Citation Nr: 21013611 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 17-39 618 DATE: March 10, 2021 ORDER New and material evidence has been received to reopen the Veteran’s claim of entitlement to service connection for bilateral hearing loss. Entitlement to service connection for left ear hearing loss is granted. Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for headaches secondary to PTSD is granted. Entitlement to service connection for gastroesophageal reflux disease (GERD) with Barrett's esophagus is granted. Entitlement to service connection for a left shoulder disability is granted. Entitlement to service connection for a deviated septum, claimed as nose condition, is granted. Entitlement to service connection for asthma is granted. REMANDED Entitlement to an initial rating in excess of 50 percent for PTSD from February 19, 2015 and in excess of 70 percent from July 26, 2018 is remanded. Entitlement to service connection for a bilateral hand disorder, to include arthritis, is remanded. FINDINGS OF FACT 1. A January 2011 rating decision denied entitlement to service connection for a hearing loss. The Veteran did not appeal that decision and new and material evidence was not received within one year of notice of its issuance. 2. Evidence received more than one year since the January 2011 rating decision has not been previously considered and relates to an unestablished fact necessary to substantiate the Veteran’s claim of entitlement to service connection for hearing loss. 3. The Veteran’s has a left ear hearing loss disability that is proximately due to acoustic trauma in service. 4. The Veteran does not have a right ear hearing loss disability for VA purposes. 5. The Veteran’s headaches are proximately due to his service-connected PTSD. 6. The Veteran’s GERD with Barrett’s esophagus had its onset during active duty service. 7. The Veteran’s left shoulder disability is related to his active duty service. 8. The Veteran’s deviated nasal septum had its onset during active service. 9. The Veteran’s asthma had its onset during active service. CONCLUSIONS OF LAW 1. The January 2011 rating decision denying service connection for hearing loss is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156, 20.1103. 2. New and material evidence has been received to reopen the previously denied claim of entitlement to service connection for hearing loss. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for entitlement to service connection for left ear hearing loss are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for right ear hearing loss are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.385. 5. The criteria for entitlement to service connection for a headache disability are met. 38U.S.C. §§1110, 1131, 5107; 38C.F.R. §§3.102, 3.310. 6. The criteria for entitlement to service connection for GERD and Barrett’s esophagus are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.102, 3.303. 7. The criteria for service connection for a left shoulder disability are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for entitlement to service connection for a deviated nasal septum are met. 38 U.S.C. §§ 1110, 1111, 5107; 38 C.F.R. §§ 3.303. 9. The criteria for service connection for asthma are met. 38 U.S.C. §§ 1110, 1111, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from June 1974 to June 1980. These matters come before the Board of Veterans’ Appeals (Board) on appeal from June 2015, May 2017, and June 2017 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2020, the Veteran testified before the undersigned. New and Material Evidence 1. New and material evidence has been received to reopen the previously denied claim of entitlement to service connection for bilateral hearing loss. In July 2010, the Veteran filed a claim for service connection for hearing loss. In January 2011, the RO issued a rating decision denying the Veteran’s claim for lack of a current diagnosis for VA purposes. 38 C.F.R. § 3.385. The Veteran did not file a Notice of Disagreement (NOD) within one year of notification of the January 2011 denial, and new and material evidence was not received within this period. Accordingly, the January 2011 rating decision is final. See 38 U.S.C. § 7105; Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. Evidence received more than one year after the January 2011 rating decision includes an April 2017 VA audiological examination report that reflects a current left ear hearing loss disability for VA purposes. 38 C.F.R. § 3.385. Regarding both the left and the right ear, G.N. (a registered nurse) opined in a signed statement that the Veteran’s diminished hearing was apparent immediately after his discharge from active duty, progressively worsened over time, and was at least as likely as not due to in-service acoustic trauma. See July 2017 Hearing Loss Statement. This evidence is new in that it was not considered in the January 2011 denial and also material in that it demonstrates a current diagnosis of left ear hearing loss and a nexus to service. Therefore, the previously denied claim is reopened. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis for a disability proximately due to or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). To establish secondary service connection, a Veteran must show: (1) the existence of a present disability; (2) the existence of a service-connected disability; and (3) a causal relationship between the present disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Certain chronic diseases, including hearing loss, which are listed in 38 C.F.R. § 3.309(a), may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In order to be considered for service connection, a claimant must first have a current disability. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013) (holding that a recent diagnosis of disability prior to a veteran filing a claim for benefits satisfies element one of service connection); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement of a current disability is met when a claimant has a disability at the time a claim for VA compensation is filed or during the pendency of that claim). In the absence of proof of a current disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (Fed. Cir. 1992). 2. Entitlement to service connection for left ear hearing loss is granted. 3. Entitlement to service connection for right ear hearing loss is denied. The Veteran asserts that any hearing loss is the result of his conceded exposure to loud industrial shredders and equipment grinders during service. See March 2017 Veteran lay statement, August 2020 Board Hearing Transcript at 10, DD Form 214, April 1975 Service Personnel Records (SPRs). The Board agrees. For the purpose of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; or when the auditory threshold for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Regarding element one of service connection, the Veteran has a current diagnosis of left ear hearing loss for VA purposes. See April 2017 VA examination; 38 C.F.R. § 3.385. Thus, element one of service connection as to the left ear only is met. Regarding the right ear, the Veteran’s Maryland CNC Word List speech recognitions scores and pure tone thresholds, in decibels, at the November 2010 and April 2017 VA examinations were as follows: Hertz 500 1000 2000 3000 4000 CNC November 2010 15 15 15 10 20 96 April 2017 25 25 30 30 25 100 These findings do not reflect the presence of a hearing loss disability for VA purposes. 38 C.F.R. § 3.385. As there is no other audiometric testing during or just before the appeal period that reveals otherwise, there is no competent evidence that demonstrates right ear hearing loss for VA purposes, and the claim for right ear hearing loss is denied on this basis alone. Id; see also Brammer at 225. Regarding element two of service connection for the left ear, the Veteran asserts that he was exposed to loud weapons firing in his assignment as a military policeman and additionally exposed to loud industrial shredders for which he was not provided hearing protection. See March 2017 and July 2017 Veteran lay statements. The Veteran is competent to describe that which comes to him through his senses, such as exposure to loud noises, and the Board finds him credible in this regard. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Notably, the Veteran’s SPRs reflect that he served as a military policeman during his active duty service. See April 1975 SPRs. Accordingly, acoustic trauma in service is conceded as consistent with the places and circumstances of the Veteran’s service, involving work with industrial shredders and as a military policeman. 38 U.S.C. § 1154(a). Regarding the Veteran’s diagnosed left ear hearing loss, the crux of the matter is whether element three of service connection, or a nexus, is met. In this regard, there is evidence both for and against the claim. Against the claim is the April 2017 VA examiner’s opinion that relied on a lack of hearing loss at the time of the Veteran’s separation from active duty to deny that the Veteran’s current left ear hearing loss was at least as likely as not due to active duty. The Board finds such reliance to render the opinion inadequate and of no probative value. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran’s report of in-service injury and instead relied entirely on the absence of evidence in the STRs to provide a negative opinion). In favor of the claim is a privately submitted medical opinion from G.B., the Veteran’s spouse of over 40 years and a registered nurse. She opined that the Veteran’s in-service exposure to the firing of weapons and continual use of industrial shredders combined with progressively diminishing hearing loss from the time the Veteran was separated from service to the present made it at least as likely as not that the Veteran’s hearing loss had its onset in service. See July 2017 private hearing loss nexus statement, August 2020 Board Hearing Transcript at 4. See also 38 C.F.R. § 3.309(a). See 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board finds the medical opinion of G.B. to be highly probative as it considered all of the medical and lay evidence of record. Thus, element three of service connection for the Veteran’s left ear hearing loss disability is met. Accordingly, the private July 2017 medical opinion is the only probative evidence of record as to the etiology of the Veteran’s left ear hearing loss, and coupled with the Veteran’s competent and credible lay statements constitute the only probative evidence addressing the etiology of his left ear hearing loss. As all the probative evidence of record weighs in favor of the claim, the criteria for service connection for left ear hearing loss is met and the appeal is granted. To the extent the Veteran asserts that he has a current right ear hearing loss disability, his opinion is not competent, as the VA has specifically determined audiometric findings that represent hearing loss for VA purposes, and he does not have the expertise to provide the same. To the extent that G.B. opined that the Veteran’s right ear hearing loss, if any, was the result of service, she does not offer and there is not otherwise apparent any audiometric evidence to substantiate right ear hearing loss for VA purposes. 38 C.F.R. § 3.385. In reaching its conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim for right ear hearing loss, that doctrine is not applicable in the instant appeal and service connection for right ear hearing loss is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for headaches secondary to PTSD is granted. The Veteran asserts that his current headache disability had its onset during active duty service or is otherwise related to his active duty service, to include as due to his PTSD or obstructive sleep apnea (OSA). See August 2020 Board Hearing Transcript at 2- 3. The Board agrees. The Veteran has a current diagnosis of migraine headaches and is service-connected for both OSA and PTSD. See September 2020 private medical nexus statement. Thus, elements one and two of secondary service connection are met. Regarding element three, or nexus, the only evidence of record is in favor of the claim. The September 2020 letter from G.B., a registered nurse, recalled the Veteran’s complaints of headaches immediately post-service, but opined that they only progressed to a headache disability when the Veteran’s PTSD increased in recent years. The registered nurse went on to state that she had personally witnessed the onset of headaches correlated with periods when the Veteran’s PTSD would flare or the Veteran was experiencing stress. She then concluded that it was at least as likely as not that the Veteran’s headaches were the result of the Veteran’s PTSD. The Board notes the Veteran complained of a headache that lasted a week in service. See STRs. Thus, the only probative evidence is the September 2020 registered nurse’s medical opinion in favor of the claim, all three elements of service connection are met, and service connection for headaches is granted as secondary to the Veteran’s service-connected PTSD. 5. Entitlement to service connection for GERD with Barrett's esophagus is granted. The Veteran asserts that his GERD with Barrett's esophagus had its onset during active duty service. See July 2016 VA Form 21-526EZ, June 2017 Informal Decision Review Officer Conference Memorandum. The Board agrees. The Veteran has a current diagnosis of GERD and Barrett’s Esophagus. See August 2016 private treatment records, June 2017 VA examination report. Thus, element one of service connection is met. Regarding element two, an in-service injury, the Veteran’s service treatment records (STRs) reflect that he was treated for upset stomach, vomiting, stomach pain, was provisionally diagnosed with gastroenteritis, and complained of left-sided chest pain, loss of appetite, sleep disturbances, and weight loss during active duty service. Accordingly, element two of service connection is met. Thus, the question is whether there is a nexus between the Veteran’s in-service complaints of digestive pain and his current GERD and Barrett’s esophagus. In this regard, the Board notes that the June 2017 VA examiner opined that the Veteran’s GERD was not proximately due to his service connected PTSD, but failed to address direct service connection or whether the Veteran’s PTSD had aggravated the Veteran’s digestive issues and is of no probative value. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (holding that a VA examiner’s opinion that the claimed disability was related to factors other than a veteran’s service-connected disability was insufficient, as it did not clearly encompass a discussion of aggravation). In contrast, a July 2017 letter from G.B. opined that it was at least as likely as not that the Veteran’s GERD and Barrett’s esophagus had their onset during active duty service. In support of her opinion, she noted that the Veteran’s digestive issues would flare up during periods of stress in service, as seen by digestive complaints accompanying problems sleeping. See STRs. The Veteran reported to G.B. and she confirmed that the Veteran has been experiencing digestive symptoms since his release from active duty to the present. Accordingly, element three of service connection is met and service connection for GERD and Barrett’s esophagus are granted. 6. Entitlement to service connection for a left shoulder disability is granted. The Veteran asserts that his current left shoulder disability is due to injuries he sustained in service when he was assaulted at a train station and additionally when a large pole collapsed onto his shoulder. See May 2015 VA Form 21-0781, March 2017 Veteran lay statement, July 2017 Veteran lay statement, August 2020 Board Hearing Transcript at 24-25. While the June 2017 VA examiner concluded the Veteran had no left shoulder pathology, the Board notes that November 2014 VA treatment records document that after complaining of left shoulder pain, imaging was completed of the Veteran’s left shoulder and arthritis was diagnosed by Dr. S.R. Specifically, the VA examiner concluded there was soft tissue calcification adjacent to the greater humeral tuberosity consistent with calcific tendinosis and degenerative changes of the acromioclavicular joint. See November 2014 VA treatment records. As degenerative arthritis is a chronic condition that does not resolve, element one of service connection is met. Regarding element two of service connection, and in-service injury, as noted above the Veteran reports that he was assaulted while serving in Germany and while he sought treatment, he did not discuss the source of his injuries with his treatment provider. See STRs, August 2020 Board Hearing Transcript at 26, 29. Notably, both a VA Staff Medical Doctor and a private medical orthopedist reviewed the associated service treatment record and concluded that the reports in service were consistent with the Veteran’s current left shoulder diagnosis. See October 2017 VA Nexus, June 2019 Private Treatment Record. Thus, resolving any reasonable doubt in the Veteran’s favor, the Board finds that element two of service connection is met. 38 C.F.R. § 3.102. Regarding element three of service connection, all of the evidence is in favor of the claim. As noted above, a VA medical doctor reviewed the Veteran’s STRs and his lay statements and opined that the Veteran’s current left shoulder disability was more likely than not due to the two incidents the Veteran reports occurred during active duty, the assault and the falling pole. The October 2017 VA examiner concluded that the current left shoulder symptoms and calcification of the rotator cuff were due to the traumatic in-service injuries. The June 2019 private orthopedist concluded that the large abnormal calcium deposit in the Veteran’s left shoulder was consistent with the time frame the Veteran asserts he was assaulted and, in any event, consistent with the time he was on active duty. The private orthopedist concluded that the Veteran’s current left shoulder disability was more likely than not the result of the asserted in-service trauma. In July 2017, G.B. (registered nurse) opined that it was at least as likely as not that the Veteran’s current left shoulder disability was the result of the cumulative impact of the Veteran’s in-service military occupation specialty (MOS) that required him to continuously lift heavy boxes of paper over his head, mount equipment on racks and shelves, a carry various heavy equipment from place to place caused the Veteran’s current left shoulder disability. Thus, as all of the probative nexus opinions are in favor of the claim, element three of service connection is substantiated and entitlement to service connection for a left shoulder disability is granted. 7. Entitlement to service connection for a deviated septum, claimed as nose condition, is granted. The Veteran asserts that his current nose condition, to include a deviated septum status-post septoplasty, is had its onset during service or is otherwise due to injuries he sustained in service when he was assaulted at a train station. See February 2015 VA Form 21-526EZ, May 2015 VA Form 21-0781, March 2017 Veteran lay statement, July 2017 Veteran lay statement, August 2020 Board Hearing Transcript at 26. The Board agrees. The Veteran underwent a septoplasty for a deviated septum in May 1996, thus he has a current disability of the residuals of a deviated septum status-post septoplasty and element one of service connection is met. See March 1996 operative report. Regarding an in-service event or injury, the Veteran asserts that his nose was fractured in the same assault when his left shoulder and left lower quadrant were injured. See August 2020 Board Hearing Transcript at 26. Indeed, the Veteran’s STRs demonstrate rhinitis and treatment for a bloody nose in August 1979, September 1979, and January 1980. The Board Veteran is competent to report when his nose was injured in service and likewise finds him credible in this regard. See Layno, supra. Although his service treatment records do not reflect treatment for a deviated septum, the records do indicate that he was treated for other symptoms in April 1978 when, the Veteran asserts, these injuries were incurred during an assault. Thus, element two of service connection is met. Therefore, given the diagnoses of allergic rhinitis and a bloody nose in service, the competent and credible lay testimony of the in-service assault, symptoms associated with both of these disorders during and since service, as well as the objective evidence of current diagnoses, the evidence is at least evenly balanced as to whether the Veteran’s claimed disorders had their onset in service. Thus, the Board finds that service connection is warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 8. Entitlement to service connection for asthma is granted. The Veteran asserts that exposure to chemical and particulates in service resulted in the development of asthma. See July 2017 Veteran lay statement, August 2020 Board Hearing Transcript at 9-10. The Board agrees. The Veteran has a current diagnosis of asthma and element one of service connection is met. See March 2015 VA treatment records, June 2017 VA examination report. Regarding an in-service injury, the Veteran asserts that in his military occupation specialty of telecommunications operations specialist, he was required on a daily basis to destroy highly sensitive hard copies of intelligence with industrial shredding machines and subsequently used volatile chemicals to create a uniform slurry out of the shredded paper. See July 2017 Veteran lay statement, August 2020 Board Hearing Transcript at 9. The Veteran also reported being exposed to asbestos while in service as it was used in communications rooms and as a fire retardant. See May 2015 Veteran lay statement. The Veteran’s performance reports throughout his time in service reflect work consistent with the Veteran’s statements and the Board finds him credible in this regard. See SPRs. Thus, element two of service connection is met. Regarding the final element of service connection, or nexus, there is evidence both in favor of and against the claim. Against the claim is the June 2017 VA examiner’s opinion finding that it was less likely than not that the Veteran’s asthma was a continuation or progression of the upper respiratory infections diagnosed on active duty. In support of his opinion, the examiner relied on the lack of a diagnosis of asthma at the time of the Veteran’s separation from active duty. Critically, the June 2017 VA examiner failed to address the Veteran’s reported exposure to asbestos and volatile chemicals, and the opinion is therefore inadequate in this regard. See Dalton v. Peake, 21 Vet. App. 23, 39-40 (2007) (a medical opinion is inadequate if it does not take into account the appellant’s reports of symptoms and history, even if recorded in the course of the examination); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (holding that the lack of contemporaneous medical records does not, in and of itself, render lay evidence not credible). In favor of the claim is a July 2017 nexus statement from G.B., a registered nurse. In her statement, G.B. reported that the Veteran has experienced wheezing and trouble breathing since shortly after his discharge from active duty service. She reviewed the Veteran’s service records and considered the cleaning solvents (ammonia based and others containing chlorofluorocarbons) and other solvents used on a daily basis as reported by the Veteran. She then opined that his current asthma was at least as likely as not a result of the Veteran’s daily use of these solvents in a closed environment, such as one required for the transmission and review of highly classified materials. The Board finds the July 2017 nexus statement from G.B. to be highly probative as it is based on a complete review of the Veteran’s medical history, lay statements, and personal observations since the summer of 1980. Thus, the Board finds that element three of service connection is met and service connection is warranted for asthma. REASONS FOR REMAND 8. Entitlement to an initial rating in excess of 50 percent from February 19, 2015 and in excess of 70 percent from July 26, 2018 for PTSD is remanded. The Veteran asserts that he is entitled to a rating in excess of 50 percent from February 19, 2015 and in excess of 70 percent from July 26, 2018. See July 2017 Notice of Disagreement (NOD). In this regard, the Board notes that the Veteran reported, and VA treatment records demonstrate, that he has been receiving psychiatric treatment with a VA associated Vet Center since approximately April 2017. See April 2018 VA treatment records. Such records of treatment, if present, might allow for an award of an increased rating. Additionally, at the Veteran’s August 2020 Board hearing, he testified that his PTSD had progressively worsened since his last VA examination in June 2017. Indeed, a July 2018 examination report generated by a VA practitioner demonstrates a progression. As such, an updated VA examination is needed, as the June 2017 VA examination is not reflective of the Veteran’s current level or nature of his disability. See Palczewski v. Nicholson, 21 Vet. App. 174, 182-83 (2007); Snuffer v. Gober, 10 Vet. App. 400. On remand, complete VA treatment records and Vet Center treatment records should also be secured, to include mental tele-health records 9. Entitlement to service connection for a bilateral hand disorder, to include arthritis, is remanded. The Veteran asserts that his bilateral hand disability, to include arthritis, is due to the cumulative impact of heavy lifting and years of typing while on active duty. See June 2017 Decision Review Officer Informal Conference Memorandum, September 2020 nexus statement from G.B. While the Veteran testified at his August 2020 Board Hearing that the VA recently diagnosed him with degenerative arthritis of the hands, the diagnosis is not reflected in the available records. See August 2020 Board Hearing Transcript at 20; VA treatment records. Additionally, the Veteran’s spouse, who is a registered nurse, offered a medical opinion that the Veteran’s current hand disability was the result of the cumulative impact of heavy lifting and typing during active duty. See September 2020 nexus statement. While the Board concedes that the Veteran’s assertion that he would have had to do a lot of heavy lifting and typing in conjunction with his MOS, there is currently no diagnosis or documented pain resulting in functional loss. Accordingly, remand is necessary for a hand examination. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records, to include Vet Center treatment records and all mental tele-health records. 2. With any necessary assistance from the Veteran, obtain any relevant outstanding private treatment records. 3. Then schedule the Veteran for a VA examination to determine the current severity of the Veteran’s PTSD. The entire claims file must be made available to the examiner for review in connection with the examination. All findings should be reported in detail. 4. Then, schedule the Veteran for a VA examination to address the current nature and etiology of his bilateral hand disorders. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. All findings should be reported in detail. The examiner should address the following: (a.) Identify all current bilateral hand disorders diagnosed. If no such disability is identified, the examiner must indicate whether the Veteran’s reported bilateral hand pain causes any functional impairment. (b.) For each disability or functional impairment identified, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that such disorder was incurred in or is otherwise related to service, to include as a result of the cumulative impact of heavy lifting and years of substantial typing as related to his MOS as a Telecommunications Operations Specialist. See November 2014 VA treatment records (pain in both hands), June 2017 Decision Review Officer Informal Conference Memorandum, August 2020 Board Hearing at 20, September 2020 nexus statement from registered nurse G.B. In addressing this question, the examiner must specifically discuss (1) the Veteran’s report that his duties included years of near continuous typing and heavy lifting; and (2) the September 2020 nexus statement from G.B. In addressing this question, the examiner must assume item (1) as true, even despite the absence of “objective documentation,” and determine whether a nexus to service is “medically plausible” based on the same. S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Rouse, 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.