thus highly probably that he was exposed to noise in service. Noise exposure based on the Veteran's military occupational specialty and combat experiences is thus conceded. 38 U.S.C. § 1154. Accordingly, the question is one of nexus. See Davidson, supra. As noted, the Veteran has reported ringing in his ears beginning in and existing since service, a symptom which he is competent to testify as to the existence of. See Barr and Charles, both supra. The Board finds no reason to question the veracity of the Veteran's reported onset of tinnitus in service or his report of continuity of experiencing such symptoms since that time and further notes that the Veteran served in combat, thereby entitling him to the presumption on service incurrence. 38 U.S.C. § 1154. As noted above, for chronic diseases, as defined by regulation, shown in service, the second and third elements of service connection may be established through demonstrating chronicity or continuity of symptomatology in accordance with 38 C.F.R. § 3.303(b). See Walker, supra. Applying 38 C.F.R. § 3.303(b) to the facts of this case, the Board finds that, when all reasonable doubt in resolved in the Veteran's favor, service connection for tinnitus is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102; 3.303(b); see Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006) ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). Effective Date A review of the record shows that the Veteran was award a TDIU via rating decision dated in December 2019. At that time, the RO assigned an effective date of June 17, 2019, for the award of a TDIU, which the RO stated was the date upon which the Veteran's claim for a TDIU had been received. Regarding the assignment of effectives dates, the law provides, generally, that the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. That is, the effective date of an award "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor." 38 U.S.C. § 5110(a). The Board notes that an exception to the general rule exists for increased rating claims. In a claim for increased compensation, the effective date may date back as much as one year before the date of the application for increase if it is factually "ascertainable that an increase in disability had occurred" within that timeframe. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2); see Gaston v. Shinseki, 605 F.3d 979, 983 (Fed. Cir. 2010) ("It is clear from the plain language of [section] 5110(b)(2) that it only permits an earlier effective date for increased disability compensation if that disability increased during the one-year period before the filing of the claim"); Hazan v. Gober, 10 Vet. App. 511, 519 (1997) (stating that an "increase" for this purpose is one to the next disability level). Evidence relevant to the determination of the appropriate effective date for the Veteran's award of TDIU shows that on November 26, 2016, the RO received the Veteran's claim for an increased evaluation for his service-connected PTSD. On June 17, 2019, the Veteran submitted a formal claim for TDIU, which claim led to the eventual grant of TDIU by the RO. In awarding a TDIU, the RO assigned an effective date of June 17, 2019, the date of receipt of the Veteran's formal application for TDIU. However, with regard to "claims" for a TDIU, the United States Court of Appeals for Veteran's Claims (Court) has held that "a request for a TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if a disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation." Rice, 22 Vet. App. at 453-54. In other words, when entitlement to a TDIU is raised during the pendency of a claim for a higher rating for a service-connected disability, whether an appeal as to the initial rating assigned or an increased a rating claim, the matter of entitlement to TDIU is considered to be part and parcel of claim for a higher rating. Here, the Board recognizes the Veteran's claim for a TDIU was raised part and parcel of his claim for an increased rating for his PTSD, which has been ongoing since his claim for such was received in November 2016. Rice, supra. The Board thus concludes that an effective date of November 29, 2016, is warranted for the Veteran's grant of a TDIU. This is so because entitlement to a TDIU was raised during the pendency of the Veteran's claim for an increased rating for his service-connected PTSD; as such, the matter is considered to be part and parcel of that claim, which was filed on November 29, 2016. Further, the evidence shows that the Veteran has been in receipt of a 70 percent rating for PTSD since August 18, 2015; prior to that time, his PTSD was evaluated only as 50 percent disabling. As such, he has met the threshold rating requirements for an award of PTSD since at least November 29, 2016, the date of his PTSD increased-rating claim. The evidence also shows that the Veteran has not worked since 2012. There is also no reason to conclude that the Veteran was able to engage in substantially gainful employment at any point during the period from November 29, 2016, to June 17, 2019. Indeed, given that the severity of the Veteran's PTSD remained constant for the period from November 29, 2016, to June 17, 2019, the Board finds no reason to conclude that the Veteran was not in fact unemployable during this time period. Therefore, the Board finds that an effective date of November 29, 2016, the date of claim for an increased rating, is warranted for the Veteran's grant of TDIU. In finding that TDIU is warranted as of the date that the Veteran's underlying increased rating claim was received, the Board has considered whether application of 38 C.F.R. § 3.400(o)(2) can serve to establish an even earlier effective date, but finds that it cannot. This is so because the evidence fails to support a finding that it was factually ascertainable that the Veteran's service-connected PTSD rendered him unable to obtain or maintain substantially gainful employment within the year prior to the November 2016 increased rating claim. Indeed, the evidence suggests that the Veteran was rendered unemployable due to his service-connected PTSD well prior to November 29, 2015 (one year prior to the Veteran's November 2016 claim), which precludes the assignment of an effective date earlier than the date of the Veteran's November 2016 claim. 38 C.F.R. § 3.400(o)(2); see Gaston, supra. Accordingly, there is no basis upon which to assign an effective date earlier than the date of the Veteran's November 29, 2016, claim. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400; see Gaston, supra. REASONS FOR REMAND The Veteran is seeking service connection for bilateral hearing loss, which he believes is related to in-service noise exposure. Service connection for hearing loss may be granted where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting regulatory requirements for hearing loss, see 38 C.F.R. § 3.385, and a medically sound basis upon which to attribute the post-service findings to the injury in service, as opposed to intercurrent causes. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). In the instant case, in-service noise exposure based on the Veteran's military occupational specialty and combat experiences has been conceded. As for the current hearing loss disability requirement, impaired hearing will be considered a disability for VA purposes when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In this case, although the evidence of record suggests that the Veteran currently experiences hearing loss, as demonstrated by the fact that he has been issued hearing aids, the record fails to contain sufficient audiometric data for the Board to conclude that the Veteran has right or left ear hearing loss for VA disability purposes. Indeed, results of an October 2018 audiogram are not viewable by the Board; the Board notes, however, that they are indicated to show "essentially" within normal limits for the Veteran's right ear and mild to severe sensorineural hearing loss in the left ear. Although right ear hearing loss was not indicated at that time, in April 2019, the Veteran was issued a hearing aid for his right ear. This suggests diminished hearing acuity since the October 2018 audiogram was conducted. Ultimately, the Board finds that the evidence of record is insufficient to adjudicate the merits of the Veteran's reopened claim for service connection for hearing loss and that a remand is required for the Veteran to be scheduled for a VA audiological examination to determine whether he has right and/or left ear hearing loss, as defined by VA, and, if so, the likelihood that any such hearing loss had its onset in, or is otherwise related to, the Veteran's active military service, to include his conceded in-service noise exposure. Regarding the Veteran's claim for a rating greater than 70 percent for his service-connected PTSD, the Board notes that after the claim was certified for appeal to the Board in July 2019, a substantial amount of evidence was associated with the Veteran's claims file, to include medical records received from the Social Security Administration, VA treatment records showing ongoing mental health treatment, and the report of an October 2019 VA PTSD examination. In this regard, the Board notes that any pertinent evidence submitted by a claimant or his representative after an appeal is certified to the Board must be referred to the AOJ, unless such evidence is accompanied by a waiver of consideration by the AOJ or the Board determines that the benefit(s) to which the evidence relates may be fully allowed on appeal without such referral. 38 C.F.R. § 20.1305(c); Although former 38 U.S.C. § 7105(e), which is still applicable to Legacy appeals, provided for an automatic waiver of initial AOJ review of evidence submitted to the AOJ or to the Board at the time of or subsequent to the submission of a substantive appeal, where, as here, the substantive appeal is filed on or after February 2, 2013, and unless the claimant or claimant's representative requests in writing that the AOJ initially review such evidence, the VA treatment records and October 2019 VA examination report were not submitted by the Veteran; instead, the treatment records and examination report are VA-generated evidence. Thus, the automatic waiver provision of 38 U.S.C. § 7105(e) do not apply in this case. See 38 U.S.C. § 7105(e) (providing for initial review by the Board "if the claimant or the claimant's representative . . . submits evidence"). Further, to the extent that the Veteran could waive AOJ consideration in the first instance of VA generated evidence such as treatment records and/or examination reports, there is no waiver in this case. Accordingly, because VA treatment records dated through August 2021 and the October 2019 VA examination report are pertinent to whether a higher rating may be warranted for the Veteran's PTSD, a remand of the increased rating claim is required for the issuance of an SSOC reflecting consideration of that evidence. Lastly, as to the Veteran's claim for an initial compensable rating for residuals of shrapnel injury to the jaw, the Board notes that the Veteran's service treatment records show that he sustained a chipped tooth from shrapnel. In connection with his claim for service connection for residuals of a shrapnel injury, the Veteran was afforded a VA dental examination in October 2017. Notably, a review of the examination report indicates that there were no service treatment records or records of physical or dental examination available for review. However, the Veteran reported to the VA examiner that he had chipped a tooth from shrapnel in 2003. The Veteran stated that he has experienced pain since that time, which pain starts on the left side of his face and extends to his left temple. The Veteran described the pain as nerve pain. Upon examination of the Veteran, the examiner identified that the Veteran had a chipped incisal edge of tooth #8 and "pulpally-involved" tooth #14, which was tender to percussion. The examiner also noted that imaging studies revealed "[o]ne piece of shrapnel visible at left mandibular ramus area" and "[d]ental caries extending into pulp at tooth #14." Regarding the functional impact of the Veteran's dental condition, the examiner stated the following: In the absence of any documentation, what I have is the Veteran's history and the panoramic radiograph. I will take his word for it that the chipped tooth#8 is at least as likely as not (50/50 probability) a result of the shrapnel injury. In order to assess the role of the shrapnel in the facial pain as opposed to the role of the pulpally-involved adjacent tooth, it would be necessary to first extract non-restorable tooth #14. I cannot speculate as to what portion of the pain comes from the shrapnel injury and what portion comes from the endodontic condition. Unfortunately, the Board cannot conclude that the examination report is adequate to rely upon for evaluation purposes. This is so because the examiner did not provide an assessment regarding the severity of the Veteran's pain, to include identifying all functional limitations due to pain. In this regard, the Board notes that when an examiner is unable to distinguish the symptoms of service-connected disability from nonservice-connected manifestations, all the manifestations will be considered part of the service connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Thus, it is imperative that an examiner provide a complete assessment of the Veteran's condition, even if this means he/she is unable to definitively state what portion of the Veteran's pain is due to the shrapnel injury as opposed to the dental caries. Accordingly, the Board finds that the matter must be remanded for the Veteran to be scheduled for a new VA examination to assess the severity of his shrapnel injury residuals. Further, given the Veteran's description of the pain as well as the documented piece of shrapnel visible at left mandibular ramus area, any examination afforded on remand should consider/discuss whether a nerve injury is present, in addition to the chipped tooth. The matters are REMANDED for the following action: 1. Arrange for the Veteran to undergo a VA audiological examination by an appropriate medical professional. The contents of the entire electronic claims file, to include a complete copy of this remand, must be made available to the designated clinician, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. All necessary tests and studies (to include audiometric and speech discrimination testing (Maryland CNC), should be accomplished and all clinical findings should be reported in detail. The examining clinician should identify whether the Veteran has right or left ear hearing loss to an extent considered a disability for VA purposes. If right or left ear hearing loss is found, for each, the examiner should provide an opinion, consistent with sound medical principles, as to whether it is at least as likely as not that any such hearing loss was incurred in or is otherwise due to the Veteran's active military service, including as a result of his conceded in-service noise exposure. In providing the requested opinions, the examiner must consider and discuss all relevant medical and lay evidence, to include the Veteran's reports of in-service hazardous noise exposure and his reports pertaining to when he noticed an onset of hearing loss. Notably, the absence of documented evidence of hearing loss during service should not serve as the sole basis for a negative opinion. In this regard, the examiner is advised that the Veteran is competent to report his symptoms and history, and that such reports must be specifically acknowledged and considered in formulating any opinions. Complete, clearly-stated rationale for the conclusions reached must be provided. 2. Arrange for the Veteran to undergo a VA dental examination to assess the current nature and severity of his residuals of a shrapnel injury. The contents of the entire electronic claims file, to include a complete copy of this remand, must be made available to the designated clinician, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. Any indicated tests or studies should be completed and all pertinent findings should be described in detail. The examiner should provide all findings necessary to evaluate the Veteran's disability under the assigned DC (38 C.F.R. § 4.150, DC 9913). The examiner should also elicit from the Veteran information regarding the frequency, severity, and duration of any symptoms to which the Veteran believes are related to his shrapnel injury and describe to what extent such symptoms limit his functioning, to include any range of motion loss due to pain. The examiner should also comment on the Veteran's described nerve pain and indicate whether any nerve injury in present due to shrapnel. (If further examination is necessary to make such a finding, the Veteran should be scheduled for any additional examination deemed necessary.) If the examiner can differentiate the amount of pain due to the Veteran's shrapnel injury from that due to the dental caries, the examiner should so state. However, if it is not possible to differentiate symptoms attributable to the service-connected, as opposed to the nonservice-connected, disability, the examiner should assume that all symptomatology is related to the service-connected shrapnel injury. (Continued on the next page) Complete, clearly-stated rationale for the conclusions reached must be provided. 3. After completing any additional notification and/or development action(s) deemed warranted, issue to the Veteran and his representative an appropriate SSOC addressing the claims remaining on appeal. Regarding the PTSD increased-rating claim, the SSOC should reflect consideration of the additional evidence (particularly including the VA treatment records and the October 2019 VA PTSD examination report) received after the last adjudication of these claims in May 2019. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Neilson, 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.