Citation Nr: 21012560 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 16-60 087 DATE: March 4, 2021 REMANDED An initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). Service connection for hearing loss. Service connection for tinnitus. Service connection for a back condition.   REASONS FOR REMAND The Veteran served on active duty from August 1990 to September 1994, with additional service in the Army National Guard. The claim is on appeal from an August 2015 rating decision. In February 2021, the Veteran testified at a Board hearing. 1. An initial rating in excess of 30 percent for PTSD. The Veteran contends that he is entitled to a higher rating for his service-connected PTSD. At his February 2021 Board hearing, the Veteran testified that the severity of his symptoms has gotten worse since his June 2015 VA examination, describing sleep problems, irritation, strained relationships, and the need to work alone to avoid people. The Board finds that a remand is warranted for a new VA examination to determine the current severity of the Veteran’s service-connected PTSD, and for a new medical opinion as to the severity throughout the appeal period since service connection. See Snuffer v. Gober, 10 Vet. App. 400 (1997); see also Fenderson v. West, 12 Vet. App. 119 (1999). In light of the remand, updated VA treatment records should be obtained. 2. Service connection for hearing loss. 3. Service connection for tinnitus. The Veteran seeks service connection for hearing loss and tinnitus, and contends that it is a result of his time during service. At his February 2021 Board hearing, he described exposure to loud noise, particularly airplane noise while stationed at Fort Bragg. The Veteran’s DD 214 lists his primary specialty as Administrative Specialist. The Veteran was afforded a VA examination with puretone audiometry measurements and the Maryland CNC Test in June 2015. The result of the audiological examination indicated that the Veteran’s hearing loss did not meet the criteria for disability purposes under 38 C.F.R. § 3.385. The VA examiner additionally stated that he did not report recurrent tinnitus. A current disability is a threshold issue for service connection. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). However, at the February 2021 Board hearing, the Veteran testified that his hearing has gotten worse since the June 2015 VA examination, and that he experiences tinnitus ringing despite the contrary reporting by the examiner. Additionally, the Board notes that, unfortunately, most of the Veteran’s service treatment records (STRs) are unavailable for review. The RO took efforts to obtain these records, but determined that only his dental records were available. See August 2015 Correspondence. In appeals where a veteran’s STRs are unavailable, there is a heightened obligation to assist the veteran in the development of the case, a heightened obligation to explain findings and conclusions, and a heightened duty to consider carefully the benefit of the doubt rule. See Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005). Thus, the Board finds that another examination and opinion is warranted to determine if the Veteran currently has the disabilities of tinnitus and hearing loss at the required levels, and whether the conditions are related to service. 4. Service connection for a back condition. The Veteran contends that his back condition is a result of his military service. At the February 2021 Board hearing, he stated that he has experienced back pain ever since service as a result of road marches with heavy weights, and that he must take pain medication for the disorder. The Veteran underwent a Gulf War General Medical Examination in June 2015, in which the examiner also completed a Disability Benefits Questionnaire (DBQ) for the thoracolumbar spine. The examiner identified a diagnosis of spondylosis and degenerative disc disease. However, when providing an opinion, the examiner focused only on the Veteran’s potential exposure to environmental hazards with his Gulf War duties, and opined that it was less likely than not that his back condition was a result of exposure to any events experienced during his service in Southwest Asia. The Board finds that another medical opinion is still warranted, as the June 2015 examiner did not provide an adequate opinion as to general service connection, only referring to possible exposure to environmental hazards. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The examiner should also consider the Veteran’s lay statements. Additionally, as noted above, only the Veteran’s STR dental records are available for review. In appeals where a veteran’s STRs are unavailable, there is a heightened obligation to assist the veteran in the development of the case, a heightened obligation to explain findings and conclusions, and a heightened duty to consider carefully the benefit of the doubt rule. See Washington, 19 Vet. App. 362, 368. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records since October 2017. 2. Schedule the Veteran for a VA psychiatric examination (or telehealth interview, review of the record, etc., if an in-service examination is not feasible) by an appropriate clinician to ascertain the current severity of his PTSD. Consideration should be given to the Veteran’s statements regarding the severity of his PTSD symptoms throughout the appeal period. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s hearing loss and tinnitus. The entire claims file must be reviewed by the examiner. The examiner should first determine whether the Veteran has hearing impairment for VA purposes under 38 C.F.R. § 3.385 and also whether he has tinnitus. If so, the examiner is then asked to opine as to whether the Veteran’s hearing loss and tinnitus at least as likely as not (50 percent or greater possibility) had onset during or within one year of service, or is otherwise related to, his active military service. The examiner is asked to specifically consider and discuss: (1) any established exposure to loud noise due to his MOS and/or other duties, and (2) the Veteran’s lay statements of noise exposure. The examiner should provide rationale for all opinions expressed, including by citing to the record. 4. Schedule the Veteran for an examination (or telehealth interview, review of the record, etc., if an in-service examination is not feasible) by an appropriate clinician to determine the nature and etiology of the Veteran’s back condition. The entire claims file must be reviewed by the examiner. The examiner is then asked to opine as to whether the Veteran’s back condition at least as likely as not (50 percent or greater possibility) had its onset during or within one year of service, or is otherwise related to, his active military service. The examiner is asked to specifically consider and discuss: (1) the Veteran’s lay statements of road marches, heavy weights, and symptoms of back pain that began during service, and (2) February and October 2014 VA treatments record reports of a “chronic” back condition. The examiner should provide rationale for all opinions expressed, including by citing to the record. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Morford, 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.