Citation Nr: 21005292 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 20-17 929 DATE: February 1, 2021 ORDER Entitlement to service connection for prostate cancer is denied. Entitlement to service connection for a heart disability is denied. Entitlement to service connection for hypertension is denied. REMANDED Entitlement to service connection for thyroid cancer is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. FINDINGS OF FACT 1. The Veteran’s exposure to Agent Orange during service has not been demonstrated. 2. Prostate cancer was not shown in service, did not manifest to a compensable degree within one year of service separation, and is not otherwise related to service. 3. A heart disability was not shown in service, did not manifest to a compensable degree within one year of service separation, and is not otherwise related to service. 4. Hypertension was not shown in service, did not manifest to a compensable degree within one year of service separation, and is not otherwise related to service. CONCLUSIONS OF LAW 1. Prostate cancer was not incurred in service, nor may it be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131, 5103, 5103(A) (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2020). 2. A heart disability was not incurred in service, nor may it be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131, 5103, 5103(A) (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2020). 3. Hypertension was not incurred in service, nor may it be presumed to have been incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131, 5103, 5103(A) (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1962 to September 1965. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a July 2017 rating decisions from a Department of Veterans Affairs Regional Office (RO). In November 2020, the Veteran testified at a virtual hearing in front of the undersigned Veteran’s Law Judge. A transcript of the hearing has been associated with the electronic claim file. Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include prostate cancer, a heart disability and hypertension may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2020). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as prostate cancer, a heart disability and hypertension is through a demonstration of continuity of symptomatology. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). If a veteran was exposed to a herbicide agent (to include Agent Orange) during active military, naval or air service and has contracted an enumerated disease to a degree of 10 percent or more at any time after service (except for chloracne and acute and subacute peripheral neuropathy which must be manifested within a year of the last exposure to an herbicide agent during service), the veteran is entitled to a presumption of service connection even though there is no record of such disease during service. 38 U.S.C. § 1116; 38 C.F.R. § 3.307, 3.309(e). The enumerated diseases are AL amyloidosis; chloracne or other acneform diseases; Type II diabetes; Non-Hodgkin’s lymphoma; Hodgkin’s disease; chronic lymphocytic leukemia; multiple myeloma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; respiratory cancers; prostate cancer; and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma). The term “soft-tissue sarcoma” includes adult fibrosarcoma, dermatofibrosarcoma protuberans, malignant fibrous histiocytoma, liposarcoma; leiomyosarcoma; epithelioid leiomyosarcoma (malignant leiomyoblastoma); rhabdomyosarcoma; ectomesenchymoma; angiosarcoma (hemangiosarcoma and lymphangiosarcoma); proliferating (systemic) angioendotheliomatosis; malignant glomus tumor; malignant hemangiopericytoma; synovial sarcoma (malignant synovioma); malignant giant cell tumor of tendon sheath; malignant schwannoma, including malignant schwannoma with rhabdomyoblastic differentiation (malignant Triton tumor), glandular and epithelioid malignant schwannomas; malignant mesenchymoma; malignant granular cell tumor; alveolar soft part sarcoma; epithelioid sarcoma; clear cell sarcoma of tendons and aponeuroses; extraskeletal Ewing’s sarcoma; congenital and infantile fibrosarcoma; malignant ganglioneuroma; and amyotrophic lateral sclerosis (ALS). 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a) (6) (iii), 3.309(e), 3.313, 3.318. As noted above, the law provides that for claims based on the chronic effects of exposure to Agent Orange, presumptive service connection may be established for certain diseases, including prostate cancer and ischemic heart disease, as specified above. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). Regarding presumptive service connection for diseases associated with exposure to herbicide agents, it is warranted if a disease listed under § 3.309(e), with the exception of chloracne or other acneform disease, becomes manifest to a degree of 10 percent at any time after service. As opposed to the requirements for direct service connection, the disease need not manifest within the appellate period. Factual Background and Analysis When considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for prostate cancer, a heart disability and hypertension, to include as secondary to herbicide exposure is not warranted. The service treatment records are negative for complaints or treatments related to a prostate, heart or hypertension disabilities. The Veteran contends that the current disorders on appeal were caused by his in-service exposure to herbicide agents while stationed at the Clark Air Force Base (AFB) in the Philippines. The Veteran specifically contends that he was cross contaminated as he treated patients who had served in Vietnam. However, the Board finds that despite the Veteran’s contentions, he was not actually exposed to herbicides during service and accordingly does not warrant the presumption of service connection based on herbicide exposure. As noted above, the Veteran served on active duty from January 1962 to September 1965 and service personnel records do not show and the Veteran does not contend, that he was stationed in Vietnam as again, the Veteran contends that he was exposed to Agent Orange via the patients who has served in Vietnam who he transported while he was at Clark AFB in the Philippines. Notably, the Department of Defense (DoD) has not identified any location on the Philippine Islands, including Clark AFB, where Agent Orange was used, tested, stored, or transported. Agent Orange was developed for jungle combat operations in Vietnam and was used there from 1962 to early 1971. There were no combat operations on the Philippine Islands during those years and so there was no need for Agent Orange use there. Additionally, the Philippines were not on the Agent Orange shipping supply line, which went directly from storage at Gulfport, Mississippi to South Vietnam via merchant ships. Additionally, in a July 2018 Memorandum, the VA’s Joint Services Record Research Center (JSRRC) Coordinator documented the AOJ’s efforts and made a formal finding that exposure to herbicides could not be conceded. The Memorandum noted that the Veteran contended that he was exposed to herbicides via cross contamination while working as a medic in the Philippines where he treated wounded service members who had arrived from Vietnam. The Memorandum concluded that the Veteran was not in Vietnam and there was no credible scientific evidence to support a cross contamination scenario based on his treating patients who had been stationed in Vietnam. The above findings from the July 2018 Memorandum outweigh the Veteran’s assertions that he was exposed to Agent Orange or herbicide agents during service. The Board notes that while personnel records indicate that the Veteran served at Clark AFB, there is no evidence that Clark AFB was in the Agent Orange shipping line during the period of time that the Veteran was stationed there. While the Veteran reports being cross contaminated with Agent Orange via transporting patients who had served in Vietnam, there is no objective evidence establishing the Veteran’s contention that he was exposed to Agent Orange as the Veteran has presented no scientific evidence that such proximity can result in long-term health effects, or even be considered exposure to active Agent Orange. The Veteran has not indicated that he possesses any specialized knowledge in the scientific field such that he could determine without testing that he was exposed to herbicides. In Bardwell v. Shinseki, 24 Vet. App. 36 (2010), the Court held that a layperson’s assertions indicating exposure to gases or chemicals during service are not sufficient evidence alone to establish that such an event actually occurred during service. Rather, those statements must be weighed against other evidence of record, including lack of documentary evidence of the incident. In these circumstances, the Board finds that the above evidence weighs against his assertions of exposure to Agent Orange, and the preponderance of the evidence weighs against herbicide agent (Agent Orange) exposure during service. As a result, the Board finds that despite the Veteran’s contentions, he was not actually exposed to herbicides during service and accordingly does not warrant the presumption of service connection based on herbicide exposure. Having considered the Veteran’s contentions and statements, and after a review of all the evidence of record, the Board finds that the weight of the evidence demonstrates that the Veteran did not have “service in the Republic of Vietnam,” was not presumptively exposed to herbicides during active service, and was not actually exposed to herbicides during service to warrant the presumption of service connection. See 38 C.F.R. § 3.307(a) (6) (iii). Prostate Cancer and Ischemic Heart Disease As noted above, while the Veteran served in the Vietnam era, the Board finds that he was not deployed to Vietnam, did not set foot in Vietnam and was not otherwise exposed to herbicides during his service. Accordingly, while prostate cancer and ischemic heart disease are diseases that would warrant a regulatory presumption of service connection for as a result of in-service herbicide exposure, this is not applicable to the Veteran’s claims. Accordingly, service connection is not warranted on a presumptive basis. Instead, his claims must be reviewed to determine if service connection can be established on a direct basis. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) (holding that the Veterans’ Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2724, 2727-29 (1984), does not preclude a Veteran from establishing service connection with proof of actual direct causation). At the outset, the Board notes that neither prostate cancer nor coronary artery disease were diagnosed within a year of the Veteran’s discharge from service in September 1965. Accordingly, service connection on a presumptive basis may not be granted as the diseases were not shown in service or within one year of discharge therefrom. See 38 C.F.R. §§ 3.307, 3.309. To any extent that the Veteran is asserting that he experienced continuing symptoms of prostate cancer and ischemic heart disease thereafter, the Board acknowledges that a layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board’s categorical statement that “a valid medical opinion” was required to establish nexus, and that a layperson was “not competent” to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, as the Veteran was not diagnosed with a prostate cancer or ischemic heart disease disability until many years after service and there was a significant period between his service and his post-service complaints where the medical record was silent for complaints of a prostate cancer or ischemic heart disease disability, the Board concludes that the weight of the evidence is against a finding of any continuity of symptomatology. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Regarding service connection on a direct basis, the Board finds that the weight of the evidence is against a finding that the Veteran’s current prostate cancer or ischemic heart disease is etiologically related to the Veteran’s military service. Notably, the Veteran’s service treatment records are negative for treatments, complaints or diagnoses related to a prostate cancer or ischemic heart disease disability. Further, there is no competent evidence or opinion otherwise suggesting that there exists a nexus between a current prostate cancer and ischemic heart disease disability and the Veteran’s service on a direct basis, and neither the Veteran nor his representative have presented or identified any such existing medical evidence or opinion. Consequently, entitlement to service connection for a prostate cancer and ischemic heart disease disability is also not warranted on a direct basis. The Board finds that the competent evidence of record, while showing the currently diagnosed disabilities of prostate cancer and ischemic heart disease, does not demonstrate diabetes mellitus or ischemic heart disease manifested to a compensable degree within one year of separation. Additionally, there is no competent evidence that a prostate cancer or ischemic heart disease disability is related to the Veteran’s service to include as secondary to herbicide exposure. In sum, the Board finds that service connection for prostate cancer and ischemic heart disease disabilities 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 claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Hypertension Notably, for hypertension, regulations provide that hypertension for VA purposes means that the diastolic blood pressure is predominantly 90 or more or systolic blood pressure is predominantly 160 or more. Hypertension must be confirmed by readings taken two or more times on three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). The Veteran is seeking service connection for his hypertension. He contends that his hypertension is due to herbicide exposure. Notably, the available scientific and medical evidence does not support the conclusion that hypertension is associated with herbicide exposure, as hypertension is not listed in the enumerated presumptive diseases for Agent Orange. Regardless, as determined above, the Veteran has not been shown to have been exposed to Agent Orange during his service. The Veteran’s service treatment records are negative for treatments or complaints of hypertension or high blood pressure. Notably, the Veteran’s July 1965 separation examination demonstrated a blood pressure reading of 110/76. When considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for hypertension is not warranted. As there is a current hypertension disability, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D’Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). As noted above, service connection may be granted on a presumptive basis for certain chronic diseases, including hypertension, if such disabilities are shown to be manifest to a degree of 10 percent or more within one year following the Veteran’s separation from active military service. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this instance however, service connection for hypertension on a presumptive basis is not warranted as the record does not show evidence of hypertension within one year of the Veteran’s separation from active duty. To the extent that the Veteran is asserting that he experienced continuing symptoms of hypertension thereafter, the Board acknowledges that a layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board’s categorical statement that “a valid medical opinion” was required to establish nexus, and that a layperson was “not competent” to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). However, as the Veteran was not diagnosed with hypertension until many years after service and there was a significant period between his service and his post-service complaints where the medical record was silent for complaints of hypertension, the Board concludes that the weight of the evidence is against a finding of any continuity of symptomatology. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Regarding service connection on a direct basis, the Board again notes that the Veteran’s service treatment records are negative for complaints or treatments of hypertension or high blood pressure and his July 1965 separation examination was also negative for hypertension or high blood pressure complaints or treatments. Further, there is no competent evidence or opinion even suggesting that there exists a medical nexus between current hypertension and the Veteran’s service and neither the Veteran nor his representative have presented or identified any such existing medical evidence or opinion. The Board finds that the competent evidence of record, while showing the currently diagnosed hypertension disability, does not demonstrate that the Veteran’s hypertension is related to the Veteran’s service. In sum, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for hypertension. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b). All Disabilities The Board also notes that the Veteran was not provided with VA examinations and opinions to assess the current nature and etiology of his claimed prostate cancer, a heart disability and hypertension disabilities. However, VA need not conduct examinations with respect to the claims on appeal, as information and evidence of record contains sufficient competent medical evidence to decide the claims. See 38 C.F.R. § 3.159(c) (4). Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. Simply stated, the standards of McLendon are not met in this case as there is no credible evidence that the prostate cancer, a heart disability and hypertension disabilities manifested in service or within a year of separation from service and there is also no competent evidence suggesting that these disabilities are otherwise associated to service to include as secondary to herbicide exposure. Thus, remand for a VA examination is not necessary. The Board notes the Veteran and his representative’s contentions regarding the etiology of his claimed prostate cancer, a heart disability and hypertension disabilities. To the extent that the Veteran and his representative themselves contend that a medical relationship exists between his claimed prostate cancer, a heart disability and hypertension disabilities and his service, the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (finding that the Board’s categorical statement that “a valid medical opinion” was required to establish nexus, and that a layperson was “not competent” to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). In the instant case, however, the Board finds that prostate cancer, a heart disability and hypertension are not disabilities subject to lay diagnosis as these diagnoses require medical training. More significantly, the Veteran and his representative do not have the medical expertise to provide an opinion regarding the claimed prostate cancer, a heart disability and hypertension disabilities etiologies. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Thus, the Veteran and his representative’s assertions that there is a relationship between his claimed prostate cancer, a heart disability and hypertension disabilities and his service are not sufficient in this instance and are outweighed by other probative evidence of record. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In sum, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran’s claims of entitlement to service connection for prostate cancer, a heart disability and hypertension disabilities. The benefit-of-the-doubt rule does not apply, and the claims must be denied. 38 U.S.C. § 5107(b). REASONS FOR REMAND The Board finds that more development is necessary prior to final adjudication of the claims remaining on appeal. The Board notes that VA is obligated to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012). The threshold for finding a link between current disability and disease or injury in service is low. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Regarding the Veteran’s claim for service connection for thyroid cancer, the Veteran testified at his December 2020 hearing that while serving at Clark AFB, he was exposed to radiation from x-rays machines as he loaded and unloaded patients from the hospital. At times, he testified, he had to assist in keeping patients still while getting x-rays which exposed him to radiation. Notably, medical records show the Veteran has been diagnosed with thyroid cancer which is a radiogenic disease under 38 C.F.R. § 3.311 (b)(2). The Board also notes that VA regulations provide that diseases specific to radiation-exposed veterans shall be presumed to have been incurred in service. This presumption is rebuttable by affirmative evidence to the contrary. 38 C.F.R. §§ 3.307, 3.309. A “radiation-exposed veteran” is defined by 38 C.F.R. § 3.309 (d)(3) as a veteran who, while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. “Radiation-risk activity” is defined to mean onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima, Japan or Nagasaki, Japan by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; or internment as a prisoner of war (or service on active duty in Japan immediately following such internment) during World War II which resulted in an opportunity for exposure to ionizing radiation comparable to that of the United States occupational forces in Hiroshima or Nagasaki during the period from August 6, 1945 through July 1, 1946. See 38 C.F.R. § 3.309 (b)(i), (ii) (2017). Diseases presumptively service connected for radiation-exposed veterans under the provisions of 38 U.S.C. § 1112 (c) and 38 C.F.R. § 3.309 (d)(2) are: leukemia (other than chronic lymphocytic leukemia), cancer of the thyroid, cancer of the breast, cancer of the pharynx, cancer of the esophagus, cancer of the stomach, cancer of the small intestine, cancer of the pancreas, multiple myeloma, lymphomas (except Hodgkin’s disease), cancer of the bile ducts, cancer of the gall bladder, primary liver cancer (except if cirrhosis or hepatitis B is indicated), cancer of the salivary glands, cancer of the urinary tract; bronchiolo-alveolar carcinoma; cancer of the bone; cancer of the brain; cancer of the colon; cancer of the lung; and cancer of the ovary. See 38 U.S.C. § 1112 (c)(2); 38 C.F.R. § 3.309 (d). If a claimant does not qualify as a “radiation-exposed veteran” under 38 C.F.R. § 3.309 (d)(3) and/or does not suffer from one the presumptive conditions listed in 38 C.F.R. § 3.309 (d)(2), the veteran may still benefit from the special development procedures provided in 38 C.F.R. § 3.311 if the veteran suffers from a radiogenic disease and claims exposure to ionizing radiation in service. Under 38 C.F.R. § 3.311, “radiogenic disease” means a disease that may be induced by ionizing radiation and shall include the following: (i) all forms of leukemia except chronic lymphatic (lymphocytic) leukemia; (ii) thyroid cancer; (iii) breast cancer; (iv) lung cancer; (v) bone cancer; (vi) liver cancer; (vii) skin cancer; (viii) esophageal cancer; (ix) stomach cancer; (x) colon cancer; (xi) pancreatic cancer; (xii) kidney cancer; (xiii) urinary bladder cancer; (xiv) salivary gland cancer; (xv) multiple myeloma; (xvi) posterior subcapsular cataracts; (xvii) non-malignant thyroid nodular disease; (xviii) ovarian cancer; (xix) parathyroid adenoma; (xx) tumors of the brain and central nervous system; (xxi) cancer of the rectum; (xxii) lymphomas other than Hodgkin’s disease; (xxiii) prostate cancer; and (xxiv) any other cancer. 38 C.F.R. § 3.311 (b)(2). Under the special development procedures in § 3.311(a), dose data will be requested from the Department of Defense in claims based upon participation in atmospheric nuclear testing, and claims based upon participation in the American occupation of Hiroshima or Nagasaki, Japan, prior to July 1, 1946. See 38 C.F.R. § 3.311 (a)(2) (2017). In all other claims, 38 C.F.R. § 3.311 (a) requires that a request be made for any available records concerning the veteran’s exposure to radiation. These records normally include but may not be limited to the veteran’s Record of Occupational Exposure to Ionizing Radiation (DD Form 1141), if maintained, service medical records, and other records which may contain information pertaining to the veteran’s radiation dose in service. All such records will be forwarded to the Under Secretary for Health, who will be responsible for preparation of a dose estimate, to the extent feasible, based on available methodologies. See 38 C.F.R. § 3.311 (a)(2)(iii). In this case, as the Veteran suffers from a radiogenic disease and claims exposure to ionizing radiation in service. Thus, a remand is warranted to obtain and forward all records concerning the Veteran’s exposure to radiation to the Under Secretary for Health, for preparation of a dose estimate, to the extent feasible, based on available methodologies. Additionally, the Veteran has not been afforded a VA examination to address the nature and etiology of his thyroid cancer disability, to include as due to radiation exposure and/or directly related to service. An examination or opinion is necessary to make a decision on a claim if the evidence of record contains competent evidence that the claimant has a current disability, and indicates that the disability or symptoms may be associated with the claimant’s active military history, but does not contain sufficient medical evidence to make a decision on the claim. See 38 U.S.C. § 5103A (d) (2); 38 C.F.R. § 3.159(c) (4). Accordingly, the Board finds that he should be scheduled for a VA examination and opinion to determine whether the Veteran has a thyroid cancer disability that is related to service to include as secondary to radiation. Regarding his bilateral hearing loss claim, the Veteran contends that he has current bilateral hearing loss as a result of his in-service noise exposure. The Veteran underwent a VA examination in July 2017. The examiner opined that it was less likely than not that the Veteran’s bilateral hearing loss was caused by or a result of military service. The examiner noted that the Veteran’s separation audiogram indicated normal hearing thresholds after the military related noise exposure. However, while the July 2017 VA examiner opined that it was less likely than not that the Veteran’s bilateral hearing loss disability was caused by or a result of military service, the negative nexus opinion that was provided appears to be based solely on the absence of documented hearing loss disability in the Veteran’s service treatment records. The Board finds that this examination is inadequate and that a remand is necessary for a new examination. The absence of documented hearing loss is service is not fatal to a service connection claim for bilateral hearing loss. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Additionally, in Hensley v. Brown, 5 Vet. App. 159 (1993) the Court stated that VA regulations do not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service. When audiometric test results at a veteran’s separation from service do not meet the regulatory requirements for establishing a “disability” at that time, he or she may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley, 5 Vet. App. at 159-60. The holding in Hensley was that VA may not use audiometric tests from a claimant’s separation examination as a per se legal bar on proving service connection. Regarding the Veteran’s claimed tinnitus disability, the Board notes that the Veteran contends that his tinnitus was the result of his bilateral hearing loss disability. Accordingly, the Board finds that the Veteran’s claim for service connection for tinnitus is inextricably intertwined with his claim for bilateral hearing loss being remanded herein. See Henderson v. West, 12 Vet. App. 11 (1998), citing Harris v. Derwinski, 1 Vet. App. 180 (1991), for the proposition that where a decision on one issue would have a “significant impact” upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the claims are inextricably intertwined. Under these circumstances, the Board finds that specific VA examinations based on consideration of the Veteran’s documented medical history and assertions, and supported by fully stated rationale is needed to resolve the claims of entitlement to service connection for bilateral hearing loss and tinnitus. See 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). The matters are REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disabilities on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 2. Forward the Veteran’s personnel records, service and post-service medical records, and other pertinent documents to the VA Under Secretary for Health for a dose estimate based on his service as a Med Serv Specl in accordance with 38 C.F.R. § 3.311 (a)(2)(iii). Following receipt of such dose estimate, forward the Veteran’s claim to the VA Under Secretary for Benefits for consideration in accordance with 38 C.F.R. § 3.311(c). 3. Schedule the Veteran for an examination with an appropriate clinician to determine the nature and etiology of his thyroid cancer. The claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide an opinion as to the following: (a) Whether it is at least as likely as not (50 percent or greater probability) that any thyroid tumor was caused by radiation exposure. (b). If the examiner concludes that the thyroid cancer is not the result of radiation exposure, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it began during active service or is related to any incident of service. The examiner must provide a complete explanation for his or her opinion(s), based on his or her clinical experience, medical expertise, and established medical principles. 4. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any currently present bilateral hearing loss and tinnitus disabilities. The examiner should furnish an opinion as to: a) Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s current hearing loss disability is related to active service. b) Whether it is at least as likely as not that the Veteran’s current tinnitus disability is related to active service. The examiner is requested to discuss the Veteran’s in-service noise exposure as the Veteran contends that he had in-service noise exposure due to his proximity to the flight line during his service. Notably, the absence of treatment for hearing loss in the Veteran’s service treatment records cannot, standing alone, serve as the basis for a negative opinion. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. However, if the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 5. Thereafter, readjudicate the issues on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then   be returned to the Board for further appellate review, if otherwise in order. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James A. DeFrank, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.