Citation Nr: 21070714 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 12-12 010 DATE: November 24, 2021 ORDER Entitlement to service connection for recurrent left leg cellulitis residuals to include a scar is granted. REMANDED Entitlement to service connection for left ear hearing loss is remanded. Entitlement to an initial compensable rating for right ear hearing loss is remanded. FINDING OF FACT Recurrent left leg cellulitis residuals including a scar were manifested during active service. CONCLUSION OF LAW The criteria for entitlement to service connection for recurrent left leg cellulitis residuals including a scar have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from September 2004 to September 2006 and from June 2008 to April 2009. Service Connection for a Left Leg Disability Service connection may be granted for a recurrent disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 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). The Veteran contends that service connection for a recurrent left leg disability is warranted as the claimed disability was manifested during active service. The service treatment records reflect that the Veteran was seen for a left leg infection. A July 2005 treatment record states that the Veteran was diagnosed with cellulitis. The site was incised, drained, and packed. The report of a May 2009 Department of Veterans Affairs (VA) examination notes that the Veteran had an in service infection which was drained and packed. On examination, the Veteran exhibited a left leg scar associated with the in service infection and the associated treatment. The service treatment records reflected that the Veteran sustained a left leg infection which necessitated an incision for drainage. On VA examination, the Veteran was diagnosed with left leg infection residuals including a scar. Therefore, entitlement to service connection for recurrent left leg cellulitis residuals including a scar is granted. REASONS FOR REMAND 1. Entitlement to service connection for left ear hearing loss is remanded. The report of the August 2006 physical examination for service separation states that the Veteran exhibited pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 35 25 45 30 LEFT 25 35 20 20 30 The Veteran was diagnosed with an "abnormal audiogram." The report of a May 2009 VA audiology examination states that the Veteran exhibited pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 5 10 15 LEFT 10 15 10 10 10 Speech audiometry revealed bilateral speech recognition of 100 percent. The examiner commented that "although patient's audiometric pure tone hearing thresholds were normal, the findings were consistent with early cochlear dysfunction." The audiologist did not address the relationship, if any, between the evidence of early cochlear dysfunction and the documented in service abnormal audiogram. Given such deficiency, the examination report is of limited probative value, VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that further VA audiological evaluation is needed. Clinical documentation dated after May 2015 is not of record, VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. Entitlement to an initial compensable rating for right ear hearing loss is remanded. The issue of an initial compensable rating for right ear hearing loss is inextricably intertwined with the issue of service connection for left ear hearing loss being remanded and must also be remanded. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any hearing loss disability. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after May 2015. 3. Schedule the Veteran for a VA audiology examination to assist in determining the nature of any left ear hearing loss disability and any relationship to active service and the current nature and severity of service-connected right ear hearing loss. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all left ear hearing loss found. (b) Conduct audiometric testing and speech recognition testing using the Maryland CNC test. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified left ear hearing loss had its onset during active service or is related to any incident of service, including the in service abnormal audiogram, and the evidence of early cochlear dysfunction found at the May 2009 VA examination. (d) The examiner should specifically address the impact of right ear hearing loss on the Veteran's vocational pursuits. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Douglas 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.