Citation Nr: 21012802 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 17-09 769 DATE: March 5, 2021 ORDER Entitlement to service connection for a right elbow disability is denied. REMANDED Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for bilateral hearing loss is remanded. FINDING OF FACT The appellant’s right elbow disability did not originate in service and is not otherwise etiologically related to the appellant’s active service. CONCLUSION OF LAW The criteria for service connection for a right elbow disability have not been met. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant served in the Army National Guard from April 1982 to April 1993 with periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) from July to September 1982, July to August 1983, July 1984, June 1985, May 1986, and from January 11 to January 12, 1992. See February 2013 DPRIS - DD 215 Corrected DD 214 Certificate of Release or Discharge from Active Duty; February 2013 STR – Medical. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2019, the appellant testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. By way of background, the Board denied the appellant’s claims for entitlement to service connection for a right elbow condition, bilateral hearing loss, and tinnitus in January 2020, and the appellant appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). See January BVA Decision. In October 2020, the Court granted the parties’ Joint Motion for Remand (JMR), which vacated the Board’s January 2020 decision and remanded the matters for readjudication. See October 2020 CAVC Decision. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Initially, the Board notes that a veteran is a person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable. 38 C.F.R. § 3.1(d). The term "active military, naval, or air service" includes active duty, any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a), (d). The advantage of certain evidentiary presumptions, provided by law, that assist veterans in establishing service connection for a disability do not extend to those who claim service connection based on a period of active duty for training (ACDUTRA) or inactive duty for training (INACDUTRA). Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying presumptions of sound condition and aggravation to appellant's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period). Thus, the evidentiary burden is on the claimant to show that he or she became disabled from an injury or disease incurred in line of duty during ACDUTRA or from an injury incurred in line of duty during INACDUTRA. See Acciola v. Peake, 22 Vet. App. 320, 323-324 (2008); Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). At the outset, the Board notes that the appellant has not achieved veteran status. Specifically, the Board finds that the appellant does not have any periods of active duty service and is not currently service connected for any disabilities incurred in or aggravated during a period of ACDUTRA or INACDUTRA. 1. Entitlement to service connection for a right elbow disability is denied. In his February 2017 substantive appeal, the appellant reported that he injured his right elbow after he slipped on ice while carrying a toolbox across the motor pool in January 1992 and that he has had pain and numbness in his right elbow since the in-service incident. In this regard, the appellant reported that he stuck his arm out to brace his fall, and subsequently experienced pain, which radiated from his right palm up to his right shoulder. The appellant also stated that his commanding officer witnessed the fall and forced him to get treatment, even though the appellant wanted to complete his job and return home. See February 2017 VA Form 9. In addition, the appellant has reported and provided multiple statements to explain why he did not report elbow pain at the time of his in-service injury. To this end, in a February 2013 statement, the appellant reported that he avoided complaining about bodily pains because he did not want to lose his job. See February 2013 VA Form 21-4138 Statement in Support of Claim. Thereafter, in his January 2016 notice of disagreement (NOD), the appellant reported that he injured his elbow after he slipped on ice during service but stated that he chose not to report the injury because he was still able to perform his job and did not want to let his unit down or be teased for complaining about the pain. See January 2016 NOD. In addition, the appellant stated that he chose not to report his right elbow injury during service because it manifested several weeks after an in-service fall, and during his August 2019 Board hearing, the appellant testified that he did not report elbow pain following his in-service injury because he was more concerned with wrist, buttock, and back pain, and because he wanted to retire. See February 2017 VA Form 9; August 2019 Hearing Transcript, pages 4-5. A review of the service treatment records (STRs) shows a September 1986 report of medical examination to the Army National Guard that notes the appellant’s upper extremities to be normal. A statement of medical examination and duty status dated on January 11, 1992, during a period of INACDUTRA, shows that the appellant fell while walking on ice and injured his right wrist and buttock. The following day, the appellant was treated at St. Vincent hospital for lower back pain. Records from St. Vincent hospital further show that an x-ray of the appellant’s lumbar spine revealed five level morphology and mild L5-S1 disc narrowing but was otherwise normal. The assessment was low back pain. A February 1992 quad report of medical examination to the Army National Guard noted the appellant’s upper extremities to be normal, and the appellant reported that his usual occupation was teamster truck driver and denied swollen or painful joints and bone, joint or other deformity on the corresponding report of medical history. See February 2013 STR – Medical. A review of the post-service treatment records shows that the appellant was involved in an automobile accident in February 1994. Following the accident, the appellant had multiple sutured facial and neck lacerations and contusions of the right knee and left hand. In March 1994, the appellant reported continued right knee pain and loss of range of motion, but he was noted to be in excellent health otherwise. See March 2016 Medical Treatment Record – Government Facility. Medical records dated in April 1998, March 1999, December 2000, and August 2009 show that the appellant denied any symptoms of weakness in his arms and hands and difficulty moving his arms. See October 2014 Medical Treatment Record – Non-Government Facility. The appellant underwent a VA examination for elbow and forearm conditions in August 2013. The examiner diagnosed the appellant with right elbow strain. During the examination, the appellant reported that he slipped and fell on ice while he was serving in the Army National Guard in 1992. To this end, the appellant reported that he fell on his outstretched right arm, which gave way and caused his right elbow and wrist to hit the ground. He stated that he noticed pain in his right elbow approximately one or two days after the initial injury. An x-ray of the appellant’s right elbow obtained in conjunction with the examination was normal. After reviewing the evidence of record and performing an evaluation, the examiner opined that it was less likely than not that the appellant’s right elbow disability was incurred in or caused by the claimed in-service injury, event or illness. In support of her opinion, the examiner noted that the appellant reported that he injured his elbow when he fell while walking on ice in 1992. However, the examiner stated that the evidence of record showed that the appellant’s reported fall resulted in a right wrist injury but that there was no record showing that the appellant sustained a right elbow injury at that time. The examiner further noted that the appellant’s medical records did not show any additional documentation of a right elbow disability. As such, the examiner opined that the appellant’s diagnosed right elbow strain was less likely than not the result of his in-service fall. See January 2015 CAPRI. A February 2014 radiology report revealed moderately severe degenerative joint space narrowing and intermediately robust marginal osteophyte formation. In addition, a nerve conduction study obtained the following month, revealed right cubital tunnel carpal tunnel syndrome. A March 2014 private treatment record shows that the appellant reported right elbow pain and stiffness. The private physician noted that the appellant had a remote injury in service, had worked as a manual labor for several years, and gradually noticed increasing stiffness and pain. Following an examination, the private physician diagnosed the appellant with moderate to severe osteoarthritis of the ulnohumeral and radiocapitellar articulations and right elbow osteoarthritis. See August 2019 Medical Treatment Record – Non-Government Facility. In June 2014, the appellant stated that he fell and injured his right arm while he was serving in the military and reported that his arm extension had been limited since the in-service injury. Nerve conduction studies revealed profound slowing of the right ulnar nerve in the elbow to wrist segment, and a right ulnar sensory study showed normal latency at the wrist and below the elbow, though nothing could be obtained above that point. The impression was ulnar neuropathy, tardy right symptomatic. See August 2014 Medical Treatment Record – Non-Government Facility. The appellant was afforded a VA examination for peripheral nerve conditions in December 2014. The examiner noted that the appellant had been diagnosed with right ulnar neuropathy. During the examination, the appellant stated that he fell on ice and attempted to break his fall with his right arm during service. In this regard, the appellant reported that his wrist gave way, causing him to land directly on his elbow. The appellant further stated that he began experiencing pain in his elbow a few hours after the fall but reported that he did not seek treatment at that time and that the pain eventually resolved. However, the appellant noted that he developed numbness in the two lateral fingers a few months after the initial injury. After preforming an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the appellant’s right elbow disability was incurred in or caused by the claimed in-service injury, event or illness. In support of her opinion, the examiner noted that medical records from the appellant’s January 1992 fall showed that he reported a right wrist injury but failed to mention any elbow injury. The examiner further noted that a February 1992 VA examination showed that the appellant’s upper extremities were normal and that the appellant had denied elbow pain and neuritis on a corresponding report of medical history. See January 2015 CAPRI. In support of his claim, the appellant submitted a private treatment record and medical opinion from Dr. Michael Baten, dated in September 2019. Dr. Baten noted that he initially saw the appellant in June 2014, at which time he diagnosed the appellant with neuropathy. Dr. Baten noted that the appellant sustained an injury from a fall in January 1992 and began experiencing problems with his right upper extremity shortly thereafter. To this end, the appellant reported tingling and numbness affecting the fourth and fifth digits of his right hand and gradual onset weakness, which the private physician reported was directly related to the appellant’s in-service injury. On neurologic examination, Dr. Baten found pain and decreased sensation to light touch over the fourth and fifth digits of the appellant’s right hand. Nerve conduction studies revealed severe right ulnar neuropathy about the elbow segment. Following the examination, Dr. Baten diagnosed the appellant with a lesion of the ulnar nerve of the right upper limb (elbow segment). After examining the appellant, Dr. Baten stated that the appellant’s right elbow disability stemmed from a 1992 accident that occurred during service. To this end, Dr. Baten noted that the appellant reported that his original injury occurred when he fell and struck his right wrist and that his symptoms developed mediate and subsequent to that. In this regard, Dr. Baten stated that he suspected that the in-service accident was the proximate cause of the appellant’s current right elbow problems based on the history of the immediacy of the appellant’s symptoms. The appellant also submitted a document titled “example of a nexus letter” dated in September 2019. In the letter, an unidentified physician opined that it was at least as likely as not that the appellant’s right cubital tunnel syndrome and right elbow arthritis were directly related to his military service. See October 2019 Medical Treatment Record – Non-Government Facility. The appellant also submitted a private medical opinion from Dr. Neal Hermanowicz, dated in March 2020. After seeing the appellant in a neurology clinic, Dr. Hermanowicz diagnosed the appellant with ulnar neuropathy at the elbow secondary to degenerative joint disease, which was caused by a fall and trauma incurred in January 1992. In support of his opinion, Dr. Hermanowicz noted that the degenerative changes in the appellant’s right elbow were unusual and due to prior trauma. He further noted that the appellant reported that he slipped on ice during service in January 1992 and struck is right arm, to include his right elbow and wrist, on the ground, but denied any other injuries. In addition, the appellant submitted a private medical opinion from Dr. Richard Cook, dated in March 2020. After evaluating the appellant, Dr. Cook opined that, given his history, the appellant’s right arm problems likely started with his 1992 injury. In support of his opinion, Dr. Cook noted that the appellant reported that he slipped on ice and landed on his right arm while he was in the military in 1992. He further noted that the appellant acknowledged that he initially had more pain in his wrist but subsequently noticed worsening problems with his right elbow. Dr. Cook also stated that nerve studies conducted in 2014 and 2019 indicated that the appellant had ulnar neuropathy at his right elbow and that x-rays and CT scans revealed severe osteoarthritis of the right elbow. Notably, in a progress note dated on the same day, Dr. Cook stated that, given his history, “it sound[ed] like” the appellant’s problems likely started with his 1992 fall, but that he could not with any certainty know when the problem initially started. See December 2020 Medical Treatment Record - Non-Government Facility. After a review of the evidence of record, the Board finds that service connection for a right elbow disability is not warranted. In the present case, there is sufficient evidence that the appellant meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Specifically, the August 2013 VA examiner diagnosed the appellant with right elbow strain and the December 2014 VA examiner noted that the appellant had been diagnosed with right ulnar neuropathy. See January 2015 CAPRI. Accordingly, the remaining question is whether the appellant’s diagnosed right elbow disability originated in service or is otherwise etiologically related to the appellant’s active service. With respect to an in-service injury or disease, a review of the STRs confirms that the appellant fell while walking on ice during a period of INACDUTRA in January 1992. However, while the STRs show that the appellant reported injuries to his buttock, lower back, and right wrist following the in-service fall, they do not show any complaints of or treatment for a right elbow injury during service. See February 2013 STR – Medical. In this regard, the Board recognizes the appellant’s statements explaining why he did not seek medical care for a right elbow injury immediately after his INACDUTRA injury. To this end, as stated above, the Board notes that the appellant has stated that he chose not to seek treatment at the time of his reported injury for the following reasons: he did not want to lose his job; he was still able to perform his job; he did not want to let his unit down or be teased for complaining about the pain; the pain did not manifest until several weeks after the in-service fall; he was more concerned with wrist, buttock, and back pain; and he wanted to retire. See February 2013 VA Form 21-4138 Statement in Support of Claim; January 2016 NOD; February 2017 VA Form 9; August 2019 Hearing Transcript, pages 4-5. The Board does not find his explanations credible. The multiple justifications, provided at different times throughout the appeal as outlined above, made decades after his separation from service, are not persuasive. The most probative evidence is evidence that is recorded contemporaneous with the actual event. This is because the evidence was recorded in real time, when an accurate assessment of the injury was important in order for the appellant to receive the necessary treatment. With time, in this case, decades, memories fade and events are reported based on recollections, as opposed to factual information. As reflected above, there were no reports of right elbow pain or injury at the time of the fall. The most likely explanation for the lack of right elbow complaints is because there were no right elbow complaints at that time. Further, the appellant was examined in February 1992, more than a month after the fall and upon clinical evaluation, his upper extremities (including right elbow) were normal. The Board finds this contemporaneous evidence more probative than his justifications made years after service for why there is no record of a right elbow injury. The appellant is competent to describe the extent of his current right elbow symptomatology and the onset of perceivable right elbow symptomatology during service and onward. See Layno v. Brown, 6 Vet. App. 465 (1994). However, the Board finds that the more probative evidence of record weighs against the credibility of the appellant’s assertions that he has been experiencing elbow pain since his INACDUTRA injury. See Gardin v. Shinseki, 613 F.3d 1374, 1380 (Fed. Cir. 2010) (upholding Board finding that inconsistent lay statements were not credible because they were in direct contradiction to the more credible, competent, reliable, and clearly documented medical evidence). To this end, the Board finds that the most probative evidence of record reflects that the appellant’s right elbow symptoms did not manifest until many years after his separation from service. A review of the post-service treatment records shows that the appellant was initially diagnosed with right elbow sprain in August 2013, approximately 20 years after he was discharged from the Army National Guard. Moreover, medical records dated in April 1998, March 1999, December 2000, and August 2009 show that the appellant repeatedly denied symptoms of weakness in his arms and hands and difficulty moving his arms. See October 2014 Medical Treatment Record – Government Facility. Although he may not have been specifically asked about his elbow, the Board finds that it is reasonable to assume that when asked about difficulty moving his arms, if the appellant was having problems with his elbow, he would have reported such as elbows are involved in arm movements. Thus, the Board finds that the absence of reports or findings related to the appellant’s right elbow disability until August 2013, or approximately 20 years after his separation from service, considered in conjunction with the presence of medical records showing that the appellant repeatedly denied weakness and difficult motion in his right arm, to be more probative than the appellant’s assertions that he has been experiencing symptoms since service. The Board also notes that there are conflicting medical opinions of record as to whether the appellant’s current right elbow disability is related to service. After a review of those opinions, the Board finds the August 2013 and December 2014 VA medical opinions, when considered together, to be the most probative evidence of record. In this regard, the Board finds the September 2019 private medical opinion from Dr. Baten and the March 2020 private medical opinions from Dr. Hermanowicz and Dr. Cook to be speculative as they appear to be based upon the appellant’s lay statements, which have been shown to be unreliable. To this end, the Board notes that none of the aforementioned private physicians address the absence of complaints or treatment for right elbow pain following the appellant’s INACDUTRA injury. In addition, the private physicians did not discuss the appellant’s repeated denials of weakness or difficulty with locomotion, which continued until August 2009, or the significance, if any, that the appellant initially reported an in-service right shoulder injury in February 2013, approximately 20 years after the appellant was discharged from the Army National Guard. See February 2013 VA Form 21-4138 Statement in Support of Claim. Moreover, there is no indication that the private physicians reviewed the appellant’s STRs prior to proffering their medical opinions. In this regard, all three physicians reported that they relied on the appellant’s statements regarding his initial injury and did not reference any objective medical evidence, other than their own treatment records. See October 2019 Medical Treatment Record – Non-Government Facility; December 2020 Medical Treatment Record – Non-Government Facility. Thus, the Board finds that the September 2019 private medical opinion from Dr. Baten and the March 2020 private medical opinions from Dr. Hermanowicz and Dr. Cook are based, at least in part, on an incomplete and inaccurate factual premise, and as such, are currently inadequate to adjudicate the issue on appeal. See Reonal v. Brown, 5 Vet. 458, 461 (1993) (medical opinions based on an incomplete or inaccurate factual premise are not probative). In addition, the Board finds the September 2019 private medical opinion from Dr. Baten and the March 2020 private medical opinion from Dr. Cook to be inadequate as they are speculative in nature. In this regard, the Board notes that speculative language such as “I suspect,” “sounds like,” and “cannot with any certainty know” create an adequate nexus for the purposes of establishing service connection, as they do little more than suggest the possibility of a relationship. See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Utendahl v. Derwinski, 1 Vet. App. 530, 531 (1991); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993). Moreover, the Board finds that the September 2019 “example of a nexus letter” is also inadequate. In this regard, the Board notes that the top of the opinion states that it is “not a form to fill out” and directs physicians to retype the language of the form onto their professional letterhead stationery. Moreover, the medical opinion merely states that it is at least as likely as not that the appellant’s diagnosed right cubital tunnel syndrome and right elbow arthritis were the direct result of his military service, without offering rationale or stating what evidence was reviewed in conjunction with the opinion. The Board also notes that it is not clear from the form who authored the opinion or whether it was completed by a physician or another individual competent to offer a medical opinion. See October 2019 Medical Treatment Record – Non-Government Facility. In contrast, the Board finds the August 2013 and December 2014 VA medical opinions to be the most probative evidence of record. The VA examiners thoroughly reviewed the claims file and discussed the relevant evidence, considered the contentions of the appellant, and provided an adequate supporting rationale for the conclusions reached. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board recognizes that the August 2013 and December 2014 VA examiners did not address the appellant’s explanations as to why he chose not to seek treatment for his right elbow disability during service. However, for the reasons stated above, the Board finds that the appellant’s assertions lack credibility, and as a result, that a discussion of such evidence is unnecessary. Miller v. Wilkie, 32 Vet. App. 249 (2020). The Board notes that, in the October 2020 JMR, the Court found that the August 2013 and December 2014 VA medical opinions were incomplete because the examiners failed to address the appellant’s statements explaining why he did not report elbow pain at the time of his in-service injury, and thereby inadequate to adjudicate the issue on appeal. However, “the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself[.]” Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (“The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements.”). In this regard, as the appellant’s lay statements explaining why he did not seek treatment during service and regarding the onset of his right elbow symptoms have been found to lack credibility, the Board finds that a remand for another VA examination is unnecessary as there is nothing for the examiner to consider. Based on the foregoing, the Board finds that the second and third Shedden requirements have not been met. Although the appellant is entitled to the benefit-of-the-doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for service connection for a right elbow disability. The claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). Reasons for Remand 1. Entitlement to service connection for tinnitus is remanded. 2. Entitlement to service connection for bilateral hearing loss is remanded. In the October 2020 JMR, the Court found that the December 2014 VA hearing loss and tinnitus examination was inadequate with respect to the appellant’s claim of entitlement to service connection for tinnitus because the examiner’s opinion was not clear enough to the useful to the Board. In this regard, the December 2014 VA examiner opined that it was at least as likely as not that the appellant’s tinnitus was a symptom associated with his diagnosed clinical hearing loss. In support of her opinion, the examiner noted that tinnitus was known to be a symptom associated with hearing loss. In addition, the examiner opined that it was less likely than not that the appellant’s diagnosed tinnitus was caused by or a result of military noise exposure. To this end, the examiner noted that she could not determine tinnitus etiology during active service with reasonable certainty based on the available evidence of record or scientific knowledge. However, she noted that the appellant’s service treatment records (STRs) did not reveal any significant shift in hearing between the time of his enlistment and separation from service, and there was no record of complaints or treatment for tinnitus during service. As such, the examiner opined that the appellant’s reported tinnitus was likely related to the post-military events that caused his hearing loss disability as tinnitus was known to be a symptom of hearing loss. See January 2015 CAPRI. However, the examiner did not explain the causal connection between the post-military events, the appellant’s noise exposure in recreation and employment, and his current hearing loss disability. In addition, the examiner failed to make this connection in the hearing loss portion of her examination report. Thus, absent further explanation, the Board finds that this December 2014 VA examiner’s opinion to be unclear, and as a result, currently inadequate to adjudicate the appellant’s claim. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (stating that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). In addition, the Court found that the December 2014 VA examiner failed to address evidence potentially contrary to her medical opinion. In this regard, during his August 2019 Board hearing, the appellant’s representative testified that the appellant complied with hearing protection requirements in his post-service employment. See August 2019 Hearing Transcript, page 3. In this regard, a private treatment record from Premier Hearing Center, dated in February 2014, shows that the appellant reported occupational noise exposure in the military and around heavy machinery, and the private audiologist found that the appellant had intermittent tinnitus and slightly decreased hearing in his left ear. See August 2014 Medical Treatment Record – Non-Government Facility. The Court also referenced a private audiological evaluation from Dr. Patricia Gillilam, dated in September 2019. In this regard, after conducting an examination, Dr. Gillilam opined that the appellant’s tinnitus was likely due to in-service noise trauma from a grenade explosion because that was when the onset of tinnitus was reported. See October 2019 Medical Treatment Record – Non-Government Facility. After the October 2020 JMR, the appellant also submitted an additional private medical opinion from Dr. Paul Christian Daly, a family physician, dated in December 2020. Dr. Daly noted that the appellant’s primary diagnosis was tinnitus, and that he had a secondary diagnosis of progressive hearing loss, left greater than right. Dr. Daly noted that the appellant reported that he was exposed to a grenade explosion while undergoing basic training in June 1982. Notably, Dr. Daly stated that he reviewed the circumstances, history, and events of the appellant’s military service but acknowledged that he did not have access to any of the appellant’s service records. In addition, Dr. Daly reported that he was not aware of the appellant’s personal experiences or history. However, after reviewing available records, Dr. Daly opined that it was at least as likely as not that the appellant’s tinnitus began after he was exposed to a grenade explosion during basic training. In addition, Dr. Daly opined that the explosion and noise exposure in his military occupational specialty (MOS) may have at least contributed to the appellant’s current hearing loss disability, particularly with regard to his left ear hearing disorder. In this regard, Dr. Daly reported that National Institute of Health (HIH) and National Institute on Deafness and Other Communication Disorders (NIDCD) literature showed that a single episode of loud explosion could cause ongoing tinnitus. See December 2020 Medical Treatment Record – Non-Government Facility. In addition, in an email dated one day later, Dr. Daly noted that the appellant’s hearing loss was worse in his left ear, which would be accounted for if the appellant’s left side was facing the grenade at the time of the reported basic training accident. However, Dr. Daly further noted that there were other diagnoses, which although unlikely, could account for the difference, to include an acoustic neuroma. See December 2020 Email Correspondence. VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, the Board finds that a remand is necessary to obtain a VA examination and opinion to determine the nature and etiology of the appellant’s tinnitus and to reconcile and/or address the conflicting medical evidence of record. Moreover, because the December 2020 medical opinion from Dr. Daly suggests that the appellant’s hearing loss may be secondary to his tinnitus, the appellant’s claim for entitlement to service connection for bilateral hearing loss must also be remanded to obtain an adequate medical opinion. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the appellant, request all VA treatment records not already associated with the file from the appellant’s VA treatment facilities, and all private treatment records from the appellant not already associated with the file. 2. After completion of the above development, schedule the appellant for a VA examination by an appropriately qualified examiner to determine the nature and etiology of his claimed bilateral hearing loss and tinnitus disabilities. The examiner should provide the following opinions: (a.) Is it at least as likely as not (50 percent probability or greater) that the appellant’s tinnitus was incurred or aggravated during a period of ACDUTRA or INACDUTRA, to include as due to noise trauma from a grenade explosion? Please explain why or why not. (b.) Is it at least as likely as not (50 percent probability or greater) that the appellant’s bilateral hearing loss was incurred or aggravated during a period of ACDUTRA or INACDUTRA? Please explain why or why not. (c.) Is it at least as likely as not (50 percent probability or greater) that any currently diagnosed hearing loss disability was (i) caused or (ii) aggravated by the appellant’s diagnosed tinnitus? Please explain why or why not. If aggravation is found, the examiner should identify, to the extent possible, the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the appellant’s diagnosed tinnitus. The appellant’s file, to include a copy of this remand must be made available to and be reviewed by the examiner in conjunction with the examination. The examiner should consider the February 2014 private treatment record from Premier Hearing Center, the September 2019 private treatment record from Dr. Gillilam, the December 2020 private medical opinion and email from Dr. Daly, and any other conflicting medical evidence of record, to include all other records identified in the body of this Remand. (Continued on the next page)   All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Justis, Attorney-Advisor 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.