Citation Nr: 21011953 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 15-02 627 DATE: March 3, 2021 Entitlement to service connection for coronary artery disease (CAD) with atrial fibrillation (AFIB) and cardiomyopathy is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for sensorineural hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include Post Traumatic Stress Disorder (PTSD), and depressive and anxiety disorders is remanded. Entitlement to service connection for erectile dysfunction and impotence is remanded. Entitlement to service connection for chronic fatigue is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1961 to October 1965. This matter is before the Board of Veterans’ Appeals (Board) on appeal from September 2010 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). 1. Entitlement to service connection for CAD and hypertension is remanded. The Veteran originally alleged that his hypertension was due to depression, anxiety and PTSD and has submitted treatise evidence which addresses this. As set out below, the mental disorders claim is being remanded. This claim is inextricably intertwined with the mental disorders claim and must also be remanded. The Veteran has submitted a Radiation Risk Activity Information Sheet recently which details his reported exposure to ionizing radiation. Inform the Veteran that he does not have a radiogenic disease. Inform the Veteran that he should cite to or submit competent scientific or medical evidence indicating that the CAD and/or hypertension is a radiogenic disease. If such evidence is received, then VA must undertake the development appropriate to claims for service connection for radiogenic diseases based on ionizing radiation. 38 C.F.R. § 3.311. 2. Entitlement to service connection for sensorineural hearing loss and tinnitus are remanded. The Veteran underwent a VA examination for hearing loss and tinnitus in July 2010. At the examination, mild sensorineural hearing loss was shown and recurrent tinnitus was reported. The VA examiner concluded that the Veteran’s hearing loss was less likely than not caused by or the result of noise exposure in the military. She cited, the institute of medicine report on noise exposure that reported NIHL (noise induced hearing loss) occurred immediately and there is no scientific support for delayed onset NIHL weeks, months, or years after the exposure event. As for the Veterans tinnitus, the examiner did not give an opinion. It was reported that an opinion could not be given without a resort to mere speculation. Since there was no hearing loss, it could not be determined to a reasonable degree of certainty based on the evidence; instead, occupational noise exposure may have contributed to impaired hearing and/ or tinnitus. The Board finds this opinion is inadequate for ratings purposes. The Veteran reported that he had had tinnitus and hearing loss during active duty. The Veteran is competent to report on this symptomology. The etiology opinion must address the Veteran's reports of continuous symptomology. Moreover, as shown below, the Veteran had threshold shifts (temporary and permanent) in his hearing during service. The significance of this evidence has not been addressed. Since his active duty was prior to January 1, 1967, the Board assumes the American Standard Association (ASA) units was used. However, the ISO-ANSI standard has been included below in the parentheses. Right Ear Hertz 500 1000 2000 3000 4000 6000 November 2, 1961 -10 (5) -10 (0) -15 (5) -10 (0) -10 (-5) 30 (40) July 15, 1963 15 (30) 15 (25) 15 (25) 15 (25) 15 (20) 30 (40) July 13, 1965 10 (25) 5 (15) 15 (25) 15 (25) 20 (25) 15 (25) Left Ear Hertz 500 1000 2000 3000 4000 6000 November 2, 1961 15 (30) -10 (0) 0 (10) -10 (0) -10 (-5) 0 (10) July 15, 1963 15 (30) 15 (25) 15 (25) 15 (25) 15 (20) 20 (30) July 13, 1965 15 (30) 10 (20) 15 (25) 15 (25) 15 (20) 10 (20) Also, in December 1962, an earache / ear block was reported. This evidence must be addressed on appeal. The Board acknowledges the Veteran has submitted a November 2020 private medical opinion from a certified registered nurse practitioner that reports the Veteran had tinnitus and hearing loss and that it is most likely due to his six year exposure to jet engines while in the military. Unfortunately, the clinician did not provide a rationale to support the opinion. Furthermore, to the extent that it was based on an inaccurate factual background, it is questioned. The opinion cites to the Veteran's active duty service where he was exposed to jet engines for six years. Significantly, the Veteran’s active duty was from October 1961 to October 1965. An opinion should be obtained which addressed the above concerns to the extent possible. 3. Entitlement to an acquired psychiatric disorder, to include PTSD, depression, and anxiety is remanded. The Veteran claims that his mental disorder is due, in part, to his participation in air plane crash investigations. He provides the details for one incident and reports that he also participated in numerous other investigations. The Veteran's participation in these non-combat events has not been verified. Attempts must be made to verify these claimed stressors. The Veteran reports that his duty consisted, in part, of programing targeting codes into nuclear weapons during the Cuban Missile crisis and that he has been affected by this ever since. The Veteran's claimed stressor in this regard should be verified. The Veteran also submitted an August 2018 opinion from his licensed professional counselor. The counselor reported, in pertinent part, that the Veteran had been seeing him since January 2018, for one-on-one interviews. The notes or medical records from these interviews have not been associated with the record. Attempts must be made to obtain this evidence. The Veteran has submitted a recent accounting of his reported radiation exposure during active duty. He has alleged that this exposure also caused mental disorders. Further development is required regarding the radiation exposure. 4. Entitlement to service connection for erectile dysfunction and chronic fatigue are remanded. The Veteran originally reported that his erectile dysfunction began during active duty. At the Veteran’s December 2020 hearing, he reported that his erectile dysfunction and chronic fatigue are secondary to his reported acquired psychiatric disorder. As his claim for the psychiatric condition is being remanded, the Board will defer adjudication, as the claims are inextricably intertwined. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (providing that two or more issues are inextricably intertwined if one claim could have significant impact on the other). The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Obtain all pertinent updated treatment records and associate them with the claims file. The Board is particularly interested in the Veteran’s private medical records associated with his claimed acquired psychiatric disorders. 3. Inform the Veteran that he should cite to or submit competent scientific or medical evidence indicating that CAD and/or hypertension are a radiogenic disease. If such evidence is received, then VA must undertake the development appropriate to claims for service connection for radiogenic diseases based on ionizing radiation under 38 C.F.R. § 3.311. 4. Verify to the extent possible the claimed stressors of participating in air plane crash investigations. Verify to the extent possible the claimed stressor of having to program location codes into nuclear weapons during the Cuban Missile crisis. 5. Obtain an addendum opinion by a suitably qualified health care professional to determine the nature and etiology of the Veteran's bilateral hearing loss disability. After review of the claims file, including inservice audiology examinations and the December 2020 hearing testimony, the examiner should respond to the following inquiries: (a.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's bilateral hearing loss had its onset during service or is related to service? (b.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s tinnitus had its onset during service or is related to service? The examiner must specifically address the Veteran's testimony with respect to his in-service noise exposure and continuity of symptoms of hearing loss and tinnitus from active duty to the present. The Veteran's exposure to loud noises from jet engines is to be presumed. 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 rendering the requested opinions, the examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If the examiner 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 examiner 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. 6. Conduct any additional development as required based on the results of the above action paragraphs. G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Wade 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.