Citation Nr: 21009150 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 17-63 568 DATE: February 19, 2021 REMANDED Entitlement to service connection for otitis externa is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1986 to July 2007. This appeal to the Board of Veterans’ Appeals (Board) is from an October 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In support of this claim, the Veteran testified at a videoconference hearing in January 2019 before the undersigned Veterans Law Judge (VLJ) of the Board. A transcript of the hearing is of record. The Board subsequently remanded this claim back to the Agency of Original Jurisdiction (AOJ) in May 2020 for further development and consideration – including to obtain relevant treatment records and for an examination and medical opinion concerning the etiology of the Veteran’s otitis externa, especially in terms of whether related or attributable to his service. Still more development of this claim is required, however, so the Board is again remanding it back to the AOJ. In May 2020, the Board also remanded a claim of entitlement to service connection for headaches secondary to the otitis externa. But, on remand, service connection was granted for headaches – albeit, instead, as directly related to the Veteran’s service rather than as secondary to his otitis externa. See December 2020 rating decision. In any event, if he disagrees with the initial rating and/or effective date assigned for this now service-connected disability, he must separately appeal these “downstream” issues. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Entitlement to service connection for otitis externa is remanded. The Veteran asserts that his current otitis externa is related to the treatment he received in service for ear pain. As already alluded to, in May 2020 the Board remanded this claim back to the AOJ for a medical opinion concerning this posited correlation (“nexus”) between the Veteran’s current otitis externa and his service. To this end, he was afforded a VA examination in December 2020. The VA examiner concluded the Veteran’s otitis externa is less likely than not due to his service. This VA examiner reasoned that, despite the Veteran’s confirmation of his otitis externa, this examiner was unable to find any evidence of a diagnosis of this disease in the Veteran’s military medical records (i.e., service treatment records (STRs)). This rationale is inadequate, however, since a medical opinion is deficient if it is based solely on the absence of documentation in the STRs of the now claimed disability and does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). See Dalton v. Peake, 21 Vet. App. 23 (2007). In other words, the absence of treatment or symptoms in service is not necessarily fatal to the claim for service connection, even accepting that it is a relevant consideration, but cannot be the sole or exclusive reason for disassociating the claimed condition from the Veteran’s service. But, perhaps even more importantly here, the Veteran’s STRs contain two references to treatment for earaches and even a diagnosis of otitis externa. So, the VA examiner’s opinion is predicated on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458 (1993) (An opinion is only as good and credible as the history on which it was based). Notably, in a STR dated January 24, 2001, the Veteran reported having ear pain for five days. The evaluating physician diagnosed “as/oe” (left ear otitis externa). The Veteran had the same complaint of left ear pain in according to a subsequent STR dated January 3, 2002. Thus, the December 2020 VA examiner's opinion is based on an incomplete review of the records and/or an inaccurate factual premise. When VA undertakes to have the Veteran examined for a needed medical opinion, it must ensure the examination and opinion are adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Thus, an addendum (supplemental) medical opinion must be obtained before deciding the appeal of this claim. Accordingly, this claim is REMANDED for the following still additional development and consideration: Obtain supplemental comment (an addendum opinion) concerning the etiology of the Veteran’s otitis externa, including especially in terms of whether it is as likely as not: a) directly related or attributable to his service, including particularly to the documented left ear pain he had during his service on January 24, 2001 and again on January 3, 2002, resulting in this diagnosis of left ear otitis externa or b) that is caused OR aggravated by a service-connected disability, including especially by his recurrent bilateral tinnitus. *The prior December 2020 VA examiner erroneously concluded there was no diagnosis of otitis externa during the Veteran’s service – when, in actuality, his STRs show this diagnosis and the complaints of left ear pain mentioned on those specific dates. Thus, if the current examiner agrees the current otitis externa is not the same type of ear infection the Veteran experienced during his service, there must be reconciliation of this conclusion with the STRs. When responding, either favorably or unfavorably, the examiner must provide explanatory rationale for all opinions expressed, preferably citing to evidence in the record supporting conclusions and/or accepted medical authority. If the examiner ultimately cannot provide the requested etiology opinion without resorting to mere speculation, this not only must be so stated expressly but, as importantly, the examiner must provide the reasons why an opinion would require speculation. As examples, the examiner must indicate whether there was any further need for information or testing necessary to make a determination, whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner, or whatever other reason precludes a sufficiently definitive response. In other words, merely saying he/she cannot respond will not suffice. KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Hamm, Associate 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.