Citation Nr: 21076447 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 16-07 706 DATE: December 23, 2021 ORDER Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for a disability manifested by multiple joint arthritis is denied. REMANDED Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a bilateral shoulder disability is remanded. Entitlement to service connection for a bilateral hip disability is remanded. Entitlement to service connection for a bilateral knee disability is remanded. Entitlement to service connection for a bilateral ankle disability is remanded. Entitlement to service connection for a bilateral foot disability is remanded. Entitlement to service connection for a cardiac disability, to include heart palpitations, is remanded. Entitlement to service connection for diabetes mellitus is remanded. Entitlement to service connection for a bilateral neurological disability of the upper extremities is remanded. Entitlement to service connection for a bilateral neurological disability of the lower extremities is remanded. Entitlement to service connection for a prostate disability is remanded. Entitlement to service connection for left ear hearing loss is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had right ear hearing loss at any time during or approximate to the pendency of the claim 2. The preponderance of the evidence of record is against finding that the Veteran has had a disability manifested by multiple joint arthritis at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for service connection for right ear hearing loss are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a disability manifested by multiple joint arthritis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1981 to December 1982. During his period of service, he earned the Army Service Ribbon and Expert Badge with Rifle Bar (M-16). This case was previously before the Board in September 2018, at which time the Board, in part, remanded the issues of entitlement to service connection for a headache disability, sleep disability, cardiac disability, prostate disability, disability manifested by multiple joint arthritis, cervical spine disability, lumbar spine disability, bilateral shoulder disability, bilateral hip disability, bilateral knee disability, bilateral ankle disability, bilateral foot disability, diabetes mellitus, bilateral neurological disability of the upper extremities, bilateral neurological disability of the lower extremities, and bilateral hearing loss, as well as entitlement to a total disability rating based on individual unemployability (TDIU) for further development. Subsequently, by a May 2021 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for obstructive sleep apnea. By a June 2021 rating decision, the AOJ granted service connection for migraine headaches. Lastly, by an August 2021 rating decision, the AOJ granted TDIU, effective from February 14, 2014; thus, these issues are no longer for appellate consideration. Service Connection In order to prevail on a claim of service connection, generally, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the Court held that the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. However, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a Veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. 1. Entitlement to service connection for right ear hearing loss Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels) over a range of frequencies (in Hertz), and the threshold for normal hearing is from 0 to 20 dB. Higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 156 (1993). 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, 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 (2020). A review of the medical evidence of record does not show the Veteran has a current hearing loss disability for VA purposes in the right ear. At the November 2015, January 2016, and June 2018 VA examinations, audiometric testing results did not show an auditory threshold of 40 dB or higher at any of the above-referenced frequencies or auditory thresholds of 26 dB or greater for at least three of the above-referenced frequencies in the right ear. Additionally, the reported Maryland CNC Test scores of 100 percent do not meet the VA definition of a hearing loss disability for the right ear. There are no private or VA audiograms showing hearing loss for VA purposes and the Veteran has not provided any evidence or asserted that his hearing loss has worsened since the most recent VA examination. While there are subjective complaints of hearing loss, the Board finds that the evidence does not support a finding that the Veteran has or had right ear hearing loss for VA purposes throughout the appeals period. See Brammer, supra; McClain, supra; Romanowsky, supra. Without such evidence, service connection for right ear hearing loss cannot be granted. See Shedden, supra. Although laypersons, such as the Veteran, are sometimes competent to provide opinions on certain medical questions, the specific issue in this case falls outside the realm of common knowledge of a lay person as it involves making definitive clinical diagnoses based on knowledge of audiology and how to perform and interpret audiometric testing. See Kahana, supra. While the Veteran is certainly competent to report his symptoms, he is not competent to attribute those complaints to a particular diagnosis or any diagnosis at all. See Jandreau v. Nicholson, 492 F.3s 1372, 1377 n.4 (Fed. Cir. 2007); see also 38 C.F.R. § 3.159 (a)(1). He is not competent to diagnose himself with hearing loss for VA purposes. Further, his opinion would be significantly outweighed by the lack of diagnosis from the VA audiologist, who hold the level of medical expertise to address the nature and etiology of the Veteran's complaints and performed audiometric testing. Accordingly, the Board finds that the claim of entitlement to service connection for right ear hearing loss must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to service connection, that doctrine is not applicable. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2020); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). 2. Entitlement to service connection for a disability manifested by multiple joint arthritis The Veteran asserts that he has a disability manifested by multiple joint arthritis, which he has attributed to his military service. A review of the medical evidence of record fails to establish that the Veteran has been diagnosed with a disability manifested by multiple joint arthritis at any time during the appeal period or proximate thereto. The Veteran appeared for a VA non-degenerative arthritis examination in January 2021. The VA examiner indicated that the Veteran did not have a current diagnosis associated with any disability manifested by multiple joint arthritis. Accordingly, although the medical evidence of record document multiple degenerative arthritis, the Board finds that the evidence does not support a finding that the Veteran has a current diagnosis of non-degenerative arthritis throughout the appeals period. See Brammer, supra; McClain, supra; Romanowsky, supra. Without such evidence, service connection for r a disability manifested by multiple joint arthritis cannot be granted. See Shedden, supra. Accordingly, the first element of Shedden is not met. Although the Board is sympathetic to the Veteran's claim, the preponderance of the evidence is against the Veteran's claim of service connection for a disability manifested by multiple joint arthritis. Accordingly, the claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to service connection, that doctrine is not applicable. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2020); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). REASONS FOR REMAND 1. Entitlement to service connection for a cervical spine disability 2. Entitlement to service connection for a lumbar spine disability 3. Entitlement to service connection for a bilateral shoulder disability 4. Entitlement to service connection for a bilateral hip disability 5. Entitlement to service connection for a bilateral knee disability The Veteran contends that his claimed cervical spine, lumbar spine, bilateral shoulder, bilateral hip, and bilateral knee disabilities are related to service, specifically as due to an in-service fall in Panama. Pursuant to the September 2018 Board remand, the Veteran appeared for VA neck conditions, back conditions, shoulder and arm conditions, and knee and lower leg conditions examinations in January 2021. The examiner opined that it was less likely than not that the Veteran's claimed cervical spine, lumbar spine, bilateral shoulder, and bilateral knee disabilities were incurred in or caused by service, as the service treatment records do not contain complaints, treatment, or diagnosis for these conditions. Moreover, the examiner explained that there was no evidence the Veteran's disabilities developed to a compensable degree within the specified time period after release from service to qualify for the presumption of service connection. The Veteran also appeared for a VA hip and thigh conditions examination in July 2021. The examiner opined that the Veteran's claimed bilateral hip disability was not incurred in or caused by service, as the service treatment records are silent regarding any diagnosis or symptoms of bilateral hip degenerative osteoarthritis during active service. Moreover, the examiner explained that there was no evidence of any manifestation or diagnosis of bilateral hip degenerative osteoarthritis within one year after the Veteran's separation from active service. Unfortunately, the Board finds the January 2021 and July 2021 VA opinions to be inadequate for adjudication purposes, as the examiners failed to consider the Veteran's lay contentions regarding sustaining injuries from a fall during service and continued cervical spine, lumbar spine, bilateral shoulder, bilateral hip, and bilateral knee symptomatology since separation. The examiners also failed to consider the Veteran's assertions that he was diagnosed with arthritis within three months of separation from service. See Correspondence, dated May 1, 2017. The Boards notes that a formal finding regarding the unavailability of the Veteran's complete service treatment records was made in January 2016, as the Veteran's service treatment records for his 1981 period of service were sparse or illegible. As all efforts to obtain the needed information had been exhausted, VA determined that further attempts to obtain the records would be unsuccessful. When service records are unavailable through no fault of a veteran, VA has a heightened duty to assist, as well as an obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). Accordingly, on remand, an addendum opinion should be obtained considering the full history regarding any in-service events, injuries, or treatment. 6. Entitlement to service connection for a bilateral ankle disability 7. Entitlement to service connection for a bilateral foot disability The Veteran contends that his claimed bilateral ankle and bilateral foot disabilities are related to service. Pursuant to the September 2018 Board remand, the Veteran appeared for VA ankle conditions and foot conditions examinations in January 2021. The examiner indicated that the Veteran does not have a current diagnosis associated with any of the claimed conditions. As to the Veteran's claimed bilateral ankle disability, the examiner noted that arthritis of the ankles was noted in the record; however, no substantial objective evidence to support this diagnosis was available until January 2021, at which time small spurs were identified in the calcaneal bone bilaterally. Moreover, the examiner noted that there was no substantial objective physical finding to support significant impact over functionality due exclusively to an ankle impairment. As to the Veteran's claimed bilateral foot disability, the examiner noted that the reviewed medical evidence of record did not provide substantial objective data to support a medically determinable impairment based in structural damages or physiological alteration of the feet, despite a January 2021 X-ray that revealed a small calcaneal spur in both feet. Moreover, physical examination revealed normal sensory response to pinprick and filament testing, normal ankle joints and pulses, good mirror movements, and no deformity in the feet. Unfortunately, the Board finds that additional VA opinions are warranted. Of note, the VA examiner cited a prior diagnosis of arthritis of the ankles in the medical evidence of record; however, the examiner determined that there was no substantial objective evidence to support this diagnosis. As such, a clarification of the Veteran's current diagnosis is warranted. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Further, the examiner failed to consider the medical evidence of record that notes degenerative joint disease of the feet, right foot bursitis, foot pain, blisters, and plantar fasciitis. See Medical Treatment Records Furnished by SSA, received October 13, 2015, pp. 7, 11, 24; see also Medical Treatment Record, received August 12, 2015, p. 5. The Board acknowledges that once VA undertakes the effort to provide an examination when developing a service connection claim, an adequate examination must be provided. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, a remand is required to obtain addendum opinions. 8. Entitlement to service connection for a cardiac disability, to include heart palpitations 9. Entitlement to service connection for diabetes mellitus The Veteran contends that his claimed cardiac disability, to include heart palpitations, and diabetes mellitus are related to service. Pursuant to the September 2018 Board remand, the Veteran appeared for VA heart conditions and diabetes mellitus examinations in January 2021. The examiner indicated that the Veteran does not have a current diagnosis of heart condition nor diabetes mellitus. As to the Veteran's claimed heart disability, the examiner noted the Veteran had a history of chest pain, shortness of breath, accelerated beats, and palpitations; however, there was no official diagnosis of record. As to the Veteran's claimed diabetes mellitus, the examiner noted there was a longstanding mention of diabetes mellitus, type II. Further, the Veteran reported a diagnosis of diabetes mellitus, type II since 1982. However, the examiner indicated that there is no official diagnosis of diabetes mellitus, type II documented with fasting plasma glucose (FPG) of 126 mg/dl or A1C of 6.5 percent or greater for 2 or more occasions in the medical evidence of record. Unfortunately, the Board finds that additional VA opinions are warranted. Of note, the VA examiner cited a history of palpitations in the medical evidence of record; however, the examiner determined that there was no substantial objective evidence to support a specific cardiac diagnosis. However, the examiner failed to consider the medical evidence of record that notes hypertensive cardiovascular disease. See Medical Treatment Record Non-Government Facility, received August 12, 2015, p. 4. As such, a clarification of the Veteran's current diagnosis is warranted. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Further, the examiner failed to consider the medical evidence of record that notes A1C of 6.5 percent in February 2013. See VA Examination, received May 16, 2014. The Board acknowledges that once VA undertakes the effort to provide an examination when developing a service connection claim, an adequate examination must be provided. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, a remand is required to obtain addendum opinions. 10. Entitlement to service connection for a bilateral neurological disability of the upper extremities 11. Entitlement to service connection for a bilateral neurological disability of the lower extremities 12. Entitlement to service connection for a prostate disability As there is some indication that the Veteran's claimed prostate disability and bilateral neurological disability of the upper and lower extremities may be related the diabetes mellitus claim remanded herein, the Board finds these claims are inextricably intertwined. Therefore, the Board finds that remanding the claims of entitlement to service connection for a prostate disability and bilateral neurological disability of the upper and lower extremities for contemporaneous consideration is also warranted. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that claims are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). 13. Entitlement to service connection for left ear hearing loss The Veteran appeared for a VA hearing loss examination in November 2015. The examiner noted that there were no complaints or diagnosis of hearing loss nor audiological treatment or care while in active service, or within one year after separation from service found in the medical evidence record. The examiner further noted that actual hearing loss could be the result of a natural aging process, hereditary factors, post-service noise exposure, or a combination thereof. The Veteran next appeared for a VA hearing loss examination in January 2016. The examiner opined that it was less likely as not that the Veteran's left ear hearing loss was related to the noise exposure while in service. The examiner noted that the Veteran's enlistment and separation audiograms showed hearing within normal limits at 500 through 4000Hz. The examiner further noted that there were no complaints or diagnosis of hearing loss while in active service, or within one year after separation from service. There was also no evidence of audiological treatment or care found in the medical evidence until February 2013. The examiner explained that it is well known that prolonged exposure to noise of high intensity and short duration, such as the military type, could cause permanent damage in the structures of the inner ear resulting in irreversible hearing loss with the hearing deficit either appearing immediately after a noise trauma or gradually during the noise exposure period. However, no retroactive hearing loss is expected to be seen many years after being exposed to noise. Conversely, the examiner explained that hearing loss might also be associated to the effects of the normal aging process due to progressive outer hair cell dysfunction. Unfortunately, the Board finds the November 2015 and January 2016 VA examinations to be inadequate for adjudication purposes. The examiners appear to base the negative opinion on an absence of hearing loss findings at entrance and upon separation from service. The Board notes that service connection for hearing loss is not precluded where hearing was within normal limits on audiometric testing at separation from service. See Hensley v. Brown, 5 Vet. App. 155, 160 (1993). Moreover, the examiners failed to provide sufficient rationale for the finding that the Veteran's hearing loss was related to the natural aging process, hereditary factors, post-service noise exposure, or a combination thereof. Further, the examiner failed to sufficiently address whether the threshold shifts documented on the separation audiogram were significant. See September 1980 enlistment and October 1982 separation examinations. In light of the foregoing deficiencies, the Board finds that a remand is necessary to obtain an addendum opinion as to the nature and etiology of his left ear hearing loss. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: Obtain addendum medical opinions from an appropriate medical practitioner(s) to determine the nature and etiology of his cervical spine disability, lumbar spine disability, bilateral shoulder disability, bilateral hip disability, bilateral knee disability, bilateral ankle disability, bilateral foot disability, diabetes mellitus, cardiac disability, bilateral neurological disability of the upper extremities, bilateral neurological disability of the lower extremities, prostate disability, and left ear hearing loss. The practitioner(s) must review pertinent documents in the Veteran's claims file. All tests and studies deemed necessary by the practitioner(s) should be performed. Whether additional physical examination of the Veteran is necessary is left to the discretion of the practitioner(s). If a practitioner(s) determine additional examinations are necessary the relevant examination must be scheduled. (a.) With regard to the cervical spine condition claim, the practitioner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) the Veteran's claimed neck condition (i) had its onset in service; (ii) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); or (iii) is otherwise etiologically related to active service. The practitioner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. If the practitioner rejects the Veteran's reports, the practitioner must provide a reason for doing so. (b.) With regard to the lumbar spine condition claim, the practitioner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) the Veteran's claimed back condition (i) had its onset in service; (ii) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); or (iii) is otherwise etiologically related to active service. The practitioner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. If the practitioner rejects the Veteran's reports, the practitioner must provide a reason for doing so. (c.) With regard to the bilateral shoulder condition claim, the practitioner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) the Veteran's claimed bilateral shoulder condition (i) had its onset in service; (ii) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); or (iii) is otherwise etiologically related to active service. The practitioner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. If the practitioner rejects the Veteran's reports, the practitioner must provide a reason for doing so. (d.) With regard to the bilateral hip condition claim, the practitioner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) the Veteran's claimed bilateral hip condition (i) had its onset in service; (ii) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); or (iii) is otherwise etiologically related to active service. The practitioner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. If the practitioner rejects the Veteran's reports, the examiner must provide a reason for doing so. (e.) With regard to the bilateral knee condition claim, the practitioner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) the Veteran's claimed bilateral knee condition (i) had its onset in service; (ii) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); or (iii) is otherwise etiologically related to active service. The practitioner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. If the practitioner rejects the Veteran's reports, the examiner must provide a reason for doing so. (f.) With regard to the bilateral ankle condition claim, the practitioner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) the Veteran's claimed bilateral ankle condition (i) had its onset in service; (ii) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); or (iii) is otherwise etiologically related to active service. In providing the opinion, the practitioner must specifically address, and attempt to reconcile, the previous diagnosis of degenerative joint disease of the ankles by Dr. C. E. M. Q. See Medical Treatment Record, received August 12, 2015, p. 5. (g.) With regard to the bilateral foot condition claim, the practitioner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) the Veteran's claimed bilateral foot condition (i) had its onset in service; (ii) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); or (iii) is otherwise etiologically related to active service. In providing the opinion, the practitioner must specifically address, and attempt to reconcile, the previous diagnosis of degenerative joint disease of the feet by Dr. C. E. M. Q. See Medical Treatment Record, received August 12, 2015, p. 5. The practitioner must also specifically address, and attempt to reconcile, the previous diagnoses of right foot bursitis, foot pain, blisters, and plantar fasciitis. See Medical Treatment Records Furnished by SSA, received October 13, 2015, pp. 7, 11, 24 (h.) With regard to cardiac condition claim, the practitioner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) the Veteran's claimed cardiac disability, to include heart palpitations, had its onset in service or is otherwise etiologically related to active service. In providing the opinion, the practitioner must specifically address, and attempt to reconcile, the previous diagnosis of hypertensive cardiovascular disease. See Medical Treatment Record Non-Government Facility, received August 12, 2015, p. 4. The practitioner should also clarify whether heart palpitations are a symptom or a diagnosis or a cardiac disability. (i.) With regard to diabetes mellitus claim, the practitioner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) the Veteran's claimed diabetes mellitus had its onset in service or is otherwise etiologically related to active service. In providing the opinion, the practitioner must specifically address, and attempt to reconcile, the previous diagnosis of diabetes mellitus. See Medical Treatment Record Non-Government Facility, received August 12, 2015, p. 4. a. If the practitioner renders a positive opinion regarding the claim for diabetes mellitus, then the practitioner should opine whether the Veteran's claimed prostate condition, bilateral neurological disability of the upper extremities, and bilateral neurological disability of the lower extremities are at least as likely as not proximately due to or aggravated by his diabetes mellitus (if service connected). (j.) With regard to left ear hearing loss claim, the practitioner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) the Veteran's claimed diabetes mellitus had its onset in service or is otherwise etiologically related to active service. In rendering the opinion, the practitioner must address the thresholds shifts documented on the separation in comparison to the Veteran's entrance audiogram. (Continued on the next page) The practitioner is advised that 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). Rationale for all requested opinions shall be provided. If the practitioner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the practitioner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tracy O. Joseph, 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.