Citation Nr: 21069307 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 17-36 932 DATE: November 18, 2021 ORDER Entitlement to service connection for tinnitus is granted. Entitlement to service connection for deviated septum is granted. Entitlement to service connection for sleep apnea is granted. Entitlement to service connection for hypertension is granted. Entitlement to service connection for gastroesophageal reflux disease (GERD) is granted. Entitlement to service connection for sinusitis is granted. Entitlement to service connection for asthma is granted. Entitlement to an initial rating in excess of 10 percent for forehead scar is denied. REMANDED The issue of entitlement to service connection for bilateral hearing loss is remanded. The issue of entitlement to service connection for a right knee disability is remanded. The issue of entitlement to service connection for gastritis is remanded. FINDINGS OF FACT 1. The Veteran's tinnitus began during his active service. 2. The Veteran's deviated septum had its onset during his active service. 3. The probative evidence is at least in equipoise as to whether the Veteran's sleep apnea was caused by his service-connected deviated septum. 4. The probative evidence is at least in equipoise as to whether the Veteran's hypertension was caused by his service-connected sleep apnea. 5. The probative evidence is at least in equipoise as to whether the Veteran's GERD was caused by his service-connected sleep apnea. 6. The probative evidence is at least in equipoise as to whether the Veteran's sinusitis was caused by his service-connected deviated septum. 7. The probative evidence is at least in equipoise as to whether the Veteran's asthma was caused by his service-connected sinusitis. 8. The Veteran's forehead scar is not manifested by visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features or two or three characteristics of disfigurement. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C. §§ 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303. 2. The criteria for entitlement to service connection for deviated septum have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303. 3. The criteria for entitlement to service connection for sleep apnea have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 4. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 5. The criteria for entitlement to service connection for GERD have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 6. The criteria for entitlement to service connection for sinusitis have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 7. The criteria for entitlement to service connection for asthma have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 8. The criteria for entitlement to an initial rating in excess of 10 percent for forehead scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.400, 4.3, 4.7, 4.14, 4.21, 4.118, Diagnostic Code 7800. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1985 to March 1989. These matters come before the Board of Veterans' Appeals (Board) on appeal of a January 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2021, the Veteran testified during a video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. The Board is cognizant of the ruling of the United States Court of Appeals for Veterans Claims (Court) in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on individual unemployability (TDIU) due to service-connected disability, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has not argued, and the record does not otherwise reflect, that the disability at issue renders him unemployable. Accordingly, the Board concludes that a claim for TDIU has not been raised. Neither the Veteran nor his representative has raised any issues with regard to the duty to notify or duty to assist as they pertain to the issues decided herein. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310 (a). Any increase in 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 progress of the nonservice-connected disease, will also be service connected. 38 C.F.R. § 3.310 (b). 1. Entitlement to service connection for tinnitus is granted. The Veteran seeks entitlement to service connection for tinnitus, which he believes is due to in-service noise exposure. He reported in an August 2019 statement that he has suffered tinnitus since his active service. With respect to the current disability element of service connection, tinnitus is readily observable by laypersons, and medical expertise is not required to establish its existence. See Charles v. Principi, 16 Vet. App. 370 (2002). Therefore, the Veteran's assertion that he currently has tinnitus constitutes competent evidence of a current disability of tinnitus. Furthermore, the Board finds that nothing in the record impugns the Veteran's credibility on the matter, and concludes that the Veteran has a current disability of tinnitus. With respect to an in-service injury or disease, the Veteran's service treatment records do not reflect complaint of or treatment for tinnitus. However, his DD Form 214 shows that he had a primary specialty of system organizational maintenance technician and that he has military education for basic aviation training. Therefore, his reports of in-service noise exposure are credible. In addition, he has stated that the condition had its onset during his active service. As noted above, the Veteran's statements as to the presence of tinnitus constitute competent evidence of its existence. The Board finds that nothing in the record impugns the Veteran's credibility as to the onset of the condition. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (lack of contemporaneous medical evidence does not, in and of itself, render lay evidence not credible). Therefore, the Veteran's statement is competent and credible evidence that his tinnitus began during his active service. Tinnitus, as an organic disease of the nervous system, may be service connected where it is first shown in service and has subsequent manifestations. See 38 C.F.R. §§ 3.303 (b), 3.307(a) (3), 3.309 (a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, the Veteran has credibly reported that his tinnitus began during his active service and has persisted through the present. The Board resolves any remaining doubt in the Veteran's favor and finds that the claim for entitlement to service connection for tinnitus must be granted as a presumptive chronic condition. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for deviated septum is granted. The Veteran seeks entitlement to service connection for deviated septum. He testified at the April 2021 Board hearing that his deviated septum is related to being hit in the head by an airplane door hatch during his active service. The Veteran's medical treatment records reflect that he has a current diagnosis of deviated septum. Additionally, in the January 2015 rating decision the RO noted that although the in-service event is not recorded in the Veteran's service-treatment records, the event is conceded based on multiple buddy statements reporting the in-service event. Thus, the question becomes whether the current disability is related to service. In August 2017, the Veteran's private physician noted that the Veteran has a current diagnosis of deviated septum and opined that the Veteran's deviated septum is directly related to his active service. As rationale, the private examiner noted that the RO conceded the in-service event occurred and that the concession should also apply to the Veteran's deviated septum. The private examiner noted that the Veteran's MRI clearly shows the shift of his nose due to the improper way it healed, which caused his deviated septum. The Board finds the Veteran's private physician's opinion to be probative because it is based on an accurate understanding of the Veteran's medical history and current treatment, and because it is supported by an appropriate rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444 (2000). Therefore, the Board concludes that the evidence is at least in equipoise as to whether the Veteran's current deviated septum is directly related to his active service. Accordingly, after resolving any doubt in the Veteran's favor, the Board finds that entitlement to service connection for deviated septum is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for sleep apnea is granted. The Veteran seeks entitlement to service connection for sleep apnea. He asserts that the disability is caused by his service-connected deviated septum. In April 2017, the Veteran's private physician opined that the Veteran's sleep apnea is caused by his service-connected deviated septum. As rationale, the private physician noted the Veteran's history of extensive trauma and that the tests all confirm that the injury to the nose and facial bones the Veteran suffered while on active duty with the Navy are the direct cause of his sleep apnea. Additionally, in June 2017, the Veteran's private physician reported that during sleep apnea episodes the airway collapses and with septal deviation there is already a nasal obstruction. The Board finds the Veteran's private physician's opinion to be probative because it is based on an accurate understanding of the Veteran's medical history and current treatment, and because it is supported by an appropriate rationale. See Nieves-Rodriguez, 22 Vet. App. 295; Prejean, 13 Vet. App. 444. Therefore, the Board concludes that the evidence is at least in equipoise as to whether the Veteran's current sleep apnea is proximately due to his service-connected deviated septum. Accordingly, after resolving any doubt in the Veteran's favor, the Board finds that entitlement to service connection for sleep apnea is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for hypertension is granted. The Veteran seeks entitlement to service connection for hypertension. He asserts that the disability is caused by his service-connected sleep apnea. In June 2017, the Veteran's private physician opined that the Veteran's hypertension is caused by his sleep apnea. As rationale, the private physician explained that during the Veteran's sleep apnea episodes or airway collapse oxygen is not able to move into the lungs and the amount of oxygen in the blood declines (hypoxemia). The hypoxemia stimulates the body to release catecholamines which is one of the causes of hypertension. The Board finds the Veteran's private physician's opinion to be probative because it is based on an accurate understanding of the Veteran's medical history and current treatment, and because it is supported by an appropriate rationale. See Nieves-Rodriguez, 22 Vet. App. 295; Prejean, 13 Vet. App. 444. Therefore, the Board concludes that the evidence is at least in equipoise as to whether the Veteran's current hypertension is proximately due to his service-connected sleep apnea. Accordingly, after resolving any doubt in the Veteran's favor, the Board finds that entitlement to service connection for hypertension is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for GERD is granted. The Veteran seeks entitlement to service connection for GERD. He asserts that the disability is caused by his service-connected sleep apnea. In June 2017, the Veteran's private physician opined that the Veteran's GERD is caused by his sleep apnea. As rationale, the private physician explained that during the Veteran's sleep apnea episodes negative pressure in the chest and lungs produces GERD. The private examiner further explained that the negative pressure in the chest sucks gastric contents from the stomach into the esophagus, which produces the symptoms associated with GERD. The Board finds the Veteran's private physician's opinion to be probative because it is based on an accurate understanding of the Veteran's medical history and current treatment, and because it is supported by an appropriate rationale. See Nieves-Rodriguez, 22 Vet. App. 295; Prejean, 13 Vet. App. 444. The Board observes that the January 2015 VA examiner opined that it is less likely than not that the Veteran's GERD is proximately due to or the result of his service-connected sleep apnea. However, the Board finds no reason to afford that opinion greater probative value than the Veteran's private physician's opinion. Therefore, the Board concludes that the evidence is at least in equipoise as to whether the Veteran's current GERD is proximately due to his service-connected sleep apnea. Accordingly, after resolving any doubt in the Veteran's favor, the Board finds that entitlement to service connection for GERD is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Entitlement to service connection for sinusitis is granted. The Veteran seeks entitlement to service connection for sinusitis. He asserts that the disability is caused by his service-connected deviated septum. In February 2015, the Veteran's private physician opined that the Veteran's sinusitis is caused by his deviated symptoms. As rationale, the private physician explained that significant nasal injury accompanied by septal deviation is a major contributing cause of chronic sinusitis. The Board finds the Veteran's private physician's opinion to be probative because it is based on an accurate understanding of the Veteran's medical history and current treatment, and because it is supported by an appropriate rationale. See Nieves-Rodriguez, 22 Vet. App. 295; Prejean, 13 Vet. App. 444. The Board observes that the January 2015 VA examiner opined that it is less likely than not that the Veteran's sinusitis is proximately due to or the result of his service-connected deviated septum. However, the Board finds no reason to afford that opinion greater probative value than the Veteran's private physician's opinion. Therefore, the Board concludes that the evidence is at least in equipoise as to whether the Veteran's current sinusitis is proximately due to his service-connected deviated septum. Accordingly, after resolving any doubt in the Veteran's favor, the Board finds that entitlement to service connection for sinusitis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 7. Entitlement to service connection for asthma is granted. The Veteran seeks entitlement to service connection for asthma. He asserts that the disability is caused by his service-connected sinusitis. In February 2015, the Veteran's private physician opined that the Veteran's asthma is caused by his sinusitis. As rationale, the private physician explained that chronic sinusitis and sleep apnea are significant causes of asthma. The Board finds the Veteran's private physician's opinion to be probative because it is based on an accurate understanding of the Veteran's medical history and current treatment, and because it is supported by an appropriate rationale. See Nieves-Rodriguez, 22 Vet. App. 295; Prejean, 13 Vet. App. 444. Therefore, the Board concludes that the evidence is at least in equipoise as to whether the Veteran's current asthma is proximately due to his service-connected sleep apnea and sinusitis. Accordingly, after resolving any doubt in the Veteran's favor, the Board finds that entitlement to service connection for asthma is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increase Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). 8. Entitlement to a higher initial rating for forehead scar is denied. The Veteran seeks a higher initial rating for his service-connected forehead scar. The applicable rating period is from July 15, 2013, the effective date for the award of service connected for forehead scar, through the present. See 38 C.F.R. § 3.400. The Veteran testified that his forehead scar is itchy and does not hurt. The Veteran's forehead scar is rated under 38 C.F.R. § 4.118, Diagnostic Code 7800, which pertains to burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, Diagnostic Codes 7800, 7804, and 7805 were not changed by the August 13, 2018 amendments. Under Diagnostic Code 7800, one characteristic of disfigurement warrants a 10 percent rating. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement warrants a 30 percent rating. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement warrants a 50 percent rating. A scar with visible or palpable tissue loss and either gross distortion of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement warrants an 80 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7800 list the eight characteristics of disfigurement: a scar 5 or more inches (13 or more centimeters) in length; a scar at least one-quarter inch wide (0.6 or more centimeters) at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding 6 square inches (39 square centimeters); skin texture abnormal in an area exceeding 6 square inches (39 square centimeters); underlying soft tissue missing in an area exceeding 6 square inches (39 square centimeters); and, skin indurated and inflexible in an area exceeding 6 square inches (39 square centimeters). Id. Under Diagnostic Code 7804, one or two scars that are unstable or painful warrant a 10 percent rating. Three or four scars that are unstable or painful warrants a 20 percent rating. Five or more scars that are unstable or painful warrant a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. Note 2 to Diagnostic Code 7804 instructs that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Diagnostic Code 7805 instructs that any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate diagnostic code. The Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent for the Veteran's service-connected forehead scar because he does not have visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features or two or three characteristics of disfigurement. The Veteran has stated that his scar is itchy but not painful. Furthermore, a January 2015 VA examiner indicated that the forehead scar is not painful or unstable, measures 1 centimeter by 0.3 centimeters (which calculates to an area of 0.3 square centimeters). Additionally, the scar had no other disfigurement or distortion of facial features and tissue loss. The Veteran was provided a VA examination in February 2019. The VA examiner reported that the Veteran's forehead scar is not painful or unstable. The Veteran's forehead scar measured 1.5 centimeters by 0.25 centimeters (which calculates to an area of 0.375 square centimeters). There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue, abnormal pigmentation. The VA examiner further noted that the Veteran did not have gross distortion or assymetry of facial features or visible or palpable tissue loss. Additionally, the VA examiner noted that the Veteran's forehead scar does not result in limitation of function. Thus, the record does not show that the Veteran's forehead scar manifests in visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features or two or three characteristics of disfigurement. Therefore, the criteria for a disability rating in excess of 10 percent under Diagnostic Codes 7800, 7804, and 7805 for the service-connected forehead scar were not met during the relevant period. The Board has also considered the other diagnostic codes pertaining to scars as they relate to the service-connected forehead scar. However, the Veteran's forehead scar is not deep and non-linear and is not associated with underlying soft tissue damage. The February 2019 VA examiner indicated that the forehead scar has an area of 0.375 square centimeters. Therefore, Diagnostic Codes 7801, 7802, and 7804, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effects for the forehead scar that is not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. Neither the Veteran nor his representative has raised any other issues with regard to the rating for the service-connected forehead scar, nor have any other such issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017). In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 10 percent for the service-connected forehead scar. To the extent the Veteran seeks an initial rating in excess of 10 percent for the forehead scar the preponderance of the evidence is against the appeal, the doctrine of reasonable doubt is not for application, and the appeal must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran contends that he has bilateral hearing loss that is directly related to his active service. Specifically, the Veteran contends that he was exposed to significant hazardous noise exposure during his active service as an airline mechanic. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz 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. The Veteran was provided a VA examination in December 2014. Upon examination the Veteran demonstrated the following puretone thresholds in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 20 20 25 LEFT 15 20 20 20 30 The Maryland CNC test results were 86 percent in the right ear and 72 percent in the left ear. The VA examiner opined that the Veteran has bilateral normal hearing within limits. The VA examiner explained that the Veteran's bilateral hearing was marked as within normal limits upon separation and that there was no significant worsening of hearing acuity when compared to the hearing test completed at the time of enlistment. However, the Board notes that the VA examination reflects bilateral hearing loss disability for VA purposes, as defined under 38 C.F.R. § 3.385 since speech recognition scores using the Maryland CNC Test are less than 94 percent. Additionally, under applicable law, the absence of in-service evidence of a hearing loss disability is not always fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). In this case, the Veteran has presented evidence of in-service acoustic trauma from noise exposure. The VA examiner essentially based the negative nexus opinion on the fact that the Veteran's service treatment records do not show in-service bilateral hearing loss. The examiner did not explain why evidence showing an in-service hearing loss is required to determine that the Veteran's current bilateral hearing loss was incurred in active service or is otherwise etiologically related to his active service, to include the reported exposure to noise. The Board therefore finds the December 2014 VA audiological examination to be inadequate for decision-making purposes, and that a remand is required so that an addendum opinion may be obtained. 2. Entitlement to service connection for a right knee disability is remanded. The Veteran contends that he has a right knee disability that may be etiologically related to the in-service event of being hit in the head by an aircraft door causing him to fall and twisting his right knee. The medical treatment records show that he has been diagnosed with chondromalacia patellae, right knee. In addition, the RO has conceded that the in-service event occurred. The Board concludes that the threshold for providing an examination has been met, and that the issue must be remanded so that the Veteran may be provided an examination as to his claim for entitlement to service connection for a right knee disability. See 38 U.S.C. § 5103A (d) (2); 38 C.F.R. § 3.159 (c) (4) (i); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 3. Entitlement to service connection for gastritis is remanded. The Veteran asserts that his gastritis is secondary to his service-connected GERD. He was afforded a VA examination in January 2015. The January 2015 VA examiner opined that the Veteran's gastritis is not at least as likely as not proximately due to or the result of his GERD. However, the VA examiner did not provide an opinion as to whether the Veteran's GERD may have aggravated his gastritis. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). Therefore, the issue must be remanded so that an addendum opinion may be obtained. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's bilateral hearing loss is at least as likely as not (50 percent probability or greater) related to his in-service exposure to noise. The clinician must note that, under applicable law, the absence of in-service evidence of hearing loss is not always fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Thus, the clinician's opinion should reflect consideration of whether, given the in-service noise exposure, the evidence establishes that the Veteran's bilateral hearing loss was incurred in active service or is otherwise etiologically related to his active service, such as being the delayed result of the in-service acoustic trauma. See 38 C.F.R. § 3.303 (d). 2. Schedule the Veteran for a VA examination to determine the nature and etiology of any right knee disability. Provide a copy of this remand and the record for the examiner to review. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner must address the following: (a.) Provide a diagnosis for any right knee disability demonstrated since service, found on current examination or in the record. (b.) For each right knee disability, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the condition had its onset during the Veteran's service or is otherwise etiologically related to the Veteran's service, to include twisting his knee after falling. 3. Forward the record and a copy of this remand to the examiner who conducted the January 2015 VA examination, or if the examiner is unavailable, another suitably qualified examiner, for completion of an addendum opinion. If the examiner determines that another in-person examination of the Veteran is required to provide the below-requested information, then such an examination should be scheduled. Following review of the record, the examiner should express an opinion as to: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's gastritis is proximately due to or the result of his service-connected disabilities, specifically to include his service-connected GERD. Rationale must be provided for the opinion proffered. In rendering the requested rationale, the examiner must note that it is not required that the gastritis is shown to be "predominantly" due to or result of GERD, but rather, whether there is any contributing degree of etiological relationship to GERD. (b.) If not, whether it is at least as likely as not (50 percent or greater probability) that the Veteran's gastritis is aggravated beyond natural progression by his service-connected disabilities, specifically to include his service-connected GERD. Rationale must be provided for the opinion proffered. In rendering the requested rationale, the examiner must note that it is not required that the gastritis is shown to be aggravated beyond natural progression "predominantly" by GERD, but rather, whether there is any contributing degree of aggravation beyond natural progression by the service-connected GERD. 4. After completion of the above, review the expanded record, including the evidence entered since the most recent statement of the case, and determine whether service connection bilateral hearing loss, a right knee disability and/or gastritis may be granted. If any benefit sought remains denied, furnish the Veteran and his representative with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. ANTHONY C. SCIRÉ, JR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. G. LeMoine, 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.