Citation Nr: 21075684 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 16-34 449 DATE: December 21, 2021 ORDER Entitlement to a higher evaluation for posttraumatic stress disorder (PTSD) rated 50 percent prior to September 16, 2019; and 70 percent thereafter (excluding those periods during which a total rating was assigned) is denied. Entitlement to service connection for bilateral hearing loss is denied. Resolving reasonable doubt in the Veteran's favor, service connection for benign prostatic hypertrophy, claimed as an enlarged prostate, is granted. REMANDED Entitlement to service connection for tinnitus is remanded. FINDINGS OF FACT 1. The competent and persuasive evidence shows the Veteran's PTSD does not manifest with symptoms that cause occupational and social impairment with deficiencies in most areas or total occupational and social impairment. 2. The preponderance of the evidence of record is against finding that the Veteran has had a bilateral hearing loss disability at any time during or approximate to the pendency of the claim. 3. Resolving all reasonable doubt in the Veteran's favor, benign prostatic hypertrophy, claimed as an enlarged prostate, is related to military service. CONCLUSIONS OF LAW 1. The criteria for a higher evaluation for PTSD rated 50 percent prior to September 16, 2019; and 70 percent thereafter (excluding those periods during which a total rating was assigned) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.130, Diagnostic Code 9411. 2. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 3. The criteria for service connection for benign prostatic hypertrophy, claimed as an enlarged prostate, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army National Guard from November 1990 to July 1991. He also had a period of active duty for training (ACDUTRA) from September 1978 to March 1979, with additional periods of inactive duty for training (INACDUTRA) from 1978 to 1999. These matters are before the Board of Veterans' Appeals (Board) on appeal from December 2013 and August 2016 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge; a transcript is of record. In December 2019, the Board remanded the issues shown above for further development. There has been substantial compliance with the remand directives as it pertains to the issues adjudicated herein. See Stegall v. West, 11 Vet. App. 268 (1998). In December 2019, the Board also remanded the following issues which have been granted in full during the appeal, and are no longer before the Board: entitlement to service connection for lower back and bilateral knee disabilities and a total disability rating based on individual unemployability prior to February 17, 2017. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. Id. A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. 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 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 1. Entitlement to a higher evaluation for PTSD rated 50 percent prior to September 16, 2019; and 70 percent thereafter (excluding those periods during which a total rating was assigned) is denied. The Veteran filed the current increased rating claim for PTSD on January 31, 2013. He was in receipt of a 50 percent rating at the time of the claim for increase. In an August 2016 rating decision, the RO awarded a temporary total rating (i.e., 100 percent) effective from December 30, 2015 to March 1, 2016; a 50 percent rating was continued thereafter. In a June 2021 rating decision, the RO awarded a 70 percent rating from September 15, 2019, and a total schedular rating was granted from March 19, 2021. The appeal period begins on January 31, 2012, one year prior to the receipt of the claim for increase. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). For the reasons that follow, the Board finds that the Veteran's PTSD is properly rated at 50 percent prior to September 16, 2019; and 70 percent thereafter, excluding those periods during which a total rating was assigned. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The Veteran's PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under this Code, a 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting 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); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for 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; or memory loss for names of close relatives, own occupation or own name. As noted above, the Veteran was assigned a total rating from December 31, 2015 to February 29, 2016; and from March 19, 2021. The question for the Board is whether the Veteran is entitled to a rating in excess of 50 percent from January 31, 2012 to December 30, 2015, and from March 1, 2016 to September 15, 2019, and in excess of 70 percent from September 16, 2019 to March 18, 2021. During a March 2012 VA psychology evaluation, the Veteran reported recurrent thoughts of combat traumas, increased irritability, physiological reactions (e.g., sweating and increased heart rate) to external cues, and exaggerated startle response. He reported episodes of mania, nightmares, difficulty staying asleep, getting out of bed to ensure that the doors are locked. He stated he does not feel safe around individuals he does not know, and therefore avoids crowds. He denied any current suicidal intent or plan. On mental status examination, he was casually dressed and well-groomed; he was alert and oriented to time, place, person, and situation (x4); he maintained appropriate eye contact; his speech was generally fluent, spontaneous, and goal-oriented; and his affect was appropriate. In a July 2012 VA psychiatry record, the Veteran reported nightmares about Desert Storm every other night with night sweats and occasional startle. He avoids news about shootings and wargames. He sleeps 5-6 hours and has adequate appetite. He denied any significant depression. He was active with daily exercise of walking. On mental status examination, he was alert and oriented to time, place, and person (x3); was casually dressed; had good eye contact; his mood was good; his affect was appropriate; his speech had normal rate and rhythm; his thought process was linear; his insight/judgment was good. He did not have delusions or hallucinations. He denied suicidal or homicidal ideations, intent, or plans. In a VA psychiatry record dated March 7, 2013, the Veteran reported he lives at home with his wife without any relational difficulties. He reported auditory hallucinations about twice a week that said, "don't do it; don't commit suicide." He reported intermittent, fluctuating suicidal ideation. On mental status examination, his appearance was clean with casual attire; his eye contact was good; his mood was depressed; he was oriented x3; his memory was intact; his attention span/concentration was fair; his speech was loud; his thought process was linear; and his insight/judgment was fair. In an August 2013 VA mental health note, the Veteran reported he spends his free time walking and praying daily at noon at his church. He denied suicidal or homicidal ideations. He reported hearing the words "don't do it," and visual hallucination of seeing "shadows...every now and then." He reported nightmares and awakenings at night. On mental status examination, his eye contact was good; his mood displayed mild depression and anxiety; his affect was appropriate; he was orientated x4; his memory was intact; his speech was slightly pressured but with normal volume; his thought process was linear; his insight/judgment was fair/poor; and his attention span/concentration was fair. The Veteran underwent a VA examination in December 2013. He was diagnosed with PTSD. The Veteran reported he remains married and is living with his wife. He reported his wife remains supportive, but that his PTSD symptoms continue to place a strain on their relationship. He reported limited social support beyond his wife, and that anxiety prevents him from being more involved in the community. He stated he remains retired due primarily to physical health problems. The examiner noted the following symptoms: depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; difficulty in establishing and maintaining effective work and social relationships; and suicidal ideation. Regarding behavioral observation, the examiner noted that the Veteran was cooperative during the assessment interview. The examiner noted the Veteran was capable of managing his financial affairs. The examiner summarized the Veteran's level of occupational and social impairment with regards to the Veteran's PTSD as occupational and social impairment with reduced reliability and productivity. In a July 2014 VA psychiatry note, the Veteran reported nightmares twice a week about Saudi Arabia, fire, and dead bodies being burned up. He reported he is easily angered, and that there are "[c]ertain people I like to be around, certain people I don't." He denied violence for over 3 years. He reported he sleeps about 4 hours without medication. He reported anxiety due to worries about his mother's health. He had good appetite and energy, and fair concentration. He reported he hears things from the military trauma, and that he sees "shadows" sometimes. The Veteran was well-groomed; his eye contact was good; he was alert and oriented x3; his speech had regular rate, rhythm, and volume; his mood was euthymic; his affect was congruent; his thought process was logical; his insight/judgment was fair. He denied suicidal or homicidal intent. He denied auditory or visual hallucinations or delusions. At the February 2015 VA examination for PTSD, a diagnosis of chronic PTSD was noted. The Veteran reported he is married for 22 years with his second wife. He stated he gets along well with his wife and a grown up son. He reported he is not working because of his knee and back pain. He reported he takes medication for his PTSD, has nightmares, and sleeps poorly. The examiner noted the following symptoms: depressed mood; anxiety; chronic sleep impairment; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Regarding behavioral observation, the examiner noted the Veteran is moderately depressed. The Veteran was capable of managing his or her own financial affairs. The Veteran's level of occupational and social impairment with regards to his PTSD was summarized as occupational and social impairment with reduced reliability and productivity. In a September 2015 VA record, the Veteran reported he is depressed because of his mother's death a year ago. He said it just hit him, and now is angry and wants to hurt someone. He reported he wanted to come into hospital. The assessment was depression and homicidal thoughts. In another September 2015 VA record, the Veteran stated, "I lost my mother last year and the depression is coming back on me." He reported homicidal ideations towards his wife where he had thoughts of choking his wife but without detailed plan. He reported previous suicidal attempt of cutting his left wrist in July 2015; VA records did not reveal injuries to left wrist. A December 2015 VA psychiatry record noted he had suicidal thoughts that "come and go" but without any intent or plan. A December 2015 VA psychiatry record noted the Veteran had combat flashbacks about Desert Storm once a week with night sweats and hypervigilance. He denied suicidal ideas, intent, or plans. He had auditory hallucinations once a week and feeling paranoid at times. He had no visual hallucinations. He reported he lives with wife, actively walks 2 miles a day, reads Bible, goes to church, and visit neighbors and grandchild. The Veteran was alert and oriented x3; he was casually dressed; his eye contact was good; his mood was dysphoric; his affect was appropriate; his speech was normal in rate and rhythm; his thought process was linear; he had no suicidal or homicidal ideations, intent, or plans; and his insight/judgement was good. A March 2016 VA psychiatry record noted the Veteran is having combat flashbacks about Desert Storm once a week with night sweats and hypervigilance. He denied suicidal ideas, intent, or plans. He was having auditory hallucinations twice a week, and feeling paranoid at times. He lives with his wife, actively walks 30 minutes a day, reads Bible, goes to church, and visits neighbors and grandchild. In an August 2016 VA psychiatry record, the Veteran reported combat flashbacks about Desert Storm. He reported night sweats and hypervigilance, and that he avoids crowds. He reported he sleeps 3-4 hours. He stated his appetite and energy were adequate. He denied auditory or visual hallucinations, but felt paranoid at times. He stated he lives with his wife, reads Bible, takes walks, and goes to church. He was alert and oriented x3; he was casually dressed; he had good eye contact; his mood was good; his affect was appropriate; his speech was normal in rate and rhythm; his thought process was linear; he denied suicidal or homicidal ideations, intent, or plans; and his insight/judgement was good. In a January 2017 VA record, the Veteran reported he was depressed last week and had thoughts of harming himself. He reported he sees someone pointing a gun at him, which he denied happening today. He reported he has nightmares about Persian Gulf. He was alert and oriented x4; his speech was articulate and coherent; he was neat and appropriately dressed; his thought process was linear and concrete; his thought content was appropriate; he denied hallucinations; he denied suicidal or homicidal ideations; his insight/judgment was intact; his recent and remote memories were intact; and his judgment was good. A July 2017 VA record noted the Veteran did not have significant depression. It noted he sleeps 5 hours, had adequate appetite, and that his concentration and energy were fluctuating. He reported occasional auditory and visual hallucinations. He denied paranoia. He reported combat dreams about Desert Storm once a week, hypervigilance, and avoidance of crowd. He stated he lives with his wife, is active with push-ups and sit-ups twice a week, reads Bible, and goes to church once a month. On mental status examination, he was alert and oriented x3; he was casually dressed; he had good eye contact; his mood was euthymic; his affect was appropriate; his speech was normal in rate and rhythm; his thought process was linear; he denied suicidal or homicidal ideas or intent; and his insight/judgement was good. In a February 2018 VA record, the Veteran denied feeling suicidal or homicidal. He reported he continues to have PTSD symptoms, and that he hears voices "on and off." The clinician noted the Veteran seemed to have a supportive wife and a good family support system. On mental status examination, the Veteran was alert and oriented x3; his appearance was neat and appropriately dressed; his mood was euthymic; his thought process was linear and concrete; he denied hallucinations; his insight/judgment was good; and his recent and remote memories were intact. In a July 2018 VA record, the Veteran reported trouble with sleeping when he gets depressed about something. He was alert and oriented x3; he maintained good eye contact; and he was dressed appropriately for weather and situation. He denied suicidal or homicidal ideations, and he denied auditory or visual hallucinations. His sleep was fair, and his appetite was good. In a January 2019 VA psychiatry record, the Veteran reported he has been taking medications with good response and with improved sleep. He reported his appetite is fine. He stated he functions relatively well for personal life and social life. He denied manic symptoms. He denied suicide or homicide ideations, and denied delusions or hallucinations. On his mental status examination, he was alert and oriented x 3; his attitude was cooperative; his eye contact was good; his speech was normal in rate, volume, and production; his mood was anxious; his thought process was logical; his thought content included hopeful thoughts without any suicide or homicide ideations; his memory, attention, concentration, language, insight/judgement, and impulse control were intact. In an August 2019 VA record, the Veteran reported he has been forgetting to take his medication and forgetting the day of the week. On mental status examination, he was oriented x4; his appearance was neat and appropriate to setting; his speech was normal in rate, volume, and prosody; his speech was linear and goal-directed; his eye contact was avoidant/minimal; his affect was constricted; his mood was depressed and anxious; his insight was poor; and his judgment was fair. He denied current suicidal ideation; he endorsed suicidal ideation in the past month. At the September 2019 VA contract examination for PTSD, the Veteran was diagnosed with PTSD and unspecified depressive disorder. The Veteran reported passive suicidal ideations, but denied plan, intent, or past attempts. The examiner noted it is not possible to differentiate which symptoms or impairments are attributable to each diagnosis because the symptoms of the disorders and their resulting impairments overlap. The Veteran reported he has been married for 38 years, which has been positive overall. He reported he prefers to be by himself, and that this causes strain in the relationship with his son. He stated he currently has about 2 friends. The examiner noted the following symptoms: depressed mood; anxiety; suspiciousness; pain attacks that occur weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and suicidal ideation. On behavioral observation, his mood appeared depressed; his affect was congruent; his eye contact was normal; and he appeared fully oriented on all spheres. He was capable of managing his financial affairs. The examiner summarized the Veteran's level of occupational and social impairment with regards to the Veteran's mental diagnoses as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. In an October 2019 VA mental health note, the Veteran reported, "I have chronic pain, feel depressed, my PTSD is worse and feel suicidal/homicidal." He stated he did not want to continue taking narcotics due to increased suicidal ideations and mood changes. He stated his sleep is fragmented due to increased nightmares. He stated he has been feeling helpless, hopeless, and worthless for the last 2 weeks with increase in depression/PTSD symptoms and suicidal/homicidal thoughts but without plans or intentions. He was admitted to High Intensity Psychiatric Unit (HIPU) for emotional stabilization. A November 2019 VA neuropsychology consult record noted the Veteran was admitted to HIPU for 10 days in October 2019 for suicidal ideation and elevated stress due to pain. The Veteran described his sleep as variable and his sleep is often disturbed by his pain. He denied suicidal ideation, but reported occasional suicidal thoughts. His protective factor was his grandchildren. In a March 2020 VA record, the Veteran reported "I am doing better, I take my medicine every day, it seems to help me[.] I want to go to PTSD classes." He stated he had anxiety problems in crowded places. He stated he quit driving, and that his wife takes him around. He reported he has been active in church, talks to friends, and had a new grand baby born a few weeks ago. He reported he has nightmares almost every other night, and that he had hallucinations mainly at night. He denied any suicidal intent or plans. He stated his wife is supportive. The Veteran was causally attired; he was alert and oriented x3; he had normal concentration; his speech was normal in rate and volume; his thought process was linear and goal-oriented; he denied delusions; and his insight/judgment was limited. A May 2020 VA Veterans Crisis Line record noted the Veteran had expressed suicidal intent on Sunday and left home. It noted the Veteran is currently with a member of the local police department. The outcome of call/action taken noted "Rescue called without suicidal behavior." The clinical impression and level of suicide risk was "moderate to low risk." A June 2020 VA suicide risk evaluation noted that prior to May 15, 2020, the Veteran had left his home in his car and was gone for a full week. It noted he had thoughts of jumping into a river. The clinician noted there was low acute risk as evidenced by no current ideations, plan, or intents, strong alliance with mental health providers, and strong protective factors of faith and family. There was intermediate chronic risk as evidenced by chronic PTSD and chronic pain conditions, and strong protective factors of faith and family. An August 2020 VA record noted the Veteran had a 7-day hospitalization in May 2020. The Veteran adamantly denied any current suicidal ideation, plan, or intent. He described spiritual beliefs and familial relationships as strong protective factors. He reported feeling "much better" at this time, and that medication changes and consistent VA care were likely a part of his progress. On mental status examination, he was oriented x4; his mood/affect was dysthymic with restricted affect; there were speech dysfluencies; his thought processes were perseverative and tangential; he denied hallucinations or delusions; he displayed unspecified cognitive concerns with comprehension and memory; and his judgment/insight was limited. In a November 2020 VA record, the Veteran reported he is doing "pretty good," and that he needs his sleep medicine. He reported he hears voices sometimes telling him to do things, but that he does not follow. He stated he had suicidal thoughts before but not anymore, and that his wife is with him all the time and helps him out. He reported good response with his current medication without any side effects. He reported dreams and nightmares few nights a week. He stated he is mostly at home, and does not have interaction with others except his wife. He stated he avoids going in public places. He reported increased anxiety and depression since the COVID pandemic. He reported recent memory slowing and forgetting names of people. The Veteran was friendly, cooperative, and pleasant; he was alert and oriented x3; he had normal speech; his sleep pattern was fragmented with 5-6 hours of sleep; denied suicidal or hopeless thoughts; his thought process was linear and goal-directed; and his insight/judgement was limited. In a December 2020 and February VA records, the Veteran adamantly denied any suicidal ideations, plan, or intents. The Veteran described his spiritual beliefs and familial relationships were strong protective factors. He stated he was admitted for 7 days in May 2020, and that he is feeling much better at this time. He stated medication changes and consistent VA care were likely a part of his progress. Period prior to September 16, 2019 (excluding those periods during which a total rating was assigned) Prior to September 16, 2019 (and excluding those periods during which a total rating was assigned), the Veteran displayed symptoms of avoidance of crowds, increased irritability, flashbacks, nightmares, sleep impairment, exaggerated startle response, hypervigilance (including getting out of bed to ensure that the doors were locked), and mild memory loss. Nightmares, sleep impairments and mild memory loss are symptoms found in the 30 to 50 percent criteria under Diagnostic Code 9411. He reported he wakes up at night to check the doors are locked, and this hypervigilance is similar to suspiciousness in the 30 percent criteria. Exaggerated startle response is similar to flattened affect in the 50 percent criteria. Avoidance is similar to anxiety in the 30 percent criteria, or difficulty in establishing and maintaining effective work and social relationships in the 50 percent criteria. While increased irritability was noted, it is different from unprovoked irritability with periods of violence that is contemplated in the 70 percent criteria. Indeed, a July 2014 VA record shows he had no period of violence for over three years. Thus, the frequency and severity of the Veteran's irritability symptoms is more similar to disturbances of mood in the 50 percent criteria. Furthermore, social impairment in most areas is not shown as he continues to maintain decent relationship with his wife and socializes with people at his church, his neighbors, and his grandchildren. The Board further observes that the record reflects intermittent reports of suicidal ideation. In a March 2013 record, the Veteran intermittent, fluctuating suicidal ideation. The December 2013 VA examination report showed symptoms of depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; difficulty in establishing and maintaining effective work and social relationships; and suicidal ideation. The February 2015 VA examiner noted similar symptoms, however, memory loss and suicidal ideation were not present. A December 2015 VA record noted he had suicidal thoughts that "come and go." He also reported in December 2015 that he was angry and wanted to hurt someone. The Board finds that despite the intermittent reports of suicidal ideation, a 70 percent rating is not warranted. Taking a holistic view of the evidence, the Veteran's infrequent reports of suicidal ideation are not shown to have resulted in serious social or occupational impairment during this period. The few isolated reports of audio and visual hallucinations, which also do not appear to have resulted in serious impairment as it relates to social and occupational functioning, do not support the assignment of a 70 percent rating either. It is significant that the VA examiners who evaluated the Veteran and reviewed the clinical record determined that his overall level of social and occupational impairment was not commensurate with the level of severity contemplated by a 70 percent rating. The December 2013 and February 2015 VA examiners opined the Veteran's level of occupational and social impairment was best characterized as 'occupational and social impairment with reduced reliability and productivity.' This is commensurate with a 50 percent disability rating. The VA examiners are competent to assess the nature and severity of the Veteran's psychiatric impairment considering their specialized medical training. In short, the Veteran's PTSD did not manifest with symptoms that more closely approximated a 70 percent rating. For this reason, a rating in excess of 50 percent is not warranted prior to September 16, 2019. Period from September 16, 2019 to March 18, 2021 From September 16, 2019 to March 18, 2021, the records do not show total social and occupational impairment due to the PTSD as to warrant the assignment of a 100 percent rating. Notably, the record does not contain any evidence of symptoms such 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); or memory loss for names of close relatives, own occupation, or own name, as is considered for a 100 percent disability rating for PTSD. The Veteran's suicidal ideations and hearing voices only occurred intermittently. His admittance to HIPU was not more than 21 days. Further, the Veteran was generally neat and well-groomed, had normal speech, was alert and oriented x3, displayed linear and goal-directed thought process, and was sociable with people at his church and his family. Thus, total occupational and social impairment is not shown. Moreover, none of the VA examiners during this period noted total occupational and social impairment due to PTSD. In sum, the preponderance of the evidence is against higher ratings for the service-connected PTSD. 38 C.F.R. §§ 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 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). 2. Entitlement to service connection for bilateral hearing loss is denied. The Veteran contends that he is entitled to service connection for bilateral hearing loss disability due to in-service acoustic trauma. See October 2021 Appellant's Post-Remand Brief (Brief). For the reasons explained below, service connection is not warranted. The existence of a current disability is the cornerstone of a claim for VA disability compensation. In the absence of proof of a claimed disability at any time during the period on appeal, there is no valid claim of service connection. Degmetich v. Brown, 104 F. 3d 1328 (1997). For VA compensation purposes, impaired hearing will be considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 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 Board concludes that the Veteran does not have a current diagnosis of bilateral hearing loss and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran filed a service connection claim for bilateral hearing loss in June 2016. An August 2016 VA examination report reveals that the Veteran experienced a subjective symptom of "trouble hearing all the time." The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, indicate that he did not have a diagnosis of bilateral hearing loss for VA compensation purposes. His results were as follows: Aug. 2016 HERTZ CNC 500 1000 2000 3000 4000 RIGHT 20 20 15 15 20 96 LEFT 15 15 15 15 20 96 The Veteran had an audiology exam during a December 2016 VA audiology consultation. He reported difficulty understanding normal conversational speech. The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds indicate that he did not have a diagnosis of bilateral hearing loss for VA compensation purposes. His results were as follows: Dec. 2016 HERTZ CNC 500 1000 2000 3000 4000 RIGHT 10 10 15 15 20 96 LEFT 10 5 10 15 20 96 A May 2021 VA contract examination reveals that the Veteran experienced subjective symptoms of difficulty hearing his family, television, and other people talking. The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds indicate that he did not have a diagnosis of bilateral hearing loss for VA compensation purposes. His results were as follows: May 2021 HERTZ CNC 500 1000 2000 3000 4000 RIGHT 15 15 20 20 25 96 LEFT 10 10 15 20 20 96 There are no private or VA treatment records which contain a diagnosis of a hearing loss disability for VA compensation purposes. The Board expressly acknowledges its consideration of the lay evidence of record when adjudicating this claim. The Veteran is competent to report difficulty with his hearing; however, determining whether a hearing loss disability exists, as defined by 38 C.F.R. § 3.385, is not a simple medical condition or determination because the diagnosis requires audiometric testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). In this case, the competent medical evidence does not show current audiometric findings which meet the criteria for a finding of bilateral hearing loss for VA compensation purposes. As there is no current bilateral hearing loss disability, service connection may not be granted. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert, 1 Vet. App. at 55-57. Service connection for bilateral hearing loss is not warranted. 3. Entitlement to service connection for an enlarged prostate is granted. The Veteran contends that he began experiencing symptomatology related to his prostate, including urinary and weight loss issues, shortly after returning from Southwest Asia in July 1991. See July 2019 Board hearing at 31. The Veteran also contends that while his current benign prostatic hyperplasia (BPH) did not present until 2005, the chemical exposure he was exposed to during his deployment to Southwest Asia led to his prostate condition as chemicals and toxins can lay dormant in the body for years before symptoms appear. See October 2021 Brief. Pursuant to the July 2019 Board remand, the Veteran was provided a VA contract examination in February 2021. The examiner diagnosed BPH and opined that it was at least as likely as not related to military service. In the rationale, the examiner cited to a study that showed 'veterans at the Department of Veterans Affairs health care centers increased 61 percent for urinary cancers which include bladder, kidney, and ureter cancers from the fiscal year 2000 to 2018.' Addendum opinions were obtained in June and August 2021. However, the new VA provided an unfavorable opinion. For the rationale, the examiner indicated: "It is not known that the [v]eteran's BPH is related to his conceded exposure to burn pit toxins. There is no known mechanisms that burn pits toxins can cause BPH." Given the two contrary VA opinions, both of which are probative as they were provided by clinicians competent to offer medical opinions and supporting with rationale, the Board resolves reasonable doubt in the Veteran's favor on the question of causal nexus. REASONS FOR REMAND 1. Entitlement to service connection for tinnitus is remanded. The Veteran contends that in-service acoustic trauma and lack of proper hearing protection caused his tinnitus. See October 2021 Brief. For the reasons that follow, the Board finds that service connection for tinnitus is not warranted. The August 2016 VA examination reflects a current diagnosis of recurrent tinnitus. A May 1991 in-service audiogram noted that the Veteran was routinely exposed to hazardous noise. Thus, the current disability and in-service noise exposure elements have been met. The question for the Board is whether the Veteran's tinnitus began during service or is at least as likely as not related to his in-service noise exposure. At the July 2019 Board hearing, the Veteran reported he began experiencing tinnitus during active service. The Veteran underwent a VA contract examination in May 2021; an addendum was obtained in June 2021. In the June 2021 addendum, the examiner noted that when the Veteran was asked if he experienced tinnitus, sounds in ears, or etc., he reported he did not experience them. The examiner noted the Veteran denied previous or current tinnitus despite he was asked twice. An addendum opinion is still required because the Veteran has a current diagnosis of tinnitus pursuant to the August 2016 VA examination report. Indeed, the requirement of a current disability is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). Further, the 2016 opinion rendered an opinion based on a 2006 Institute of Medicine (IOM) report on noise exposure in the military. In McCray v. Wilkie, 31 Vet. App. 243 (2019), the United States Court of Appeals for Veterans Claims (Court) found that the IOM study contained contradictory findings. The study found that "based on current knowledge of cochlear physiology there was no sufficient basis for the existence of delayed-onset hearing loss." The Court noted, however, the IOM report also indicated "there is not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one's lifetime, long after the cessation of that noise exposure" and that "definitive studies to address this issue have not been performed." Given the August 2016 VA examiner's reliance on the 2006 IOM report and what appears to be a rejection of the Veteran's lay statements regarding continuity of symptomatology, a remand is warranted for the purpose of obtaining an addendum opinion. The matter is REMANDED for the following action: Obtain an addendum opinion regarding the etiology of the Veteran's current tinnitus disability. The examiner must opine as to whether it is at least as likely as not that the Veteran's current tinnitus is related to his noise exposure in service. A complete rationale must be provided and must reflect consideration of the Veteran's reported onset and continuity. The examiner is also advised that if he or she relies on the 2006 IOM study for his or her opinion, then he or she must explain why the conclusions of that study apply to this particular Veteran, given its contradictory aspects (as noted by the Court in McCray), and the specific facts of this case. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jake Choi, 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.