Citation Nr: 21076916 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 16-45 138 DATE: December 28, 2021 REMANDED Entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for vitiligo, to include as secondary to PTSD is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1967 to May 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal from January 2016 and November 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to an evaluation in excess of 30 percent for PTSD is remanded. The Veteran was last afforded a VA PTSD examination in January 2016. The examiner identified his symptoms as including anxiety, chronic sleep impairment, and difficulty establishing and maintaining effective work and social relationships. The Veteran reported sleep disruption, hypervigilance and irritability. In September 2019, the Veteran submitted a sworn affidavit regarding the effects of his PTSD. He reported experiencing panic attacks; extreme difficulty concentrating; memory impairment such as forgetting the names of significant acquaintances; extreme anger outbursts resulting in social isolation and being fired from a job; avoidance of contact with others; and extreme hypervigilance. While the mere passage of time is not grounds for a new examination, a new examination is appropriate when there is an assertion (and indication) of an increase in severity since the last examination. See 38 C.F.R. § 3.159; see also Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). As the aforementioned suggests that the Veteran's condition has worsened significantly during the appeal period, a remand is necessary to adequately evaluate the current severity of the Veteran's PTSD. Caffrey v. Brown, 6 Vet. App. 377, 381 (1995) (VA must provide a new examination where a veteran claims the disability is worse than when originally rated and the available evidence is too old to adequately evaluate the current severity). Therefore, a new VA examination is needed to assist in determining the current severity of the Veteran's service-connected PTSD. Snuffer, 10 Vet. App. at 400. 2. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran was afforded a VA hearing loss examination in January 2016. The examiner provided a negative etiological opinion regarding the association between hearing loss and service. It was reasoned that review of entrance and exit examinations showed normal hearing with no significant changes greater than normal measurement variability. The Board finds this rationale to be inadequate for adjudication purposes. The absence of in-service evidence of hearing loss is not fatal to a claim for service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability (i.e., one meeting the requirements of 38 C.F.R. § 3.385, as noted above) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. Hensley v. Brown, 5 Vet. App. at 159. Moreover, to establish service connection for sensorineural hearing loss, a veteran is not obligated to show that his hearing loss was present during active service. However, if there is insufficient evidence to establish that a claimed chronic disability was present during service or during the one-year presumptive period thereafter, the evidence must establish a nexus between his current disability and his in-service exposure to loud noise. Godfrey v. Derwinski, 2 Vet. App. 352 (1992). Therefore, the Board finds that further remand is necessary for a VA addendum opinion. 3. Entitlement to service connection for tinnitus is remanded. The Veteran was afforded a VA tinnitus examination in January 2016. The examiner opined that the Veteran's tinnitus is at least as likely as not related to his hearing loss disability. Thus, service connection for tinnitus is remanded as inextricably intertwined with the Veteran's service connection claim for bilateral hearing loss, remanded herein. 4. Entitlement to service connection for vitiligo, to include as secondary to PTSD is remanded. The Veteran was afforded a VA skin diseases examination in January 2018. It was opined that the Veteran's vitiligo is less likely than not related to service-connected PTSD. The examiner reasoned that there is no causal relationship between PTSD and vitiligo, and no evidence to suggest the theory that mental health issues cause or contribute to the causing of or aggravation of vitiligo. The examiner also noted that there is mental distress stemming from the appearance of vitiligo, but that medical literature does not support a causal association between PTSD and vitiligo. Nonetheless, the Veteran submitted medical literature in April 2018, suggestive of an associative relationship between PTSD and neurodegeneration and oxidative stress which the examiner acknowledges is best supported by research data as causative of vitiligo. He further stated that none of the proposed series are themselves sufficient to explain the diverse vitiligo phenotypes. The Board finds the January 2018 VA examiner's opinion to be internally inconsistent, and as such, insufficient for adjudication purposes. Additionally, the Board notes that the VA examination only addresses secondary service connection for vitiligo. The Veteran did not exclusively claim his vitiligo as secondary to PTSD, and in fact, his representative also argues that vitiligo is a result of Agent Orange exposure in service. Therefore, the Board finds this matter must be remanded for an adequate and complete VA etiological opinion. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all outstanding VA and private treatment records with regard to the Veteran's claimed disabilities. 2. Thereafter, schedule the Veteran for a VA psychiatric examination to determine the severity of his PTSD. The claims file, including a copy of this remand, must be made available to the examiner for review in connection with the examination. All necessary tests and studies, including appropriate psychological studies (if determined to be necessary by the examiner), should be conducted in order to identify the degree of social and occupational impairment attributable to PTSD. The results of any such testing and studies should be included in the examination report. The examiner should provide a detailed account of all manifestations of the service-connected PTSD found to be present. Additionally, the examiner should discuss all occupational impact attributable to PTSD. 3. Forward the claims file to a VA clinician to obtain an addendum opinion regarding the etiology of the Veteran's bilateral hearing loss. If an examination is deemed necessary to respond to the question presented, one should be scheduled. Following a review of the claims file, including a copy of this remand, the examiner is asked to address the question of whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's current hearing loss was is related to an in-service injury, event, or disease. The Board notes that the absence of a hearing loss diagnosis in service is not fatal to a service connection claim, and is insufficient as a rationale. The examiner must be advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and chronic nature of his symptoms, must be considered, along with the other evidence of record, in formulating the requested opinions. The Veteran's statements may not be discounted solely on the basis of the lack of confirmation in the medical records. A complete rationale must be provided for all opinions. If the examiner is unable to provide an opinion without resorting to speculation, an explanation as to why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered should be provided. 4. Forward the claims file to a VA clinician to obtain an addendum opinion regarding the etiology of the Veteran's vitiligo. If an examination is deemed necessary to respond to the question presented, one should be scheduled. Following a review of the claims file, including a copy of this remand, the examiner is asked to address the question of a. Whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's vitiligo is related to an in-service injury, event, or disease, to include exposure to an herbicide agent. b. Whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's vitiligo was caused OR aggravated by the Veteran's PTSD, to include the reported symptomatology. The examiner is advised that the term "aggravation" is defined for legal purposes as a chronic worsening of the underlying condition beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of disability (i.e., a baseline) before the onset of the aggravation. The Board notes that the absence of a vitiligo diagnosis in service is not fatal to a service connection claim, and is insufficient as a rationale. The examiner must address the causal relation, if any, based on available medical knowledge and treatise evidence, between PTSD, oxidative stress and vitiligo. The examiner must do the same in addressing the causal relation, if any, between Agent Orange exposure and vitiligo. The examiner must be advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and chronic nature of his symptoms, must be considered, along with the other evidence of record, in formulating the requested opinions. The Veteran's statements may not be discounted solely on the basis of the lack of confirmation in the medical records. A complete rationale must be provided for all opinions. If the examiner is unable to provide an opinion without resorting to speculation, an explanation as to why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered should be provided. A. J. Spector Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Comninos, Georgio 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.