Citation Nr: 21007108 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 16-11 131A DATE: February 8, 2021 ORDER Entitlement to service connection for bilateral hearing loss, claimed as deafness, is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for chronic myositis, paralumbar spine muscles is remanded. Entitlement to service connection for chronic myositis, right hip is remanded. Entitlement to service connection for chronic myositis, left hip is remanded. Entitlement to service connection for chronic myositis, left lower extremity is remanded. Entitlement to service connection for chronic myositis, right lower extremity is remanded. Entitlement to a total disability rating due to individual unemployability resulting from service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran is not currently shown to have a right ear hearing loss disability by VA standards. 2. A left ear hearing loss disability was not shown during service or for many years thereafter, and the weight of the probative evidence is against a finding that a current left ear loss disability is related to active military service. 3. Tinnitus was not shown during service or for many years thereafter, and the weight of the probative evidence is against a finding that tinnitus is related to active military service. 4. The Veteran does not have a current diagnosis of PTSD. 5. The Veteran does not have a current acquired psychiatric disorder. CONCLUSIONS OF LAW 1. A bilateral hearing loss disability was not incurred in the Veteran’s active military service, and it may not be presumed to have been incurred therein. 38 U.S.C.§§ 1110, 1112, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2020). 2. Tinnitus was not incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2020). 3. The criteria for service connection for an acquired psychiatric disorder, to include PTSD are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1976 to March 1978. This matter is on appeal from a February 2015 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). In August 2018, the Board remanded these issues for additional development. The Board notes that in the February 2015 rating decision, the RO denied service connection for PTSD, a sleep disorder, generalized anxiety disorder and major depressive disorder. However, the Board notes that the United States Court of Appeals for Veterans Claims (Court) has held that claims for service connection for PTSD encompass claims for service connection for all psychiatric disabilities. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record). As a result, in conjunction with Clemons and as addressed below, the claim has been characterized as entitlement to service connection for an acquired psychiatric disorder, to include PTSD. 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. §§ 1110, 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 sensorineural hearing loss and psychosis, 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 sensorineural hearing loss and psychosis 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). Hearing Loss and Tinnitus 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, 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 Tests are less than 94 percent. 38 C.F.R. § 3.385. Additionally, it is noted that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Factual Background and Analysis The Veteran’s service treatment records are negative for complaints of, treatment for, or findings of bilateral hearing loss or tinnitus. Audiometric testing on the Veteran’s February 1974 pre-enlistment examination revealed pure tone thresholds, obtained by air conduction, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 n/a 15 LEFT 15 15 25 n/a 25 Audiometric testing on the Veteran’s April 1976 enlistment examination revealed pure tone thresholds, obtained by air conduction, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 20 10 20 LEFT 20 15 25 20 10 Audiometric testing on the Veteran’s February 1978 separation examination revealed pure tone thresholds, obtained by air conduction, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 10 15 15 LEFT 5 5 15 20 20 In a June 2014 correspondence, a private physician noted that the Veteran presented with complaints of hearing loss and tinnitus that he related to his military noise exposure. The diagnosis was tinnitus and bilateral deafness. Per the August 2018 Board remand instructions, the Veteran underwent a VA audiological examination in November 2019. Audiometric testing in November 2019 revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 15 20 25 LEFT 15 20 20 45 50 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 96 percent in the left ear. The examiner noted that the Veteran served as an infantryman which had a high probability for military noise exposure. The examiner opined that it was less likely than not that the Veteran’s bilateral hearing loss was caused by or the result of an in event in military service. The examiner noted that the Veteran’s hearing was normal in service and that the Veteran had normal hearing levels on his separation examination. The records also did not demonstrate a hearing injury in service. The examiner noted that it was well known that prolonged exposure to high intensity noise such as military type noise may cause damage to auditory structures resulting in hearing loss. Exposure to military noise can also cause permanent damage in the structures of the inner ear resulting in irreversible hearing loss. Damage to the auditory system after a single extremely intense acoustic event was immediate after the noise trauma or the hearing loss could appear gradually during the noise exposure period. However, the medical literature did not support that a delayed onset or retroactive effect was expected to be evidenced as a hearing loss so many years after being exposed to military noise. Hearing loss instead might be associated to the combined effect of middle ear pathology, normal aging process due to inner ear dysfunction, and exposure to occupational or recreational noise. The examiner also determined that the Veteran had a diagnosis of tinnitus that was associated with his hearing loss. The examiner opined that it was less likely than not that the Veteran’s tinnitus was related to his in-service noise exposure as it was most likely a result of the combined etiologies of post-service occupational and/or recreational noise exposure, and/or presbycusis effect due to progressive inner hair cell dysfunction. When considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for bilateral hearing loss and tinnitus is not warranted. Regarding the Veteran’s right ear, the post-service evidence demonstrates that the Veteran does not have a current right ear hearing loss disability as defined by 38 C.F.R. § 3.385, as the auditory thresholds obtained during the pendency of this claim were not 40 decibels or greater at any of the frequencies, the auditory thresholds at the minimum three of the frequencies were not 26 decibels or greater, and the Maryland CNC speech recognition score was not less than 94 percent. See 38 C.F.R. § 3.385. Notably, the VA examination in November 2019 does not show a right ear hearing loss disability by VA standards. Thus, there is no competent evidence reflective of a right ear hearing loss disability as defined by 38 C.F.R. § 3.85 at any time during the pendency of this appeal. The Board appreciates the Veteran’s contentions and statements related to his claimed right ear hearing loss. However, even conceding that the Veteran was exposed to significant noise in service, the evidence does not show a right ear hearing loss disability by VA standards. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110. Thus, where, as here, competent and persuasive medical evidence establishes that the Veteran does not have a right ear hearing loss disability for which service connection is sought, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the claim for service connection for right ear hearing loss must be denied because the first essential criterion for a grant of service connection-competent evidence of the currently-claimed disability-has not been met. With respect to the Veteran’s contention that he currently has right ear hearing loss disability, 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). As a layperson, the Veteran is competent to report that he experiences difficulty hearing. However, he is not competent to render a diagnosis of a right ear hearing loss disability that satisfies the regulatory criteria set forth in 38 C.F.R. § 3.385. Absent evidence of a current right ear hearing loss disability diagnosis, the Board concludes that the claim of entitlement to service connection for a right ear hearing loss disability must be denied. Regarding the Veteran’s left ear and tinnitus claims, the record shows that the Veteran currently has left ear hearing loss for VA compensation purposes and a diagnosis of bilateral tinnitus. Accordingly, as there are current left ear hearing loss and tinnitus disabilities, 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). Turning to in-service injury, the Board notes that the Veteran has asserted that he sustained acoustic trauma during service. In this regard, the Veteran is competent to give evidence about what he experienced, and acoustic trauma is subject to lay observation. See e.g., Layno v. Brown, 6 Vet. App. 465 (1994); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006). Therefore, the Board finds that the Veteran was exposed to hazardous noise during service and noise exposure has been conceded. However, the Veteran’s service treatment records are negative for complaints or treatments regarding a bilateral hearing loss or tinnitus disability. Additionally, the Board notes that there are no clinical findings or diagnoses of left ear hearing loss or tinnitus during service or for several years thereafter. None of the private or VA treatment records show that the Veteran was diagnosed with left ear hearing loss or tinnitus to a compensable degree within one year of service. To the extent that the Veteran is asserting a continuity of symptomatology since service, the Board does not find the Veteran to be credible with regard to any assertions that he has had symptoms of a left ear hearing loss disability or tinnitus since service. There was no indication in the record, to include any statements from the Veteran of hearing trouble or tinnitus within one year of his separation. On the contrary, the lack of any findings pertaining to hearing loss during service weigh against a finding that the Veteran’s current left ear hearing loss disability and tinnitus were originally manifested during service and have continued since service. As the Veteran’s service treatment records were negative for any complaints, treatment, or diagnoses of a hearing loss disability or tinnitus, he was not diagnosed with a hearing loss 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 hearing loss disability and tinnitus, the Board concludes that the weight of the evidence is against a finding of continuity of symptomatology since service. See Maxson v. West, 12 Vet. App. 453 (1999), aff’d, 230 F.3d 1330 (Fed. Cir. 2000). Additionally, the most probative opinions do not show a relationship between left ear hearing loss and tinnitus disabilities disability and the Veteran’s in-service noise exposure. As noted above, a private treatment record in June 2014 noted that the Veteran presented with complaints of hearing loss and tinnitus that he related to his military noise exposure. However, the Board notes that a mere transcription of lay history, unenhanced by any additional medical comment by the transcriber, does not become competent medical evidence merely because the transcriber is a medical professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995); see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993) and Elkins v. Brown, 5 Vet. App. 474, 478 (1993). In contrast, the November 2019 VA examiner determined that it was less likely as not that the Veteran’s hearing loss and tinnitus disabilities were caused by or a result of military noise exposure. The Board finds the November 2019 opinions to be highly probative, as it was based on a thorough review of the Veteran’s medical records, cited to relevant medical principles and specifically addressed the Veteran’s contentions. The opinion is also consistent with the other evidence of record and is supported by a detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion.). In this regard, the Board may favor the opinion of one competent medical professional over that of another so long as an adequate statement of reasons and bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). An evaluation of the probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the examiner’s knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one physician’s opinion over another depending on factors such as reasoning employed by the physicians and whether or not and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert’s qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). As a result, the Board finds that the November 2019 opinions of the VA examiner to be the most probative. As a result, the Board finds that the competent evidence of record, while showing the currently diagnosed disability of left ear hearing loss and tinnitus, does not demonstrate hearing loss manifested to a compensable degree within one year of separation. Additionally, given that the most probative opinion is against a finding of a relationship between a claimed hearing loss and tinnitus disabilities and service, the Board finds that service connection is not warranted. For the foregoing reasons, the Board concludes that the preponderance of the evidence is against the claims of entitlement to service connection for a bilateral hearing loss and tinnitus disabilities. The benefit of the doubt doctrine is therefore not applicable, and the claims must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Acquired Psychiatric Disorder to Include PTSD Service connection for PTSD specifically requires medical evidence establishing a diagnosis of the disability, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran’s service, the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (1); see also, 38 U.S.C. § 1154(b). Similarly, if a stressor claimed by a veteran is related to the Veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the Veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran’s service, the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (3). Otherwise, the law requires verification of a claimed stressor. Where a determination is made that the Veteran did not “engage in combat with the enemy,” or the claimed stressor is unrelated to combat, the Veteran’s lay testimony alone will not be enough to establish the occurrence of the alleged stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record must include service records or other credible evidence that supports and does not contradict the Veteran’s testimony. Doran v. Brown, 6 Vet. App. 283, 289 (1994). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. See Moreau, 9 Vet. App. at 395-396; Cohen v. Brown, 10 Vet. App. 128, 42 (1997). Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders so as to replace outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V). 38 C.F.R. § 4.130 (2016). VA directed that the changes be applied only to applications for benefits received by VA or pending before the agency of original jurisdiction (AOJ) on or after August 4, 2014, but not to claims certified to, or pending before, the Board, the Court of Appeals for Veterans Claims (CAVC), or the United States Court of Appeals for the Federal Circuit. The Board notes that this claim was not certified to the Board until August 2016. Accordingly, this claim was pending before the agency of original jurisdiction on August 4, 2014, and DSM-5 applies to this claim. 79 Fed. Reg. 45094 (Aug. 4, 2014). Factual Background and Analysis The Veteran contends that his current acquired psychiatric disability began during, or is related to, his active duty service. The Veteran’s service treatment records are negative for complaints, treatment or diagnoses of a psychiatric disability. In a June 2014 correspondence, a private physician who specialized in internal medicine noted that the Veteran presented with nervousness, anxiety, increased irritability, difficulty in adapting to stressful circumstances, an inability to establish and maintain effective work and social relationships, disturbances of motivation and mood, depressed mood, isolative episodes, easy crying and insomnia with nightmares and flashbacks of his traumatic experiences during active duty. The diagnosis was generalized anxiety disorder, major depression disease, PTSD and a sleep disorder. The physician opined that the Veteran presented with psychiatric disorders that were more probable than not secondary to his military service performance. Per the August 2018 Board remand instructions, the Veteran underwent a VA examination in November 2019. The examiner found that the Veteran did not have a diagnosis of PTSD that conformed to the DSM-5 criteria. The examiner found that there was no mental disorder diagnosis. The Veteran denied receiving any psychiatric interventions or any psychiatric medications. The examiner indicated that after taking a psychiatric history and performing a mental status examination, it was determined that there was no evidence to fulfill DSM-5 diagnostic criteria for any formal mental disorder at present to include PTSD. There was no history of hospitalization or any emotional crisis intervention and he had not been receiving any psychiatric treatment or taking any medications. The actual mental examination, clinical history and psychosocial course were negative for a formal mental condition at present. Therefore, the examiner could not render an opinion as to whether the Veteran had an acquired psychiatric disorder related to service as the Veteran’s mental examination was negative for any formal mental condition. The examiner noted that the June 2014 report by the private physician was revised and a completed mental status examination needed for a psychiatric diagnosis formulation was not found. In a May 2020 addendum opinion, the November 2019 VA examiner again found that the Veteran did not have a diagnosis of PTSD that conformed to the DSM-5 criteria. The examiner noted that after taking a psychiatric history and performing a mental status examination, it was determined that there was no evidence to fulfill DSM-5 diagnostic criteria for any formal mental disorder at present to include PTSD. The examiner again that the June 2014 report by the private physician was revised and a completed mental status examination needed for a psychiatric diagnosis formulation was not found. The examiner also noted that the Veteran’s 1978 separation examination was negative for psychiatric complaints and the mental status examination conducted in November 2019 demonstrated a clinical history and psychosocial course that were both negative for a formal medical condition. As a result, the examiner again determined that an opinion as to whether the Veteran had an acquired psychiatric disorder related to service could not be rendered as the Veteran’s mental examination was negative for any formal mental condition to include PTSD and a sleep disorder. Considering the claim for service connection for an acquired psychiatric disability to include PTSD, the Board finds that the claim must be denied as the Board finds that the Veteran does not have a PTSD or other mental disorder diagnosis. As noted above, service connection for PTSD requires a medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) (2020). In this case, the persuasive medical evidence demonstrates that the Veteran does not currently have a diagnosis of PTSD or a diagnosis of another me. The Board notes that the June 2014 private physician who specialized in internal medicine, found that the Veteran had generalized anxiety disorder, major depression disease, PTSD and a sleep disorder. However, the Board notes that these PTSD and acquired psychiatric disorder disabilities diagnoses did not provide a rationale or explanation for concluding that the Veteran met DSM-IV or DSM-5 criteria for a diagnosis. Additionally, there was no discussion of the nature of the military stressors or trauma. In contrast, the November 2019 VA examination and May 2020 VA addendum opinion specifically found that the Veteran did not meet the criteria for a diagnosis of PTSD or any other mental disability under the DSM-5 criteria. The November 2019 VA examiner conducted a review of the record, an examination and provided a medical explanation for why the Veteran’s symptoms did not meet the DSM-5 PTSD criteria. The November 2019 VA examiner’s opinion is plausible and consistent with the evidence of record. Caluza v. Brown, 7 Vet. App. 498 (1995). Consequently, the Board considers the November 2019 VA examination and May 2020 addendum opinion to be highly probative evidence weighing against a current diagnosis of PTSD or any other mental health disorder. Additionally, while statements from the Veteran reflect his continued assertion that he has an acquired psychiatric disorder to include PTSD, the most probative medical evidence does not support his opinion. While the Veteran is competent to report symptoms, he is not necessarily competent to attribute such symptoms to a specific underlying psychiatric disorder. In this regard, the Board ultimately places more weight on the medical opinions and clinical findings of record on the matter of whether the Veteran has a current diagnosis of an acquired psychiatric disorder to include PTSD. Accordingly, the Board finds that the preponderance of the evidence is against the claim as the Veteran does not have a current diagnosis of PTSD any other mental disorder diagnosis. Hence, whereas here, the competent evidence establishes that the Veteran does not have the disability for which service connection is sought, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the instant appeal, the claims for service connection for an acquired psychiatric disorder to include PTSD must be denied because the first criterion for the grant of service connection-competent evidence of the disability for which service connection is sought-is not met. 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 an acquired psychiatric disability, to include PTSD. 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 notes the Veteran’s contentions regarding the etiology of his claimed acquired psychiatric disability, bilateral hearing loss and tinnitus disabilities. To the extent that the Veteran himself contends that a medical relationship exists between his claimed current disabilities and 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). The Board finds that an acquired psychiatric disability, bilateral hearing loss and tinnitus disabilities are not disabilities subject to lay diagnosis as these diagnoses require medical training. More significantly, the Veteran does not have the medical expertise to provide an opinion regarding the claimed acquired psychiatric disability, bilateral hearing loss or tinnitus disability 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). Additionally, the November 2019 VA examiners provided detailed rationales in support of their opinions and cited to the relevant evidence. For this reason, the VA examiners’ opinions are the most probative evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that a factor for assessing the probative value of a medical opinion includes the thoroughness and detail of the opinion). Thus, the Veteran’s assertions that there is a relationship between his claimed acquired psychiatric disability, bilateral hearing loss and tinnitus 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). REASONS FOR REMAND The Board finds that more development is necessary prior to final adjudication of the claims remaining on appeal. In August 2018, the Board remanded these issues for additional development. Unfortunately, an additional remand of the Veteran’s claims is warranted. Although the Board regrets the additional delay associated with an additional remand, further development of the record is required before the Board may render a decision in the instant case. When the Board’s remand orders are not complied with, the Board errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In its August 2018 remand, the Board instructed the RO to schedule the Veteran for VA examinations to determine the etiology of his claimed entitlement to service connection for bilateral hearing loss; tinnitus; a low back disability; chronic myositis, paralumbar spine muscles; chronic myositis, right hip; chronic myositis, left hip; chronic myositis, left lower extremity; chronic myositis, right lower extremity; a sleep disorder; generalized anxiety disorder; PTSD; and major depressive disorder disabilities. September 2019 and October 2019 correspondences addressed to the Veteran informed him that he was going to be notified by the nearest VA medical facility to schedule his VA examinations. In November 2019 the Veteran underwent VA examinations for his claimed bilateral hearing loss, tinnitus and acquired psychiatric disorder to include PTSD disabilities. A June 2020 Supplemental Statement of the Case (SSOC) indicates that the examinations for the Veteran’s claimed low back; chronic myositis, paralumbar spine muscles; chronic myositis, right hip; chronic myositis, left hip; chronic myositis, left lower extremity; and chronic myositis, right lower extremity disabilities were not conducted as the RO was informed that the Veteran did not show for his scheduled November 2019 VA examinations. However, the record is unclear as to whether the Veteran received advanced notice of these examinations. The claims file does not contain a copy of the letters notifying the Veteran of scheduled examinations. Rather, the record simply contains the June 2020 SSOC which detail the reasons for not scheduling the requested examinations. Additionally, in a September 10, 2020 letter, VA noted that previous correspondences had been returned as undeliverable and that they had discovered a new address to send the Veteran information. Notably, the September 2019 and October 2019 correspondences sent to the Veteran notifying him that a VA medical facility would be contacting him was addressed to his previous address. When a veteran fails without good cause to report for a necessary VA examination requested by VA in conjunction with a claim for increased compensation, the claim will be denied. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. 38 C.F.R. § 3.655(a), (b) (2020). In this instance, the Board finds that good cause for the Veteran’s failure to report for his VA examinations has been shown. Of particular importance to the Board in this matter is the absence of evidence in the claims folder that the Veteran was properly notified of the scheduling of his VA examinations. Additionally, as noted above, the Veteran has previously demonstrated a willingness to show for examinations as he was scheduled for and attended VA examinations for his claimed bilateral hearing loss, tinnitus and acquired psychiatric disorder to include PTSD disabilities. Therefore, the Board concludes that another attempt should be made to schedule the Veteran for the requested VA examinations. The Board does note however that VA’s duty to assist claimants is not always a “one-way street.” In other words, a claimant seeking help cannot passively wait for it in those circumstances where he or she may or should have information that is essential in obtaining putative evidence. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, in instances where a claimant fails without good cause to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. Finally, the Board again notes that further development and adjudication of this claims may provide evidence in support of his claim for TDIU. 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. The Board has therefore concluded that it would be inappropriate at this juncture to enter a final determination on that issue. 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 her 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. Schedule the Veteran for an examination to determine whether the Veteran has any low back; chronic myositis, paralumbar spine muscles; chronic myositis, right hip; chronic myositis, left hip; chronic myositis, left lower extremity; or chronic myositis, right lower extremity disabilities related to his reported head injuries in service. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. After the record review, and a thorough examination and interview eliciting a full history from the Veteran, the examiner should indicate whether it is at least as likely as not that the Veteran has any low back; chronic myositis, paralumbar spine muscles; chronic myositis, right hip; chronic myositis, left hip; chronic myositis, left lower extremity; or chronic myositis, right lower extremity disabilities that had their onset during, or are otherwise related to, his active duty service. The examiner must specifically discuss and consider the service treatment records which document treatment for low back symptoms as well as the June 2014 opinion from Dr. C.E which concluded that the Veteran’s musculoskeletal disabilities were more likely than not secondary to his military service as the Veteran suffered low back traumas during service which has led to radiating pain to para-lumbar spine muscles, hips, and legs, with associated numbness, tingling, sensorial loss, cramps, and weakness. All opinions expressed by the examiner must be accompanied by a complete rationale. Adequate reasons and bases for any opinion rendered must be provided. All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. 3. If the Veteran does not report for the aforementioned examination(s), documentation must be obtained which shows that notice scheduling the examination(s) was sent to his last known address. Such documentation should be associated with his claims folder. If the notice is returned as undeliverable, documentation attesting to that fact should also be associated with the claims folder. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of entitlement to TDIU. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. 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.