Citation Nr: 21013288 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 15-39 117 DATE: March 9, 2021 ORDER Service connection for fibromyalgia, to include as due to exposure to contaminated water at Camp Lejeune, North Carolina, is denied. Service connection for obstructive sleep apnea (OSA) is denied. Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. An initial compensable rating for bilateral hearing loss is denied. An initial rating in excess of 10 percent for tinnitus is denied. REMANDED Entitlement to service connection for headaches, to include as due to exposure to contaminated water at Camp Lejeune, North Carolina, is remanded. FINDINGS OF FACT 1. The Veteran was stationed at Camp Lejeune during both periods of active service, including prior to December 31, 1987, and is therefore presumed to have been exposed to contaminated water. 2. The preponderance of the evidence is against finding that the Veteran’s fibromyalgia began during active service, or is otherwise related to an in-service injury or disease, to include as due to contaminated water at Camp Lejeune. 3. The preponderance of the evidence is against finding that the Veteran’s OSA began during active service, or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that the Veteran’s PTSD began during active service, or is otherwise related to an in-service injury or disease. 5. For the entire period of appeal, the hearing loss is manifested by no more than Level I hearing acuity in the right ear and Level I hearing acuity in the left ear based on pure tone threshold average and speech discrimination. 6. For the entire period of appeal, the tinnitus has been assigned a 10 percent rating, which is the maximum schedular rating authorized under Diagnostic Code 6260. CONCLUSIONS OF LAW 1. The criteria for service connection for fibromyalgia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307(a). 2. The criteria for service connection for OSA have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. 5. The criteria for an initial rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.87, Diagnostic Code 6260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Marine Corps from March 1985 to January 1989, and from February to March 1991. In December 2018, the Board remanded the claims for further development, including obtaining outstanding VA and non-VA treatment records, obtaining a medical opinion on the etiology of the fibromyalgia, and scheduling the Veteran for a VA audiological examination. VA treatment records and private treatment records have subsequently been associated with the record, a medical opinion on the etiology of the fibromyalgia was obtained in October 2020, and the Veteran had a VA audiological examination in December 2020. The Board therefore finds there has been substantial compliance with the remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Stegall v. West, 11 Vet. App. 268 (1998). Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or an injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability also may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disability or if it is aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b). See also Allen v. Brown, 7 Vet. App. 439 (1995). 1. Service connection for fibromyalgia. The Veteran contends that he lived on base at Camp Lejeune, North Carolina, from August 1985 to December 1987. He remembers experiencing severe stomach aches and headaches in service. After going through a very stress-filled two years of business ownership and bankruptcy in 2013, he got very suck and was diagnosed with fibromyalgia. He still had severe muscle pain, stomach issues, and headaches. See the May 2019 statement. Effective March 14, 2017, VA amended 38 C.F.R. §§ 3.307 and 3.309 providing a presumption of service connection for certain diseases based on exposure to contaminants in the water supply at Camp Lejeune. Essentially, as amended, 38 C.F.R. §§ 3.307 and 3.309 establish a presumption of service connection for Veterans who served at Camp Lejeune for no less than 30 days (consecutive or nonconsecutive) from August 1, 1953, to December 31, 1987, and have a diagnosis of any of the following eight diseases, even though there is no record of such disease during service: kidney cancer, liver cancer, non-Hodgkin’s lymphoma, adult leukemia, multiple myeloma, Parkinson’s disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. 38 C.F.R. §§ 3.307(a), 3.309(f). These listed diseases shall have become manifest to a degree of 10 percent or more at any time after service. 38 C.F.R. § 3.307(a)(7)(ii). As fibromyalgia is not a listed disease under 38 C.F.R. § 3.309(f), presumptive service connection is not warranted; however, service connection may be established on a direct service connection basis due to in-service exposure to contaminated water. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The Veteran’s service records confirm that he was stationed at Camp Lejeune during service prior to December 31, 1987, and private treatment records clearly indicate that he has a diagnosis of fibromyalgia. As such, the question for the Board is whether the Veteran’s exposure to contaminants at Camp Lejeune caused or is related to his fibromyalgia. Unfortunately, the evidence does not support a finding that the Veteran’s exposure to contaminants in service caused or relates to his fibromyalgia. Service treatment records (STRs) are unremarkable for complaints, treatment, or diagnosis of fibromyalgia or any relevant symptoms. In an October 1988 separation examination and report of medical history, the Veteran denied currently or ever having any relevant symptoms, including swollen or painful joints; arthritis, rheumatism, or bursitis; bone, joint, or other deformity; lameness; painful shoulder or elbow; recurrent backpain; trick or locked knee; foot trouble; neuritis; frequent trouble sleeping; depression or excessive worry; loss of memory; or nervous trouble of any sort. His upper extremities, lower extremities, feet, spine, and other musculoskeletal were noted to be clinically normal. In a February 1991 annual certificate of physical condition, the Veteran indicated that he did not have any physical defects that he thought might restrict his performance of active duty; and in March 1991, the Veteran was noted to be physically qualified for separation from active duty without defects that would disqualify him from the performance of his duties. Post-service treatment records from Mayo Clinic indicate that in July 2015, the Veteran reported that he began having poor sleep and muscle pain in March 2013, and had current symptoms of chronic pain, widespread musculoskeletal pain, and fatigue. He was diagnosed with fibromyalgia by a rheumatologist at Park Nicollet approximately one year prior. In an April 2017 VA treatment record, the Veteran reported developing fibromyalgia symptoms approximately 4-5 years ago after starting a new business that ultimately failed. He was excessively stressed, and his PTSD flared. He was diagnosed with fibromyalgia by the Park Nicollet rheumatologist and the diagnosis was confirmed by Mayo Clinic. The Board notes that in May 2020, VA requested treatment records from Park Nicollet Clinic. In September 2020, however, VA was notified that the clinic required a fee to process the request. The Veteran was notified in October 2020 that VA was unable to pay the fee and that he should submit the records if he wanted them to be considered. To date, no response has been received. In October 2020, a VA medical opinion was obtained. After review of the record, a VA physician opined that the Veteran’s fibromyalgia was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran had been diagnosed with fibromyalgia in 2012-2013 at age 48 or 49 years of age, which was 25-26 years after his exposure to contaminated water at Camp Lejeune in 1987. Citing the Assessment of Evidence for the Drinking Water Contamination at Camp Lejeune and Specific Causes and Other Disease, dated January 13, 2017, the examiner noted that fibromyalgia is not a condition that has been associated with the substance trichloroethylene (TCE), perchloroethylene (PERC), or benzene, which were in the contaminated water at Camp Lejeune. The examiner explained that fibromyalgia is a chronic, noninflammatory, diffuse pain disorder with the cause unknown. Known risk factors included family history, family history of chronic pain, being female, infection, stress (early lifetime adverse event, illness, trauma, psychosocial), and physical trauma or injury. The Veteran had a history of PTSD related to childhood abuse, which encompassed the known risk factors of stress and physical trauma. Finally, the claimed condition did not satisfy any of the Bradford Hill criteria, known as Hill’s criteria for causation, which was a group of nine principles to establishing epidemiological evidence of a causal relationship between a presumed cause and observed effect. The Board finds that the VA examiner’s opinion to be competent and credible, and as such, entitled to significant probative weight. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The opinion was rendered after reviewing the Veteran’s STRs and other medical records, as well as review of medical literature. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner’s access to the claims folder and the Veteran’s history, and the thoroughness and detail of the opinion). The VA examiner provided facts and rationale on which he based his opinion, including expressly discussing post-service medical records and citing relevant medical literature. Furthermore, the Veteran has not produced a medical opinion to contradict the conclusion of the VA examiner. As such, there is no competent medical evidence that relates the current fibromyalgia diagnosis to the Veteran’s military service. The Board also finds that although the Veteran can describe observable symptoms including pain, his statements cannot be used to determine whether the fibromyalgia diagnosis is related service or to an in-service injury. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). There is no evidence that the Veteran has the medical education and training required to make competent clinical diagnosis, or to attribute such a diagnosis to specific events or injuries. Moreover, the Veteran has not been consistent with his statements regarding the cause of the fibromyalgia. As noted above, in the April 2017 VA treatment record, he attributed the onset of the fibromyalgia to stress he was under when a business failed and his PTSD (which is due to childhood trauma) flared. As such, the Board finds the Veteran’s statements probative with regard to establishing his current symptoms, but finds little probative value with regard to establishing service connection. In any case, their probative value is outweighed by the probative value assigned to an evaluation conducted by a person who has expertise and training pertinent to medical diagnoses. Finally, the earliest evidence of complaints or treatment for fibromyalgia was in approximately 2012, which was 25 years after the Veteran’s separation from his first period of service. This lengthy period of time without diagnosis or treatment weighs against the finding that any current left shoulder, left hip, right hip, or low back diagnosis has existed since service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). As noted above, STRs do not document any left shoulder, hip, or low back complaints; there is no medical evidence showing relevant symptoms or a diagnosis within one year from service separation; and the competent and credible evidence does not establish chronic and continuous symptoms of any left shoulder, hip, or low back disability. As such, service connection on a presumptive basis under 38 C.F.R. § 3.303(a) or (b) is not warranted. In sum, the probative evidence of record weighs against the claim for service connection for fibromyalgia. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Service connection for OSA. 3. Service connection for an acquired psychiatric disorder. Service connection for PTSD generally requires medical evidence establishing a diagnosis of the disorder, credible supporting evidence that the claimed in-service stressor(s) actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). The PTSD diagnosis must be made in accordance with the criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Id.; 38 C.F.R. § 4.125(a). If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). Additionally, lay evidence alone may establish an alleged stressor where: 1) the stressor is related to the Veteran’s fear of hostile military or terrorist activity; 2) a VA psychiatrist, VA psychologist, or VA-contracted psychiatrist or psychologist, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran’s symptoms are related to the claimed stressor; 3) the stressor is consistent with the places, types, and circumstances of the Veteran’s service; and 4) there is no clear and convincing evidence to the contrary. 38 C.F.R. § 3.304(f)(3). Fear of hostile military or terrorist activity is defined as occurring when a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. The Board finds that although the Veteran has diagnoses of obstructive sleep apnea (OSA) and posttraumatic stress disorder (PTSD), the weight of the evidence does not establish that either diagnosis is related to his active service. STRs are silent for complaints, diagnosis, or treatment of any related conditions. As noted above, in an October 1988 report of medical history taken upon separation from active duty, the Veteran denied currently or ever having frequent trouble sleeping, depression or excessive worry, loss of memory, or nervous trouble of any sort, and he was not noted to have any relevant clinical symptoms in the separation examination. In a February 1991 annual certificate of physical condition, the Veteran indicated that he did not have any physical defects that he thought might restrict his performance of active duty; and in March 1991, the Veteran was noted to be physically qualified for separation from active duty without defects that would disqualify him from the performance of his duties. The Veteran has not identified or submitted any medical evidence or supporting statements that would suggest that the current OSA or PTSD is related to his military service. VA treatment records indicate that in a December 2014 appointment to establish care, the Veteran reported that he was sexually assaulted when he was 12 years old. During this turmoil, his mother left the family, he was moved to several different foster homes, was in several treatment houses, and then joined the military. He reported that since separation from service, he had he owned a used car shop about four years ago, which eventually went bankrupt with great losses, and he did not sleep for almost two years after that. He was sleeping some now, using clonazepam, amitriptyline, and CPAP at night. The Veteran was seen by a VA psychologist the same day, where he reported that he had a diagnosis of PTSD related to extreme childhood sexual and psychological abuse. In a January 2015 VA mental health treatment record, the Veteran reported that although he was physically and emotionally abused by his mother while growing up, but that his PTSD symptoms primarily resulted from ongoing sexual molestation by a teacher when he was 12. His PTSD symptoms began again in 2012 when he was under significant stress, and included symptoms of panic attacks, insomnia, nightmares, anxiety, sweating, fatigue, headaches, and diffuse muscle pain. The Veteran was diagnosed with PTSD, alcohol use disorder in partial remission, and mental disorder NOS (not otherwise specified). In a July 2015 private treatment record, the Veteran reported that he began having problems with poor sleep and muscles hurting in March 2013. He used trazodone and amitriptyline to help. He sometimes could not get to sleep and always had trouble staying asleep. The Veteran indicated that he was diagnosed with PTSD related to childhood trauma, but a past sleep study did not show OSA. In an appointment at the same facility two days later, however, the Veteran reported that he had been diagnosed with OSA in 2002 and again in October 2014 at Park Nicollet Clinic. In April 2017, the Veteran reported in a VA appointment that his PTSD symptoms flared approximately 4-5 years prior when he was under excessive stress due to his business failing. To the extent to which the Veteran argues continuity of symptoms since service, the record contradicts these assertions. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). As discussed above, STRs are silent for mention of relevant symptoms or diagnosis. There is no further documentation of sleep problems until at least 11 years after the Veteran’s separation from active military service, and there is no documented diagnosis of PTSD or any other acquired psychiatric disorder until 23 years after separation from service. Moreover, the Veteran’s statements made in his 2014 and 2015 treatment records indicate that he attributed the sleep problems to his muscle pain, PTSD, and/or business losses; and his PTSD has consistently been attributed to childhood trauma. As such, the Board finds that the Veteran’s lay assertions alone are not sufficient to establish continuity since service. The Board notes that the Veteran has not been afforded a VA examination for these claimed disabilities. Under applicable law, a medical examination and/or opinion is deemed “necessary” if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of disability; (2) establishes that the veteran suffered an event, injury, or disease in service, or has a disease or symptoms of a disease listed in 38 C.F.R. §§ 3.309, 3.313, 3.316, and 3.317 manifesting during an applicable presumptive period, provided the claimant has the required service or triggering event to qualify for that presumption; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service or with another service-connected disability. 38 C.F.R. § 3.159(c)(4). Here, there is no competent and credible evidence suggesting that the Veteran’s OSA or any acquired psychiatric disorder, including PTSD, may be associated to his service. As such, an examination is not required in this case. In sum, the probative evidence of record weighs against the claims for service connection for OSA and an acquired psychiatric disorder. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. 4. Increased rating for bilateral hearing loss. Where the evaluation of hearing loss is at issue, an examination for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. Examinations will be conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). A rating for hearing loss is determined by a mechanical application of the rating schedule to the numeric designations assigned based on audiometric test results. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on organic impairment of hearing acuity, as measured by a controlled speech discrimination test and the average hearing threshold, as measured by pure tone audiometric tests at the frequencies of 1000, 2000, 3000 and 4000 hertz. The rating schedule establishes 11 auditory acuity levels designated from Level I, for essentially normal hearing acuity, through level XI for profound deafness. Under 38 C.F.R. § 4.85, Table VI (Numeric Designation of Hearing Impairment Based on Puretone Threshold Average and Speech Discrimination) is used to determine a Roman numeral designation (I through XI) for hearing impairment based on a combination of the percent of speech discrimination (horizontal rows) and the pure tone threshold average (vertical columns). The Roman numeral designation is located at the point where the percentage of speech discrimination and pure tone average intersect. 38 C.F.R. § 4.85(b). The pure tone threshold average is the sum of the pure tone thresholds at 1000, 2000, 3000 and 4000 hertz, divided by 4. This average is used in all cases to determine the Roman numeral designation for hearing impairment. 38 C.F.R. § 4.85(d). Table VI Numeric designation of hearing impairment based on puretone threshold average and speech discrimination. % of discrim- ination Puretone Threshold Average 0-41 42-49 50-57 58-65 66-73 74-81 82-89 90-97 98+ 92-100 I I I II II II III III IV 84-90 II II II III III III IV IV IV 76-82 III III IV IV IV V V V V 68-74 IV IV V V VI VI VII VII VII 60-66 V V VI VI VII VII VIII VIII VIII 52-58 VI VI VII VII VIII VIII VIII VIII IX 44-50 VII VII VIII VIII VIII IX IX IX X 36-42 VIII VIII VIII IX IX IX X X X 0-34 IX X XI XI XI XI XI XI XI Alternatively, VA regulations provide that in cases of exceptional hearing loss, when the pure tone thresholds at each of the four specified frequencies (1000, 2000, 3000 and 4000 hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). The provisions of 38 C.F.R. § 4.86(b) further provide that, when the pure tone threshold is 30 decibels or less at 1,000 Hertz, and 70 decibels or more at 2,000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. Table VIA Numeric designation of hearing impairment based only on pure tone threshold average: 0-41 42-48 49-55 56-62 63-69 70-76 77-83 84-90 91-97 98-104 105+ I II III IV V VI VII VIII IX X XI The findings for each ear from either Table VI or Table VIA, are then applied to Table VII (Percentage Evaluations for Hearing Impairment) to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal rows represent the ear having the better hearing and the vertical columns the ear having the poor hearing. The percentage evaluation is located at the point where the rows and column intersect. 38 C.F.R. § 4.85(e). Table VII Percentage evaluation for hearing impairment (diagnostic code 6100) Poorer Ear XI 100* X 90 80 IX 80 70 60 VIII 70 60 50 50 VII 60 60 50 40 40 VI 50 50 40 40 30 30 V 40 40 40 30 30 20 20 IV 30 30 30 20 20 20 10 10 III 20 20 20 20 20 10 10 10 0 II 10 10 10 10 10 10 10 0 0 0 I 10 10 0 0 0 0 0 0 0 0 0 XI X IX VIII VII VI V IV III II I Analysis The Veteran had a VA hearing loss examination in April 2015. His puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT EAR 0 25 45 40 28 LEFT EAR 10 25 45 55 34 Speech recognition scores were 94 percent in the right ear and 96 percent in the left ear. However, the examining audiologist noted that the test results were inconsistent and unreliable and should not be used for rating purposes. As such, the Board will not rely on these results. A July 2015 private treatment record indicates that the Veteran reported having hearing difficulties, but does not indicate that any audiological testing was done. The Veteran had another VA hearing loss examination in December 2020. His puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 Average RIGHT EAR 10 35 50 40 34 LEFT EAR 15 35 55 45 38 Speech recognition scores were 96 percent in the right ear and 96 percent in the left ear. The examiner noted that the test results were valid for rating purposes and use of word recognition scores was appropriate. Applying these results to Table VI results in a designation of Level I for the right ear and Level I for the left ear. VA treatment records dated throughout the period of appeal are silent for mention of any audiological testing, issuance of hearing aids, or other relevant treatment. In sum, the December 2020 VA examination, the only probative evidence for the period of appeal, translate to Level I hearing loss in the right ear and Level I hearing loss in the left ear when applied to Table VI of the rating schedule (pure tone threshold average and speech discrimination). This level of hearing loss warrants a noncompensable (zero percent) rating under Table VII of the rating schedule. Therefore, a compensable schedular rating is not warranted under Diagnostic Code 6100 at any point during the period of appeal. See 38 C.F.R. § 4.85, Diagnostic Code 6100. 5. Increased rating for tinnitus. The Veteran’s tinnitus is rated under 38 C.F.R. § 4.87, Diagnostic Code 6260. His current 10 percent rating is the maximum schedular rating available. The Board finds that an evaluation in excess of 10 percent is not warranted for the Veteran’s tinnitus. His current rating, the maximum schedular rating allowed, is warranted for recurrent tinnitus. He has described no symptoms beyond tinnitus, which is explicitly contemplated by the rating criteria. He has not identified any way in which his tinnitus is unusual and so warrants a higher rating than the vast majority of veterans experiencing his disability. For these reasons, the Board finds that an evaluation in excess of 10 percent is not warranted for the Veteran’s tinnitus. REASONS FOR REMAND 1. Entitlement to service connection for headaches is remanded. The Veteran asserts that he has headaches due to drinking contaminated water at Camp Lejeune. See the May 2019 statement. STRs indicate that in an October 1988 report of medical history, the Veteran reported having frequent or severe headaches. The Board notes that although a headache disability is not among the disabilities that may be presumptively service-connected on the basis of exposure to water contaminants at Camp Lejeune, service connection may still be granted on a direct basis as the result of the Veteran’s in-service exposure to contaminated drinking water. See Polovick v. Shinseki, 23 Vet. App. 48 (2009); see also 38 U.S.C. § 5103A(d)(1); Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the evidence of record supports the need for a VA medical opinion on the issue. See McLendon v. Nicholson, 20 Vet. App. 79 (2006), 38 U.S.C. § 5103A(d). The matter is REMANDED for the following action: Obtain a VA medical opinion on the etiology of the claimed headaches. The examiners should provide a medical opinion on whether it is at least as likely as not (50 percent probability or greater) that the claimed headaches are proximately caused by service, to include conceded exposure to contaminated water at Camp Lejeune. It is understood that headaches are not on the list of diseases considered presumptively caused by exposure to contaminated water at Camp Lejeune. The opinions should discuss direct causation, focusing on whether there was a relationship between conceded exposure to contaminated water at Camp Lejeune and the Veteran’s development of headaches. The examiner should consider and discuss the October 1988 STR in which the Veteran reported having a history of frequent or severe headaches. (Continued on the next page)   If the VA examiner determines that further examination is necessary in order to render the requested medical opinion, the AOJ should schedule the Veteran for such an examination. DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Nelson 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.