Citation Nr: 21073649 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 20-08 308 DATE: December 9, 2021 REMANDED The issue of entitlement to service connection for a left ankle condition is remanded. The issue of entitlement to service connection for a right ankle condition is remanded. The issue of entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1965 to April 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2019 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). It was previously before the Board in July 2021 at which time it was remanded for further development. There was a May 2021 Board hearing before the undersigned Veterans Law Judge (VLJ) and the transcript is of record. Unfortunately, the matter must again be remanded for additional development. When the VA orders a medical examination, it must conduct a "thorough and contemporaneous [one]." Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). All medical examinations obtained by the VA must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) ("[O]nce the Secretary undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, he must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided."). A medical opinion is adequate "where it is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Stefl v.Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Additionally, a thorough and adequate examination must consider all other relevant evidence of record, including lay statements. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). An adequate medical opinion does not contain only data and conclusions, "but also a reasoned medical explanation connecting the two." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Ultimately, if an examination report does not contain sufficient detail, "it is incumbent upon the rating board to return the report as inadequate for evaluation purposes." 38 C.F.R. § 4.2; see Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return inadequate examination reports); Hicks v. Brown, 8 Vet. App. 417, 421 (1995) (inadequate medical evaluation frustrates judicial review). 1. The issues of entitlement to service connection for left and right ankle conditions are remanded. Here, one VA examination was conducted in furtherance of the Veteran's claim for entitlement to service connection for bilateral ankle conditions. The examiner opined that the Veteran's bilateral ankle conditions were less likely than not caused by active-duty service. However, the examiner provided no commentary on the nature and etiology of the Veteran's conditions. In addition, the examiner exclusively relied on the absence of evidence in the Veteran's service treatment records as the primary basis for her negative opinion. See 10/25/2021 C&P Examination. Thus, the opinion is invalid for VA purposes. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). The opinion noted that imaging studies were performed in connection with the examination and no degenerative or post-traumatic arthritis was documented. However, the opinion also noted x-rays from 5/15/2018 which evidenced degenerative changes of the ankles bilaterally. Thus, clarification around whether or not degenerative changes are synonymous with arthritis is also needed. Accordingly, remand for an addendum opinion is warranted. 2. The issue of entitlement to service connection for bilateral hearing loss is remanded. With respect to the claim for service connection for bilateral hearing loss, the Veteran has been afforded two VA audiology examinations. The November 2018 examination provided a negative nexus opinion because the medical records reviewed indicated no significant shift in hearing threshold from the time of the Veteran's enlistment examination to the time of his retirement examination. 11/29/2018 C&P Examination. However, because the Board is aware of, and acknowledges the possibility of delayed onset hearing loss, and 38 C.F.R. § 3.385 does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service, the Board sought an additional examination opinion. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993); 7/20/2021 BVA Decision. However, while the September 2021 examiner opined that the Veteran's hearing loss was more likely due to presbycusis (i.e., age), she continued to define the attributes of presbycusis without clearly articulating the connections specifically attributable to the facts of the Veteran's condition. See 9/21/2021 C&P Examination. Specifically, the examiner noted that presbycusis always affects both ears to the same degree and is characterized by significant impact to sounds within the high-frequency range without articulating whether those factors were evident in how the Veteran's condition presented. Thus, remand for an addendum opinion is needed. The matters are REMANDED for the following action: 1. Return the claims file to the VA examiner who conducted the October 25, 2021 C&P Examination, if available, to issue a medical opinion regarding the Veteran's claim for service connection for bilateral ankle conditions. If that examiner is not available, send the claims file to another appropriate examiner. The entire claims file, including a copy of this Remand, must be made available to, and must be reviewed by, the examiner providing the opinion. If, and only if, the examiner determines that an examination should be conducted, one should be scheduled. Thereafter, the examiner should address the following: (a.) Please identify any current disability of the left and right ankle. "Current" is defined as any condition identified since the filing of the intent to file a claim in January 2018 to the present. "Disability" includes any diagnosable conditions as well as pain or symptoms that are not diagnosable but, nonetheless, cause functional impairment. Specifically identify whether arthritis is one of the Veteran's current disabilities, and whether degenerative changes specifically may be considered to be arthritis. (b.) For each disability identified in part (a.), please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's current left and right ankle disabilities were incurred in, caused by, or related to service. The examiner should consider medical and lay evidence dated both prior to and since the filing of the claim in September 2018, including Veteran statements that he injured his left ankle after stepping in a hole and injured his right ankle while compensating for his left ankle injury. The examiner must provide a complete rationale for any opinion rendered. If the examiner cannot provide an opinion without resort to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information or evidence, the limits of medical knowledge, etc.). 2. Return the claims file to the VA examiner who conducted the September 21,2021 C&P Examination, if available, to issue a medical opinion regarding the Veteran's claim for service connection for bilateral hearing loss. If that examiner is not available, send the claims file to another appropriate examiner. The entire claims file, including a copy of this Remand, must be made available to, and must be reviewed by, the examiner providing the opinion. If, and only if, the examiner determines that an examination should be conducted, one should be scheduled. Thereafter, the examiner should address the following: (a.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's bilateral hearing loss was incurred in, caused by, or related to service. The examiner should consider medical and lay evidence dated both prior to and since the filing of the claim in September 2018. (b.) If the examiner determines that the Veteran's hearing loss is attributable to presbycusis, please explain what characteristics of the Veteran's current condition are in alignment with that etiology (e.g., both ears affected to the same degree or hearing loss characterized by significant impact to sounds within the high-frequency range). The examiner must provide a complete rationale for any opinion rendered. If the examiner cannot provide an opinion without resort to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information or evidence, the limits of medical knowledge, etc.). S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Z. Sloley, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.