Citation Nr: 21007719 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 17-27 331 DATE: February 10, 2021 ORDER The appeal of the claim of entitlement to service connection for lumbosacral/cervical strain is dismissed. The appeal of the claim of entitlement to service connection for hemorrhoids is dismissed. The appeal of the claim of entitlement to service connection for prostate disability is dismissed. The appeal of the claim of entitlement to a compensable disability rating for service-connected for hypertensive vascular disease is dismissed. New and material evidence having been received, the petition to reopen the Veteran’s claim of service connection for renal cancer is granted. New and material evidence having been received, the petition to reopen the Veteran’s claim of service connection for lung cancer, to include as secondary to renal cancer, is granted. New and material evidence having been received, the petition to reopen the Veteran’s claim of service connection for tinnitus is granted. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for renal cancer is granted. Entitlement to an initial disability rating of 70 percent, and no higher, for service-connected posttraumatic stress disorder is granted. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for lung cancer, left lung, to include as secondary to kidney cancer, is remanded. FINDINGS OF FACT 1. During his June 5, 2020 Board hearing, on the record, the Veteran withdrew his claim of entitlement to service connection for lumbosacral/cervical strain. 2. During his June 5, 2020 Board hearing, on the record, the Veteran withdrew his claim of entitlement to service connection for hemorrhoids. 3. During his June 5, 2020 Board hearing, on the record, the Veteran withdrew his claim of entitlement to service connection for prostate disability. 4. On July 20, 2020, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran, requesting withdrawal of his claim of entitlement to a compensable disability rating for service-connected hypertensive vascular disease. 5. A June 2013 rating decision denied the Veterans claims of entitlement to service connection for renal cancer, lung cancer, and tinnitus; the Veteran was notified of the decision in July 2013. A notice of disagreement was not filed, and additional evidence was not received within one year of the decision. The unappealed decision became final. 6. Evidence received since the June 2013 decision is neither cumulative nor redundant of the evidence of record at the time of the last final denial and relates to an unestablished fact necessary to substantiate the claims of service connection for renal cancer, lung cancer to include as secondary to renal cancer, and tinnitus. 7. The weight of the evidence is at least in equipoise as to whether the Veteran's tinnitus began in service as a result of in-service hazardous noise exposure. 8. The weight of the evidence is at least in equipoise as to whether the Veteran's renal cancer is related to in-service herbicide exposure. 9. Throughout the rating period on appeal, the severity, frequency, and duration of the Veteran’s posttraumatic stress disorder symptoms most closely approximate occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for dismissal of the appeal of the claim of service connection for lumbosacral/cervical strain have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 2. The criteria for dismissal of the appeal of the claim of service connection for hemorrhoids have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 3. The criteria for dismissal of the appeal of the claim of service connection for prostate disability have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 4. The criteria for dismissal of the appeal of the claim of entitlement to a compensable disability rating for service-connected for hypertensive vascular disease have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 5. New and material evidence has been received since the July 2013 notice of the June 2013 rating decision denying service connection for renal cancer. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 6. New and material evidence has been received since the July 2013 notice of the June 2013 rating decision denying service connection for lung cancer, to include as secondary to renal cancer. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 7. New and material evidence has been received since the July 2013 notice of the June 2013 rating decision denying service connection for tinnitus. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 8. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.309. 9. The criteria for service connection for renal cancer have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 10. The criteria for a disability rating of 70 percent for service-connected posttraumatic stress disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has active service from July 1966 to July 1968. This case is before the Board of Veterans’ Appeals (Board) from a May 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran and his spouse appeared before the undersigned Veterans’ Law Judge at a June 2020 hearing. Withdrawals 1. Lumbosacral/cervical strain. 2. Hemorrhoids 3. Prostate disability. 4. Hypertensive vascular disease. During the Veteran’s June 2020 hearing, he withdrew the appeals of his claims of entitlement to service connection for lumbosacral/cervical strain, hemorrhoids, and prostate disability (6/05/2020 Hearing Transcript). Additionally, of record is a request in writing and signed by the Veteran to withdraw his claim of entitlement to a compensable disability rating for service-connected hypertension (7/20/2020 Correspondence; 7/06/2020 Correspondence). The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.205. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.205. It is further noted that, where a withdrawal is requested during the conduct of a Board hearing, the presiding Veterans Law Judge is obligated to explain the consequences of such withdrawal. Acree v. O'Rourke, 891 F.3d 1009, 101314 (Fed. Cir. 2018). The undersigned affirmatively addressed the Veteran and insured that he understood the full ramifications of withdrawing the appeals of his claims of entitlement to service connection for lumbosacral/cervical strain, hemorrhoids, and prostate disability. The Veteran indicated his understanding and confirmed the withdrawals. With regard to the increase rating claim for hypertension, the withdrawal was submitted in writing, outside the context of a hearing and thus the requirements of Acree do not apply. The request complies with the requirements set forth at 38 C.F.R. § 20.205 and was made prior to the Board’s promulgation of a decision on the appeal. Thus, the Board will honor the request for withdrawal. New and Material Evidence In June 2013, the AOJ denied entitlement to service connection for kidney disability, lung cancer, and tinnitus citing neither occurred in nor was caused by service, to include as a result of conceded herbicide exposure (6/27/2013 Rating Decision - Narrative). Neither new evidence nor a notice of disagreement was received within a year of the decision. The unappealed decision became file. Where a claim has been finally adjudicated, a claimant must present new and material evidence in order to reopen the previously denied claim. New evidence is that which was not previously submitted to agency decision makers. Material evidence is that which by itself, or when considered with previous evidence of record, relates to an unestablished fact that is necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial, and it must raise a reasonable possibility of substantiating the claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). For the purpose of reopening a claim, evidence received is generally presumed credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). There is a low threshold for finding new evidence that raises a reasonable possibility of substantiating a claim. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). 5. New and Material Evidence for Renal cancer. A March 2017 private positive nexus opinion (3/09/2017 Medical Treatment Record - Non-Government Facility) has been added to the record since the June 2013 prior final denial of the Veteran’s claim of service connection for renal cancer. The Board finds this medical evidence is new as it had not been previously submitted to agency decision makers, and material as it pertains to the basis for the prior final denial, that is that the Veteran’s renal cancer was caused by his service. The Board finds the new and material evidence that has been received since the June 2013 decision is sufficient to reopen the claim of entitlement to service connection for renal cancer. Accordingly, the Veteran’s petition to reopen the claim of service connection for renal cancer is granted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 6. New and Material Evidence for Lung Cancer, to include as secondary to Renal Cancer. During the Veteran’s June 2020 hearing, new testimony was received regarding the Veteran’s lung cancer. Specifically, it was explained that it had metastasized from his renal cancer. Additional private medical records have been associated with the claim since the last final denial. The Board finds the documentary and testimonial evidence is new as it had not been previously submitted to agency decision makers, and material as it directly pertains to the basis for the prior final denial, that the Veteran’s lung cancer neither occurred in nor was caused by service. As such, it is sufficient to reopen the claim of entitlement to service connection for lung cancer, to include as secondary to renal cancer. Accordingly, the Veteran’s petition to reopen the claim of service connection for lung cancer, to include as secondary to renal cancer, is granted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 7. New and Material Evidence for Tinnitus. During the June 2020 hearing, new and clarifying testimony was received regarding the onset of the Veteran’s tinnitus (6/05/2020 Hearing Transcript, pgs. 10-12). The Board finds that testimonial evidence provided by the Veteran is new, as it had not been previously submitted to agency decision makers, and material as it directly pertains to the basis for the prior final denial, that his tinnitus neither occurred in nor was caused by service. The Board finds the new and material evidence received since the June 3013 decision is sufficient to reopen the claim of service connection for tinnitus. Accordingly, the Veteran’s petition to reopen the claim of service connection for tinnitus is granted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 8. Tinnitus. The Veteran contends his tinnitus is a result of hazardous noise exposure during service, to include artillery fire while serving in Vietnam. A December 2012 VA examination for hearing loss and tinnitus confirmed the Veteran’s current tinnitus diagnosis (12/18/2014 CAPRI, pg. 24). The Veteran’s service record documents his Vietnam service and although he served as a cook, his service record confirms service with artillery and engineering units (1/21/2015 Military Personnel Record, pgs. 5 and 6). Additionally, the Veteran has competently and credibly provided lay evidence regarding the nature of inservice hazardous noise exposure (12/22/2015 Correspondence). Resolving doubt in favor of the Veteran, the Board concedes in- service hazardous noise exposure. Turning to the question whether the Veteran's current tinnitus had its onset during or was caused by an incident in service, there is probative evidence for and against the Veteran’s claim. The December 2012 examiner noted the Veteran’s service and exposure to some hazardous noise. The examiner provided a negative nexus opinion, finding the Veteran has a diagnosis of clinical hearing loss, and his tinnitus is at least as likely as not (50% probability or greater) a symptom associated with the hearing loss, as tinnitus is known to be a symptom associated with hearing loss (12/18/2014 CAPRI, pg. 24). During the Veteran’s June 2020 hearing, he endorsed ringing in the ears or some type of head noise. Although he could not pin down the day or minute when it began, he testified that it has continued from his military service forward (6/05/2020 Hearing Transcript, pg. 11). The Veteran is competent to testify regarding the in-service noise exposure, and the ringing in his ears post-service. He is further competent to describe symptoms observable to his senses; as such, he is also competent to diagnose tinnitus. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Charles v. Principi, 16 Vet. App. 370, 374 (2003) (stating that "ringing in the ears is capable of lay observation"). The Board finds that the Veteran's statements with respect to his continuity of symptomatology to be credible and probative. The Board acknowledges the probative weight of the negative opinion provided by the December 2012 examiner; however, the Board finds this opinion to be outweighed by the weight of the testimony of the Veteran pertaining to the continuity of his symptomatology. Finally, because tinnitus (organic disease of the nervous system) is a chronic disease under 38 C.F.R. § 3.309 (a), an award of service connection is appropriate solely based on evidence of continuity of symptomatology. Walker, 708 F.3d at 1336-40. In view of the foregoing, and in consideration of the probative statements of the Veteran, the Board finds that the evidence is at least in equipoise regarding the question of whether the Veteran's current tinnitus is the result of military service. In cases where the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). Accordingly, the Veteran's claim for service connection of tinnitus is granted. 9. Renal cancer. The Veteran has claimed entitlement to service connection for his diagnosed renal cancer, contending renal cancer was caused by conceded herbicide exposure while serving in Vietnam. The Veteran has a current diagnosis of clear cell renal carcinoma, status post nephrectomy (5/09/2017 CAPRI, pg. 44; 3/29/2013 Medical Treatment Record - Non-Government Facility, pg. 3). The Veteran’s military personnel record confirms his Vietnam service from August 1967 to July 1968, and as such in-service herbicide exposure is presumed pursuant to 38 C.F.R. § 3.307 (a)(6)(iii). Renal cancer is not an enumerated condition under 38 C.F.R. § 3.309 (e), therefore presumptive service connection is not appropriate in this case. The question for consideration is whether service connection is warranted on a direct basis, and whether the Veteran’s current disability is related to service. Of record are a number of articles addressing a link between kidney cancer and herbicide exposure (9/11/2012 Correspondence). Notable was a study by researchers at the Overton Brooks VAMC in Shreveport. In summary a doctor involved with the study acknowledged herbicides were extremely toxic and known to cause cancer. The data indicated a possible need to better determine whether exposure to herbicide chemicals should be considered a risk factor for kidney cancer (9/11/2012 Correspondence, pg. 4). Medical evidence of record includes probative opinions in favor of and against the claim. In favor of the claim includes a December 2016 letter from the Veteran’s treating physician for his renal cancer. The physician opined the Veteran’s kidney cancer was caused by his in-service herbicide exposure. The physician included citation to medical research and considered the Veteran’s medical history, to include his prior history of smoking and his family history, that does not suggest a genetic risk for kidney cancer. The physician also noted the Veteran had no post service occupational exposure risks for renal cancer. Medical evidence against the Veteran’s claim includes a May 2017 VA opinion that considers the December 2016 positive nexus opinion. The May 2017 examiner found that it is less likely than not that the Veteran's renal cell carcinoma is a result of herbicide exposure (5/08/2017 C&P Exam). The examiner considered the Veteran’s other risk factors, to include obesity and having quit smoking in 1981, and cited to a study that included these as risk factors. With regard to the Shreveport study, the May 2017 examiner opined only 13 of the people in the study were exposed to Agent Orange. Given that limited number, the study lacked sufficient power to establish a causal relationship between renal cell cancer and Agent Orange exposure. The May 2017 examiner cited the 2010 Institute of Medicine update summarizing there was insufficient evidence to suggest a relationship between renal cell cancer and Agent Orange exposure. With regard to the studies cited by both physicians, and articles associated with the record, the Board finds while the Shreveport study is not dispositive, it is probative, and weighs in favor of the Veteran’s claim when considered in conjunction with his specific medical history. In weighing the medical evidence, the Board finds the December 2016 opinion of the Veteran’s treating physician to be of more probative weight than the May 2017 medical opinion of record that was not associated with treatment or an examination. The December 2016 opinion is based on greater familiarity with the specifics of the Veteran’s medical history and treatment. The Board also finds, while the May 2017 examiner was qualified to render a medical opinion in this case, the December 2016 examiner, in addition to being a medical doctor, is a professor of medicine in the division of oncology at a highly esteemed university, suggestive of a more specific background and expertise in this area. In sum and after weighing the probative evidence of record, the Board finds it to be least in equipoise as to whether the Veteran’s renal cancer is related to his inservice herbicide exposure. In cases where the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). Accordingly, resolving all doubt in favor of the Veteran, the Board finds that service connection for renal cancer is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 10. Entitlement to a disability rating in excess of 50 percent for service-connected posttraumatic stress disorder. The Veteran has claimed entitlement to an initial disability rating in excess of 50 percent for service-connected posttraumatic stress disorder. His current 50 percent disability rating, effective September 17, 2014, is assigned pursuant to Diagnostic Code 9411 (5/04/2015 Rating Decision – Codesheet). 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 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. An April 2015 Initial PTSD examination described the Veteran’s symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances in motivation in mood, difficulty in establishing and maintaining effective work and social relationships as resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily with normal routine behavior self-care and conversation. Poor sleep and exaggerated startle response were also noted, with occasions when these symptoms are more pronounced (5/09/2015 C&P Exam, pgs. 4, 9, and 11). During his June 2020 hearing, the Veteran testified to having panic attacks and nightmares that were so severe that he has wanted to die; he stated that he had asked God to kill him. The Veteran described not going out at night and having panic attacks every couple weeks, occurring with noise exposure. He endorsed hypervigilance, locking gates and doors. The Veteran and his wife described occurrences of unprovoked anger or irritability, to include severe incidents of road rage, having forced drivers to the side of the road, and having shaken employees out of anger. She also noted if he had a bad night, moods present themselves. The Veteran’s wife described the Veteran’s isolating behaviors, such as spending time in the garage. She noted the Veteran sometimes refers to “little people” requiring them to shut doors and sometimes hearing gun shots that she does not hear (6/05/2020 Hearing Transcript, pgs. 19-30). The Board found the Veteran and his wife to be competent and credible in their describing of the Veteran’s behaviors and has assigned their lay testimony probative weight favoring the Veteran’s claim. Review of the evidence reveals the Veteran’s post-traumatic stress disorder has manifested with symptoms including praying for death, hypervigilance, self-isolation, references to little people and hearing gunshots that are not there, described impaired impulse control cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Board finds the severity, frequency, and duration of the Veteran’s unlisted symptoms more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. In considering the Veteran’s symptoms against the rating criteria, the Board does not find evidence that the Veteran’s symptoms have resulted in total occupational and social impairment. In this regard, he remains married and reported having a close relationship with his children. Moreover, while described as mainly being a loner, it was noted at the hearing that on occasion friends would visit and play cards. Thus, while the Veteran’s disability picture involves significant impairment, total social and occupational impairment is not shown. In summary, the Board finds the Veteran is entitled to a disability rating of 70 percent, and no higher, for service-connected posttraumatic stress disorder. REASONS FOR REMAND 11. Bilateral hearing loss is remanded. The Veteran has claimed hearing loss due to service and has described hazardous noise exposure to include 175-millimeter guns and incoming shelling during service in Vietnam (9/17/2014 VA 21-526EZ, Fully Developed Claim; 6/05/2020 Hearing Transcript, pg. 12). The Veteran does not recall undergoing a hearing acuity test during his separation examination. The Veteran was afforded a December 2012 VA examination for hearing loss, which confirmed bilateral sensorineural hearing loss (12/18/2014 CAPRI, pg. 21). Although hearing loss was noted, the examiner opined that it was not at least as likely as not (50 percent probability or greater) caused by or a result of an event in military service. The examiner explained that comparison of pure tone hearing tests at entrance and discharge indicated the Veteran’s hearing was within normal limits with no decrease in acuity. The Veteran’s entrance audiogram is dated prior to January 1, 1967. Therefore, it is presumed the audiometric results were reported in standards set forth by the American Standards Association (ASA). His separation audiogram is dated between January 1, 1967 and December 31, 1970, and it is unclear whether audiometric results were reported in standards set forth by the American Standards Association (ASA) or International Standards Organization-American National Standards Institute (ISO-ANSI). The current definition for a hearing loss disability found at 38 C.F.R. § 3.385 is based on ISO-ANSI units. Where it is necessary to facilitate data comparison for VA purposes, audiometric data originally recorded using ASA standards will be converted to ISO-ANSI standard by adding between 5 and 15 dB to the recorded data as follows: Hertz 500 1000 2000 3000 4000 6000 Add +15 +10 +10 +10 +5 +10 The Veteran’s 1966 induction physical audiometric results are below, with the conversion in parentheses: HERTZ 500 1000 2000 3000 4000 RIGHT 15 (30) 15 (25) 15 (25) 15 (25) 15 (20) LEFT 15 (30) 15 (25) 15 (25) 15 (25) 20 (25) The Veteran’s July 1968 separation physical audiometric results are below, with the conversion in parentheses: HERTZ 500 1000 2000 3000 4000 RIGHT 5 (20) 0 (10) 10 (20) N/A 5 (15) LEFT 0 (15) 0 (10) 5 (15) N/A 5 (15) When considered under ISO-ANSI, an elevated threshold of the left ear at 2000 Hz. The United States Court of Appeals for Veterans Claims (Court) has indicated that the threshold for normal hearing is between 0 and 20 dB and higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). It is not clear from the examiner’s rationale that converted hearing acuity numbers were considered in formulating the negative nexus opinion. The examiner did not address the Veteran’s recollection that he was not given a hearing acuity exam upon separation, but rather asking the Veteran how he felt and looking at him and that was it, saying he was fine (6/05/2020 Hearing Transcript, pg. 12). Remand is required to obtain a new hearing examination and an opinion that considers the converted hearing acuity measures and the Veteran’s lay statements of record. 12. Lung cancer. The Veteran has claimed entitlement to service connection for lung cancer, to include as secondary to renal cancer. During his hearing he testified that his kidney cancer metastasized to the lung (9/17/2014 VA 21-526EZ, Fully Developed Claim; 11/05/2012 Correspondence; 6/05/2020 Hearing Transcript, pg. 10). Renal cancer has been service connected by this decision. The Veteran has not been afforded a VA examination regarding the nature and etiology of his lung cancer, to include whether his lung cancer is secondary to his now service-connected renal cancer. In situations where there is insufficient medical evidence to decide a claim, the Board must remand the issues in order for a VA examination to be obtained addressing the etiology of the Veteran’s present disability. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Remand for a VA examination to assess the nature and etiology of the Veteran’s lung cancer, to include as secondary to his renal cancer is necessary. The matters are REMANDED for the following action: 1. Schedule the Veteran a hearing loss examination with an appropriately qualified clinician consistent with this remand. The examiner should note in the examination report that the claims file and the remand have been reviewed. The examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that any currently existing hearing loss began during service or is etiologically related to in-service noise exposure as described by the Veteran. In formulating this opinion, the examiner should address whether the 1966 and 1968 in-service audiometric test results, as converted to ISO-ANSI standards, indicate hearing loss attributable to the Veteran's active service. The examiner is reminded that pursuant to Hensley v. Brown, 5 Vet. App. 155, 157 (1993), the threshold for normal hearing is between 0 and 20 dB and higher thresholds show some degree of hearing loss. The examiner should address the Veteran's lay statements of record, to include in service hazardous noise exposure and his contention that he did not receive a hearing acuity examination during his separation physical. If there is a medical basis to support or doubt the contentions provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner is advised that the term "as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of conclusion as it is to find against it. 2. Schedule the Veteran for an examination by an appropriately qualified clinician to determine the nature and etiology of any lung cancer. The examiner should review the entire claims file and this remand in conjunction with the examination. The examiner is requested to render an opinion as to whether it is at least as likely as not (i.e., a likelihood of 50 percent or more) that any currently diagnosed lung cancer is a result of service or any incident occurring during service. The examiner should provide an opinion as to whether the Veteran’s lung cancer is at least as likely as not (50 percent probability) proximately due to service-connected renal cancer. The examiner should address whether it is as likely as not (50 percent probability) that the Veteran’s service-connected renal cancer has aggravated any lung cancer beyond its natural progression. If aggravation is found, the examiner should identify baseline level of disability prior to such aggravation. The examiner is reminded to consider the Veteran’s lay reports, and a reason must be provided if the Veteran’s lay reports are rejected. Lay statements cannot be rejected solely due to a lack of medical documentation. If there is a medical reason to accept or not accept the Veteran’s contentions, the examiner should provide them. If the absence of medical documentation is relevant, the relevance must be explained because the absence of evidence is not positive evidence of the existence or non-existence of an event. If the examiner is able to gather additional understanding or information regarding the circumstances surrounding any inservice injury or event, the examiner should include that information in his remarks. (Continued on the next page)   The examiner should reconcile any conflicting medical evidence of record to the extent possible. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and explain why this is so, (e.g., whether an opinion is beyond what any medical practitioner might be able to provide, based on the evidence of record and current medical knowledge). Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. A. Myers 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.