Citation Nr: 21010557 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 18-23 594 DATE: February 25, 2021 REMANDED The petition to reopen the Veteran’s claim for service connection for a right shoulder disability is remanded. Service connection for a right knee disability is remanded. Service connection for hypertension is remanded. Service connection for left ear hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2003 to July 2008. In February 2020, the Board declined to reopen the Veteran’s claim for service connection for a right shoulder disability and denied service connection for a right knee disorder, hypertension, and left ear hearing loss. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In September 2020, the Court issued an Order granting a Joint Motion of Partial Remand (JMR) which vacated the Board’s decision as it pertained to the above captioned claims and returned these issues to the Board for further appellate review.   Right shoulder In his December 2020 Informal Hearing Presentation (IHP), the Veteran stated that medical records regarding the treatment of his right shoulder disorder had not been obtained prior to the denial of his claim. As such, the Board finds remand necessary to seek to obtain any medical records regarding treatment of the Veteran’s right shoulder which are not a part of the record. Right Knee Hypertension Upon review of the record, and in consideration of the Veteran’s December 2020 IHP, the Board notes that no examinations regarding the etiology of the claimed conditions have been afforded to the Veteran; remand is necessary as the low threshold for obtaining such an examination and medical opinion has been surpassed in this case. See 38U.S.C. §5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Left Ear The Veteran is service connected for right ear hearing loss and tinnitus. At the time of the Board’s February 2020 denial of his claim the Veteran had not undergone a hearing examination of his left ear since 2016. The Board finds that a more current examination is necessary. The matters are REMANDED for the following action: 1. Contact the Veteran and afford him the opportunity to identify by name, address, and dates of treatment or examination any relevant private medical treatment records for his right shoulder disorder, specifically including Northtowns Orthopedics, as identified in the Veteran’s December 2020 IHP. After securing the proper authorizations where necessary, arrange to obtain all the records of treatment or examination from all the sources listed by the Veteran that are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making two efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 2. Schedule the Veteran for an examination(s) by an appropriate clinician to determine the nature and etiology of any diagnosed right knee disorder and/or hypertension. The claims file should be made available to the examiner for review. The examiner must opine whether it is at least as likely as not (50 percent or greater probability) that any such diagnosed right knee disability or hypertension was incurred in, or due to, the Veteran’s service. The Veteran’s lay statements regarding onset and continuity of symptomology should be recorded and considered. A rationale for all opinions must be provided. 3. Schedule the Veteran for an appropriate examination to determine the nature and likely etiology of any diagnosed left ear hearing loss. The claims file should be made available to the examiner for review. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) any diagnosed left ear hearing loss had onset in service or within one year following separation from service or was causally related to service. The examiner is to note that the Veteran’s noise exposure in service has been conceded and that he is service connected for both right ear hearing loss and tinnitus. A discussion of the facts and medical principles involved (to include acoustic trauma and military noise exposure), including any service treatment records or military personnel file records which may have been made a part of the evidence of record and the Veteran’s lay assertions, should be considered in giving this opinion. It is not a sufficient rationale for a negative nexus opinion merely to state or assume that the Veteran’s hearing was within normal limits on audiometric testing during service. In such a case, service connection is not precluded if there is sufficient evidence to demonstrate a relationship between the appellant’s service and a current disability which satisfies 38 C.F.R. § 3.385. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The examiner must explain the rationale for all opinions JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Parrish, 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.