Citation Nr: 21007104 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 16-30 406 DATE: February 8, 2021 ORDER Entitlement to a rating of 70 percent for posttraumatic stress disorder (PTSD) effective is granted. Entitlement to total disability due to individual unemployability (TDIU) effective January 8, 2010 is granted. REMANDED Entitlement to service connection for GERD, to include due to herbicide exposure or secondary to service-connected PTSD is remanded. Entitlement to service connection for bilateral hearing loss is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the severity, frequency, and duration of the Veteran’s symptoms most closely approximate an occupational and social impairment with deficiencies in most areas. 2. The Veteran’s service-connected PTSD renders him unemployable. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 70 percent for PTSD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to TDIU effective as pf January 8, 2010 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from April 1967 to March 1969. In June 2019, the Veteran and a witness testified at a Board hearing. The transcript is of record. In October 2019, the Board remanded the case for further development. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to a rating in excess of 30 percent prior to February 13, 2020 and in excess of 70 percent thereafter for posttraumatic stress disorder The Veteran filed a claim requesting entitlement to service connection for PTSD received January 8, 2010. He received a rating of 30 percent effective the date of claim. A July 2020 rating decision increased the rating to 70 percent effective February 13, 2020, the date of his VA examination for PTSD. The Veteran contends his symptoms are more severe than what is reflected by his ratings. 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). A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). 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. The Veteran attended a VA examination in February 2011 and reported experiencing nightmares and flashbacks since returning from Vietnam and getting moody and irritable. Socially, he reported living at home with his wife and not having many friends as he does not like to talk to people and is suspicious of others. Occupationally, he retired in 2008 and receives Social Security. The examiner noted that the Veteran had poor eye contact, spontaneous speech, and was oriented well to time, place and person. His mood was somewhat anxious, and he had grossly logical, relevant, and goal-oriented thought processes. He denied auditory and visual hallucinations and expressed distrust for people. His judgment, intelligence and insight were fair. He reported continued problems with sleep and frequent nightmares. The Veteran’s daily activities consisted of spending time with his wife, attending church, helping neighbors and doing chores and fishing. The examiner noted that the Veteran’s symptoms are moderate in nature and while they did not affect his job functioning, he did change jobs frequently. In June 2011, the Veteran expressed that he was doing well but having trouble focusing. He had a panic attack on a bus after a casino trip, he described the attack as a feeling of things closing in on him with tingling in his lips and fingers. In September the Veteran described himself as flat, explaining that while he enjoys time with his granddaughter, he does not enjoy day to day life. In January 2012, the Veteran reported low energy and trouble with concentration, which he attributed to the cold weather. In April 2012 the Veteran reported continued trouble with focus, loss of interest and irritability. The mental status examination described him as awake, alert and cooperative with good eye contact. His concentration and attention were within normal limits. His mood was euthymic with a full range of affect and he seemed anxious. He denied suicidal or homicidal ideations. Private medical records contain an evaluation from May 2012. The mood evaluation noted an anxious, tearful, frightened, angry, guarded and sad affect that was also appropriate to the expressed mood. He had indicators of emotional distress consisting of depressed mood, sleep disturbance, isolation, less activity and concentration and anxiety. The Veteran did not display any suicidal or homicidal behaviors, his speech was coherent and his judgment appropriate; however, he displayed paranoid perceptions. The examiner noted an improvement in insight with treatment. The mental status examination described the Veteran as cooperative, well-groomed, alert and awake but with poor eye contact. He had mild difficulty with short-term memory and decision-making ability. Socially, he reported spending time with his family, attending church but tending to be a loner. The examiner concluded that the Veteran has numerous symptoms such as: intrusive recollections, distressing dreams, intense fear, agitation, and a sense of detachment. The examiner opined that his marked anxiety, irritability, and poor concentration resulted in significant distress in social and occupational areas. In August 2012 the Veteran reported an increase in nightmares and anxiety that resulted in a verbal outburst towards his wife and that he wanted to isolate at home. The examiner noted that while he was oriented and friendly during the session, his affect was mostly subdued, and his thoughts were marked by anxiety. The Veteran underwent a mental health assessment in January 2014 and reported interrupted sleep with nightmares. The mental status examination described him as attentive, cooperative and interested but also anxious, agitated, depressed and lethargic. His speech was normal, but his mood was depressed and anxious and his affect congruent. He had normal perception and thought content and his thought processes were goal directed. He did not have hallucinations and was oriented times three and alert. He had good judgment and insight and did not display a cognitive or memory impairment. In March 2014, the Veteran had increased anxiety with disruptive sleep. The Veteran reported continued difficulty with sleep in June, specifically reporting nightmares and waking up about four times every night. In August 2014 the Veteran’s mental status examination described him alert, cooperative, awake with normal grooming and good eye contact. He did not display any formal thought disorders and denied suicidal or homicidal ideation. His concentration and attention were within normal limits. The Veteran reported anxiety in January 2015 along with several suicidal or homicidal ideations and increased nightmares. In March the Veteran had a partial improvement in symptoms, per his report, and denied suicidal or homicidal ideations. In April 2015 the Veteran reported sleeping in two hour shifts with 20 to 30 minutes interruptions three times resulting in about six hours of sleep per night. The Veteran underwent a depression screening in May 2015, which revealed severe symptoms. In June 2015 the Veteran reported that he was not doing bad. His mental status examination revealed good grooming, good eye contact and normal psychomotor activity. His affect was blunted with a mildly dysphoric mood and he had longer more fluid speech. He denied suicidal or homicidal ideations and reported going fishing and riding his motorcycle but not having an improvement in mood. At the October 2015 appointment the Veteran reported doing ok and was described as easy going with a range of facial expressions to include smiling. His affect was animated with a euthymic mood, his speech was normal, and he was described as downright chatty. He expressed no suicidal or homicidal ideations and stated that he had good success in his hunting endeavors. The physician noted an improvement in PTSD symptoms. In November 2015 the Veteran completed a depression screening indicating moderate depression, revealing an increase in symptoms from the prior screening two months earlier. The Veteran was positive, pleasant and cooperative at the appointment but expressed frustrations at his limitations. In March 2017 the Veteran reported a decrease in some symptoms, noting that there are good and bad days but complained of continued nightmares. In July 2017 the Veteran denied suicidal or homicidal ideations. The Veteran attended another private evaluation in October 2017. The examiner concluded that the Veteran has a total social and occupational impairment due to symptoms of depressed mood, anxiety, panic attacks that occur weekly or less, near continuous panic or depression, chronic sleep impairment, mild memory loss and impairment of short and long term memory, disturbances of motivation and mood, difficulty establishing and maintaining relationships, difficulty adapting to stressful circumstances and impaired impulse control. Occupationally, the examiner noted the Veteran last worked in 2008 and had difficulties with figures of authority, supervisors and coworkers. Socially, he reported having few friends, feeling alienated, and had a loss of interest in socializing and fishing. The examiner opined that the Veteran is not a rehabilitation candidate nor is he capable of sustaining substantial, gainful work activity; thus, he is unemployable due to his deficiencies in concentration with bouts of irritability and depression and difficulty interacting with others. At a psychiatric medication management review also in October 2017, the Veteran’s mental status examination described him as well-groomed with good eye contact. The examiner noted that he not only smiled but also laughed at the examiner’s attempt at humor. His affect was appropriate, and mood was essentially euthymic. His speech was normal with not a lot of elaboration, but he did expound a bit more than usual. He denied suicidal or homicidal ideations and inquired about nightmare medication. The Veteran spoke about a recent trip to Tennessee and expressed pride in his granddaughter for shooting a deer with a crossbow. The examiner noted that the Veteran has a tendency to underreport symptoms. In May 2018 the Veteran reported being likely less depressed this past year, noting a good relationship with his family and a supportive wife. However, in August he expressed continued depression with nightmares, resulting in about four hours of sleep at night and anxiousness. In September 2019, he reported getting more sleep and having less nightmares but expressed difficulty with concentration and memory. He denied any current or recent suicidal or homicidal ideations. The Veteran underwent a VA examination in February 2020 and the examiner concluded that the Veteran has an occupational and social impairment with reduced reliability and productivity due to symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, flattened affect, disturbance of motivation and mood, difficulty establishing and maintaining relationship and difficulty adapting to stressful circumstances. Socially, the Veteran reporting living with his wife and seeing his family fairly often. While he has a few friends, he does not socialize and prefers to fish and cut wood by himself. Occupationally, he reported difficulty maintaining jobs due to issues with authority and coworkers. He last worked in 2008 and reported an increase in symptoms since retirement. Behaviorally, the examiner noted that the Veteran arrived on time, appropriately dressed, fair grooming and hygiene. His speech was clear and coherent, but he displayed poor eye contact. He had dysphoric mood and restricted range of affect with logical, linear, and goal-directed thought processes. He denied suicidal and homicidal ideation and psychotic symptoms. He did not behave in a bizarre manner but was a poor historian at times. He was alert and oriented times four and polite and cooperative throughout. The examiner remarked that while the criteria chosen may reflect higher functioning than the 2017 evaluation, the criteria is appropriate and reflects significant limitations in areas of functioning. The examiner also provided an opinion stating that the Veteran’s symptoms impact both social and occupational spheres. Occupationally, he had many conflicts prior to retirement and socially he is isolated as his anxiety prevents social interaction as he is uncomfortable around people. He has poor concentration, low motivation and decreased ability to follow through with and complete tasks. The examiner noted that as the Veteran is retired it is difficult to assess current occupational functioning; however, his social functioning is markedly impaired. In April 2020 the Veteran reported that his mood is good when he takes his medicine and denied any significant periods of anger, irritability or sadness. He did express difficulty with concentration, feelings of guilt but denied suicidal or homicidal ideations. He reported that his ability to enjoy activities comes and goes. When making a decision, the Board must consider all the evidence of record, to include lay statements. 38 U.S.C. § § 5107(b), 7104(a); 38 C.F.R. § 3.303(a). At the hearing, the Veteran testified that his PTSD interferes with his daily activities and he needs to keep doors locked at all time and must always sit with his back to the wall. He reported experiencing about three panic attacks a month, and nightmares nightly. He expressed difficulty being in work settings as he is ornery and does not work well with others. The Veteran stated that while he has a couple friends, he does not see them as he prefers to isolate and only feels comfortable around other Veterans. The Veteran’s spouse also testified that he experiences nightmares and will cry out in his sleep. She described him as irritable and angry and, at times, closed off. He is anxious, suspicious and very vigilant around the house ensuring security. The Veteran denied hygiene problems but reported some memory problems. The Board finds that the Veteran and his wife are competent to provide testimony as to the presence of his observable PTSD symptoms. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The July 2020 rating decision increased the Veteran’s rating from 30 to 70 percent based on the February 2020 examiner’s findings of having over 20 jobs due to difficulty getting along with others, social isolation, disturbances of motivation and mood, difficulty establishing and maintaining relationships, and difficulty adapting to stressful circumstances. The Board finds that these symptoms have been present throughout the appeal period. While the severity of the Veteran’s symptoms fluctuated throughout the appeal period, he consistently presented with anxiety, recurrent nightmares and a preference for social isolation. The VA examiner in February 2011 concluded that the Veteran had moderate symptoms noting that he was a loner and changed many jobs when he worked. The May 2012 examiner found significant distress in social and occupational areas due to strained relationships, poor concentration, and marked anxiety and irritability. Similarly, the December 2017 examiner concluded that the Veteran had a total occupational and social impairment; however, the February 2020 examiner only found an occupational and social impairment with reduced reliability and productivity but reported significant limitations noting social isolation and having many jobs in his lifetime. These findings are consistent with the medical treatment records indicating that the Veteran is known to underreport symptoms, as well as the Veteran’s own reports of having good days and bad days. As such, the Board finds that the variations in the severity of symptoms are emblematic of the Veteran’s PTSD presentation and not suggestive of inconsistencies in reporting. Therefore, when considering the overall severity and frequency of the Veteran’s symptomology, the Board finds that there is not a discernable increase in symptomology that occurred at the February 13, 2020 VA examination. Socially, the Veteran established and maintained familial relationships with his wife, children and grandchildren; however, he did not have many friends and expressed a preference for solitary activities, such as hunting and fishing. Occupationally, prior to retirement in 2008 he reported difficulty interacting with coworkers and supervisors and discomfort with being around people, which resulted in frequent job changes. The mental status examinations frequently noted a depressed or anxious mood and sporadic loss of interest in activities. The Veteran discussed his difficulties getting along with others and its effect on his occupational history at his first VA examination in February 2011. This is consistent with the mental health record repeatedly documenting difficulty being around others and increased anxiety. The Veteran’s social struggles were described as causing significant distress in social areas by the May 2012 examiner, is also indicative of difficulty establishing and maintaining relationships, and difficulty adapting to stressful circumstances. The medical and lay evidence of record reveal that symptoms such as social isolation, recurrent nightmares, anxiety, difficultly getting along with and being around other people due to distrust and suspiciousness, disturbance of motivation and mood, difficulty establishing and maintaining relationship and difficulty adapting to stressful circumstances were present throughout the entire period on appeal. As such, a 70 percent rating is warranted. The Board concludes that the Veteran’s symptoms did not cause the level of impairment required for a disability rating of 100 percent. While the Veteran expressed suicidal ideations, which is contemplated by the 70 percent rating, it is also similar to persistent danger of self-harm contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). The Veteran reported occasional suicidal ideation, but he more frequently denied suicidal or homicidal ideations and never voiced a desire or intent to act on the plan during a suicide risk assessment. Therefore, the Board finds that the Veteran’s reports of suicidal ideation are most consistent with the criteria for a 70 percent rating and does not warrant a higher rating as the evidence does not show that the Veteran has a persistent danger of hurting himself or others. Furthermore, a rating of 100 percent requires total occupational and social impairment. The evidence reveals that the Veteran maintains positive relationships with his wife, children and grandchildren and is able to engage in limited social activities, such as attending church and going on trips. Thus, a total social impairment is not shown and a rating in excess of 70 percent is not warranted. 2. Entitlement to TDIU prior to February 13, 2020 The Board notes that the Veteran received TDIU effective February 13, 2020. However, the Veteran raised the issue of TDIU with his increased rating claim for PTSD. See Rice v. Shinseki, 22 Vet. App. 447, 455 (2009) (holding that a claim for a TDIU due to service-connected disabilities is part and parcel of an increased rating claim when such claim is raised by the record). As such, the Board must determine whether a TDIU is warranted prior to February 13, 2020. TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability or as a result of two or more disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the stated purpose of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable; and (2) disabilities resulting from common etiology or a single accident. 38 C.F.R. § 4.16 (a). “Substantially gainful employment” is that employment “which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides.” Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16 (a) (2017). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017). The Veteran alleges that his service-connected PTSD prevents him from securing and following a substantially gainful occupation. As the Veteran is entitled to a rating of 70 percent effective January 8, 2010, the applicable percentage standards set forth in 38 C.F.R. § 4.16 (a) are met. The Board incorporates by reference the Veteran’s medical history and analysis regarding PTSD discussed in detail above. The Veteran received TDIU effective February 13, 2020 based on the findings of the February 2020 examiner that the Veteran had over 20 jobs due to difficulty getting along with others, social isolation, disturbances of motivation and mood, difficulty establishing and maintaining relationships, and difficulty adapting to stressful circumstances. As these symptoms were present throughout the appeal period for the reason previously discussed, TDIU is warranted as of the date of claim. Therefore, the Board concludes that the Veteran’s markedly impaired social functioning resulting from difficultly getting along with and being around other people due to distrust and suspiciousness, disturbance of motivation and mood, difficulty adapting to stressful circumstances, depressed mood, anxiousness, and frequent nightmares resulting in chronic sleep disturbances precluded the Veteran from obtaining and sustaining substantial gainful employment prior to February 13, 2020. Accordingly, TDIU is granted effective January 8, 2010. REASONS FOR REMAND 1. Entitlement to service connection for GERD, to include due to herbicide exposure or PTSD The Board regrets the additional delay; however, a remand is necessary to ensure compliance with the Board’s prior remand instructions and to ensure that due process is met. Stegall v. West, 11 Vet. App. 268, 271 (1998). In February 2020, the VA examiner opined that GERD is less likely than not incurred in or caused by service as although there are studies to suggest that PTSD, stress and anxiety causes GERD there is no guideline that links PTSD complications for GERD and listed several factors, to include certain medications. The examiner than concluded that the earliest diagnosis date of GERD with the vast years of separation lacks connection of GERD as to incurred, caused, or aggravated beyond natural progression. The Board finds this opinion is inadequate and failed to comply with remand directives. Id. The examiner does not address whether GERD is related to the exposure of herbicide exposure or properly consider secondary service connection as the examiner did not provide an opinion as to whether the Veteran’s GERD is aggravated by PTSD. As such, a remand is necessary to obtain an addendum opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (Once VA undertakes the effort to provide an examination, it must provide an adequate one). 2. Entitlement to service connection for bilateral hearing loss The Board remanded this issue in October 2019 for a medical opinion on the nature and etiology of hearing loss. In February 2020, the examiner opined that it is not at least as likely as not that hearing loss is caused by service. The rationale noted that there was not a significant threshold beyond normal measurement variability in service; thus, the evidence does not show an in-service hearing injury. The examiner referenced studies with rodents (but did not provide a citation to the study) and the Institute of Medicine (IOM) report Noise and Military Service—Implications for Hearing Loss and Tinnitus (2006) to support the contention that based on the normal hearing tests conducted at enlistment and discharge the Veteran did not have a hearing injury. Therefore, hearing loss is less likely as not caused by or a result of noise exposure. The Board finds this opinion is inadequate for adjudication. 38 C.F.R. § 3.385 establishes that service connection for a current hearing disability is not precluded where hearing was within normal limits at separation. See Hensley v. Brown, 5 Vet. App. 155, 159-60 (1993). While normal audiological examinations at separation can be considered, normal hearing upon separation by itself does not bar service connection, rather, a normal hearing test on separation must be weighed with all the evidence of record. Id. As such, a remand is necessary for an addendum opinion. The matters are REMANDED for the following action: 1. Acquire any updated VA and/or private treatment records. If such records are unavailable, the Veteran’s claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file, and comment on the following questions: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s GERD is related to the Veteran’s military service, to include due to exposure to herbicide agents, to include Agent Orange? The fact that GERD is not a disability presumed to be related to herbicide agent exposure is not sufficient to serve as a rationale in this case. (b.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that GERD is proximately due to or the result of the Veteran’s service-connected PTSD, to include any medications required for the treatment of PTSD? (c.) If the answer to (b) is negative, is it at least as likely as not that GERD is aggravated (i.e., permanently or temporarily worsened) by the service-connected PTSD, to include any medications required for the treatment of PTSD? (d.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. The term “aggravation” means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The examiner should consider and address the Veteran’s full medical history. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 3. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s bilateral hearing loss is related to his active service or is caused by or aggravated by military service. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms of bilateral hearing loss from in-service to the present. The examiner must specifically consider and discuss the Veteran's exposure to acoustic trauma and any continuity of symptomology since service. The opinion and rationale should reflect such consideration. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner is advised that 38 C.F.R. § 3.385 establishes that service connection for a current hearing disability is not precluded where hearing was within normal limits at separation. See Hensley v. Brown, 5 Vet. App. 155, 159-60 (1993). As such, the examiner must consider and discuss all the evidence of record. If a negative opinion is offered based on the length of time between separation and the current diagnosis the examiner should explain the medical significance of this fact, i.e., why this is indicative that any current hearing loss is not related to service. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional 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). G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. A. Prinsen 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.