Citation Nr: 21072768 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 17-13 222 DATE: December 6, 2021 ORDER Entitlement to service connection for bilateral hearing loss is granted. Entitlement to service connection for tinnitus is granted. Entitlement to an initial 50 percent rating for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for a low back disability is remanded. FINDINGS OF FACT 1. The Veteran has a current bilateral hearing loss disability for VA compensation purposes that is consistent with his in-service noise exposure. 2. The Veteran has a current tinnitus disability that is consistent with his in-service noise exposure. 3. The Veteran's PTSD is manifested by symptoms consistent with occupational and social impairment with reduced reliability and productivity; neither occupational and social impairment with deficiencies in most areas nor total occupational and social impairment was shown. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral hearing loss disability are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 3. The criteria for an initial evaluation of 50 percent, but no higher, for PTSD are met. 38 U.S.C. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1980 to July 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2021 the Veteran presented testimony at a virtual hearing before the undersigned Veterans Law Judge. A copy of the transcript is associated with the evidentiary record. Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include sensorineural hearing loss, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2020). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as sensorineural hearing loss is through a demonstration of continuity of symptomatology. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Hearing Loss and Tinnitus 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 Tests are less than 94 percent. 38 C.F.R. § 3.385. Additionally, it is noted that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Factual Background and Analysis The Veteran contends that his current bilateral hearing loss and tinnitus disabilities were incurred in service. The Veteran's service treatment records are negative for complaints of, treatment for, or findings of bilateral hearing loss or tinnitus. The Veteran's April 1980 enlistment examination revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 15 10 5 LEFT 10 20 20 20 10 A June 1984 in-service audiological examination revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 20 15 10 LEFT 10 20 20 25 10 An October 1990 in-service audiological examination revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 15 15 10 LEFT 10 20 20 25 10 The Veteran underwent a VA audiological examination in April 2015. The April 2015 audiogram revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 30 30 35 LEFT 20 30 35 35 45 The examiner opined that it was less likely than not that the Veteran's bilateral hearing loss was related to his service. The examiner noted that the Veteran had normal hearing on enlistment and normal hearing at his latest in-service audiogram in October 1990. He also reported that his hearing loss began around 15 years ago in the early 2000's which was well after his 1992 separation from active duty. The examiner also opined that it was less likely than not that the Veteran's tinnitus was related to his in-service noise exposure. The examiner noted that the Veteran indicated that his tinnitus began prior to his military service and did not get worse until 15 years ago. As a result the Veteran's tinnitus was not caused or aggravated by his service. At his July 2021 hearing, the Veteran testified that he was regularly exposed to loud noises in the service as the building he initially worked in was very close to the flight line. The Veteran also testified that his ears starting ringing after his first duty station and it has gradually gotten worse. The Veteran clarified that the ringing had not begun in his childhood and instead began in service. The record shows that the Veteran currently has bilateral hearing loss for VA compensation purposes and a diagnosis of tinnitus. Accordingly, the first element of evidence of a current disability is accordingly met. Therefore, the question to be decided in the present appeal is whether the current bilateral hearing loss and tinnitus disabilities are associated with the Veteran's active duty. In this regard, the Board acknowledges that service treatment records are negative for complaints of, treatment for, or findings of hearing loss or tinnitus. However, when considering the circumstances of the Veteran's service, he was undoubtedly exposed to some noise in service and his in-service noise exposure has been conceded. Notably, the Veteran has also described his specific in-service noise exposure while also noting that he had noticed ringing in his ears since his time spent in the military. The Board acknowledges that the April 2015 VA examiner opined that it was less likely than not that the Veteran had bilateral hearing loss as a result of his in-service noise exposure. However, the negative nexus opinion that was provided by the April 2015 VA examiner appears to be based in part on the absence of documented hearing loss disability in the Veteran's service treatment records as the examiner noted that the Veteran's enlistment and latest audiological examinations both demonstrated normal pure tone audiometry with no significant changes in hearing. The absence of documented hearing loss is service is not fatal to a service connection claim for bilateral hearing loss. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). As a result, when affording the Veteran the benefit of the doubt, the Board finds that service connection is warranted for bilateral hearing loss. Regarding the Veteran's tinnitus disability, as noted above, the Veteran reported that he experienced tinnitus since his service as opposed to childhood which the April 2015 examiner reported as the onset. Accordingly, when affording the Veteran the benefit of the doubt, the Board finds that service connection is also warranted for tinnitus. Additionally, a remand for a new VA examination is not necessary because the evidence of record is sufficient to grant the Veteran's claims, and a remand would only serve to unnecessarily delay final adjudication of the claims. In sum, for the reasons and bases discussed above, all doubt is resolved in favor of the Veteran, and service connection for a bilateral hearing loss disability and a tinnitus disability, is warranted. See 38 U.S.C. § 5107(b). Higher Initial Rating Laws and Regulations The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2020). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2020). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2020). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2020). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2020). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). 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 (2020). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of his PTSD disability. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. His statements have been consistent with the medical evidence of record and are probative for resolving the matters on appeal. The Board will consider not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. In an April 2015 rating decision, the RO granted service connection for PTSD at an initial 30 percent disability rating under Diagnostic Code 9411, effective January 28, 2015. The Board notes that psychiatric disabilities other than eating disorders are rated pursuant to the criteria for General Rating Formula. See 38 C.F.R. § 4.130. Under the general rating formula for mental disorders, a noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent evaluation is warranted if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A rating of 30 percent is assigned when the Veteran exhibits occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affected the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The evidence considered in determining the level of impairment for psychiatric disorders under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the rating code. Disability ratings are assigned according to the manifestation of particular symptoms, but the use of the term "such as" in the General Rating Formula demonstrates that the symptoms after the phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the evidence considered in determining the level of impairment from psychiatric disorder under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (2002). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2020). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). According to the DSM-IV, GAF scores ranging between 61 to 70 reflect some mild symptoms [e.g., depressed mood and mild insomnia] or some difficulty in social, occupational, or school functioning [e.g., occasional truancy, or theft within the household], but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect more moderate symptoms [e.g., flat affect and circumstantial speech, occasional panic attacks] or moderate difficulty in social, occupational, or school functioning [e.g., few friends, conflicts with peers or co- workers]. Scores ranging from 41 to 50 reflect serious symptoms [e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting] or any serious impairment in social, occupational or school functioning [e.g., no friends, unable to keep a job]. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication [e.g., speech is at times illogical, obscure, or irrelevant] or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood [e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school]. VA has changed its regulations, and now requires use of DSM-5 effective August 4, 2014. Among the changes, DSM-5 eliminates the use of the GAF score in evaluation of psychiatric disorders. The change was made applicable to cases certified to the Board on or after August 4, 2014; and is not applicable to cases certified to the Board prior to that date. 79 Fed. Reg. 45093 (Aug. 4, 2014). Factual Background and Analysis The Veteran underwent a VA examination in April 2015. The examiner summarized the Veteran's level of social and occupational impairment as occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation. The Veteran had been married twice and had a 30 year old daughter but she distanced herself from him due to him divorcing her mother. His last relationship was in 1999 and he had no other relationships. He was very reclusive and had gender dysphoria which he had been struggling with. His last employment was in 2010 and he had periods of homelessness since then. The Veteran's symptoms included depressed mood, anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood and an inability to establish and maintain effective relationships. A September 2017 VA treatment report noted that the Veteran had a stable mood as there was contentment with living and work arrangements. The Veteran was alert and oriented with a euthymic mood with blunted affect. The Veteran was in no current emotional distress and denied homicidal or suicidal ideation. Insight and judgment were intact. The Veteran was experiencing symptoms of mild depression including sadness, sleep disturbance, crying more frequently, decreased enjoyment, changes in appetite, difficulty concentrating and self-criticism. The PTSD symptoms had been mild and primarily involved hypervigilance and avoidance. At his July 2021 hearing, the Veteran testified that he had panic attacks often, was startled easily, had trouble sleeping and had irritability. His irritability caused him to isolate from his friends and family. He was retired now but when he was working he had difficulty concentrating and staying on task. His mood stayed consistently low but he had never had any thoughts of self-harm. Based on the reported symptomatology of the Veteran's psychiatric symptoms, the Board finds that when affording the Veteran the benefit of the doubt, that an initial 50 percent rating is warranted from January 28, 2015, the initial date of service connection. The Veteran's PTSD symptoms were manifested by depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, isolation, flattened affect, disturbances of motivation and mood and an inability to establish and maintain effective relationships. Additionally, the Veteran endorsed having intrusive thoughts, nightmares, flashbacks, detachment from others, irritability, hypervigilance, and exaggerated startle response. As noted above, the Veteran testified in July 2021 that he had panic attacks often, was startled easily, had trouble sleeping and had irritability that caused him to isolate from his friends and family. Accordingly, the Board finds that an initial 50 percent rating is warranted from the Veteran's effective date of service connection as the Veteran's PTSD is indicative of reduced reliability and productivity. However, the preponderance of the evidence establishes that the social and occupational impairment from the disability has not more nearly approximated the deficiencies in most areas required for a 70 percent rating. In this regard, the evidentiary record was negative for obsessional rituals which interfered with routine activities, speech which was intermittently illogical, obscure or irrelevant, near-continuous panic or depression affecting his ability to function independently, spatial disorientation or neglect of personal hygiene. Additionally, there were no psychotic symptoms and there was no evidence of delusions. The Veteran's memory was also intact and was oriented times 3. There also is no indication that the Veteran demonstrated any suicidal or homicidal ideation during this period. Notably, a September 2017 VA treatment noted mild PTSD symptoms while the April 2015 VA examiner specifically found that the Veteran's social and occupational impairment with regard to all mental diagnoses was best summarized as occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation, which fits squarely for the criteria for a 30 percent evaluation under the General Rating Formula. Despite the fact that this description actually corresponds squarely with a lesser disability rating, the Board will still assign the initial 50 percent disability rating for PTSD. However, a rating in excess of 50 percent is clearly not available based on these findings. Thus, while the record demonstrates that the Veteran does have some social and occupational impairment which impact his quality of life, the greater weight of evidence demonstrates that it is to a degree less that is contemplated by an initial 50 percent rating. Furthermore, even resolving any reasonable doubt in the Veteran's favor, the Board finds that he does not meet the requirements for an evaluation greater than the 50 percent schedular rating. While the Veteran has some of the criteria for a 70 percent rating, see Mauerhan, 16 Vet. App. at 442, the Board concludes his overall level of disability does not exceed a 50 percent rating. Again, in determining that a rating in excess of 50 percent is not warranted, the Board has considered the Veteran's complaints regardless of whether they are listed in the rating criteria, but concludes that the Veteran's level of social and occupational impairment does not warrant a rating in excess of a 50 percent rating. Accordingly, this evidence demonstrates that prior to the Veteran did not have deficiencies in most of the areas in the criteria for a 70 percent rating nor had he been shown to have most of the symptoms listed as examples in the criteria. As the criteria for the next higher (70 percent) rating for a psychiatric disorder have not been met, it logically follows that criteria for an even higher rating (100 percent) have not been met. There is no showing that the Veteran had gross impairment of thought processes or communication, persistent delusions, exhibited grossly inappropriate behavior; persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, or disorientation to time or place. Thus, the Board finds that the Veteran's symptoms more closely approximated the criteria for an initial 50 percent disability rating. Thus, for all the foregoing reasons, the Board finds that an initial rating of 50 percent, but no higher, for PTSD is warranted. REASONS FOR REMAND The Board finds that more development is necessary prior to final adjudication of the claim remaining on appeal. The Board notes that VA is obligated to provide an examination 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). The threshold for finding a link between current disability and disease or injury in service is low. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Regarding the Veteran's claim for a low back disability, the Veteran's service treatment records demonstrate that he was treated on multiple occasions for back pain. Specifically, a September 1985 treatment record indicated that the Veteran presented with complaints of back pain and a February 1986 record also noted back pain and placed a restriction on heavy lifting, Notably, the Veteran underwent a VA examination in April 2015. The examiner opined that it was less likely than not that the Veteran's current low back disability was incurred or caused by the claimed in-service event, injury or illness. The examiner noted that during service, the Veteran was treated twice for low back pain but the pain described was acute in nature and resolved after treatment. However, while the April 2015 VA examiner noted that it was less likely than not that the Veteran's low back disability was due to service as the in-service back injuries were acute and resolved, the Veteran's representative noted at the July 2021 hearing that the service treatment records demonstrate ongoing back problems for 2 years during service. The Veteran testified that his in-service back pain resulted not from specific injuries but rather it came on gradually as a result of the heavy lifting he did in service. The Veteran also testified that his back pain began in service and continued since then. Therefore, the Board finds that a remand is necessary to provide the Veteran with a new VA examination relating to his claim for service connection for a low back disability in order to adequately address the Veteran's contentions of continued low back pain since his in-service injuries. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (finding that once the VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, the VA must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). The matters are REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disability on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 2. Schedule the Veteran for an appropriate VA examination, to determine the nature and etiology of his low back disability. The examiner should provide an opinion regarding whether it is at least as likely as not (e.g., a 50 percent or greater probability) that his current low back disability had its onset in or is etiologically related to the Veteran's active service. In making this determination, the examiner should specifically address the Veteran's contentions that he experienced low back pain since his documented in-service injuries. Adequate reasons and bases for any opinion rendered must be provided. All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. 3. Thereafter, readjudicate the issue on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James A. DeFrank, 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.