Citation Nr: 21013721 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 16-00 281 DATE: March 10, 2021 REMANDED Entitlement to service connection for left ear hearing loss is remanded. Entitlement to service connection for right ear hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1972 to March 1975. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2011 rating decision. In July 2019, the Board, in relevant part, reopened a claim for service connection for left ear hearing loss. The Board also remanded the claims for service connection for right and left ear hearing loss for further development. The case has since been returned to the Board for appellate review. 1. Entitlement to service connection for left ear hearing loss 2. Entitlement to service connection for right ear hearing loss In a September 2020 VA medical opinion, the examiner opined that there was no evidence upon which to conclude that the Veteran’s current hearing loss was caused by, a result of, or aggravated by his military service, to include noise exposure or trauma. In so finding, the examiner stated that there were no significant permanent changes in hearing thresholds during the Veteran’s military service in the right or left ear. However, the examiner provided no rationale for her conclusion. In particular, she did not address the relevance, if any, of the apparent threshold changes between the Veteran’s enlistment and separation examinations. For example, the Veteran’s September 1972 enlistment examination recorded a puretone threshold for the right ear as 25 decibels at 4000 Hertz, whereas his February 1975 separation examination recorded a puretone threshold of 0 decibels at 4000 Hertz. A medical opinion must support its conclusions with analysis. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In addition, although the September 2020 examiner acknowledged the Veteran’s lay statements regarding his in-service symptoms and injury, the examiner’s supporting rationale contained no discussion of the lay statements. Moreover, the examiner did not specifically address the December 1974 health record that documented complaints of ear pain. Based on the foregoing, the Board finds that a remand is necessary to obtain an additional opinion. Stegall v. West, 11 Vet. App. 268 (1998); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). In addition, in July 2019, the Board directed the Agency of Original Jurisdiction (AOJ) to request clarification from the Veteran regarding a VA medical facility where he reported receiving treatment for hearing problems. The Board noted that the Veteran reported receiving treatment at a “VA hospital (medical center)” located at Fort Bragg for hearing loss on February 28, 1975. See March 1977 Claim. The Veteran’s service treatment records include a February 26, 1975 audiology report from a medical processing center located at Fort Bragg, North Carolina. In January 2020, the AOJ requested that the Veteran identify any pertinent, outstanding VA medical records. However, the AOJ did not specifically seek clarification from the Veteran regarding his reported treatment at a VA medical facility located at Fort Bragg, as directed by the Board. Therefore, on remand, the AOJ should request clarification from the Veteran and obtain any outstanding VA medical records. Stegall, 11 Vet. App. at 271. In July 2020, the Veteran submitted an authorization form for VA to obtain treatment records from the Tahatchi Health Care Center dated in October 2013. In August 2020, the Private Medical Records Retrieval Center (PMRRC) rejected a request for records from the Tahatchi Health Care Center because the records were located at a Federal facility. However, there is no indication that the AOJ made any further efforts to obtain such records. In October 2020, the Veteran submitted copies of treatment records from the Northern Navajo Medical Center that referenced October 2013 treatment; however, the underlying treatment record is not associated with the claims file. Therefore, a remand is necessary to obtain outstanding treatment records that are in the custody of a Federal department or agency. 38 C.F.R. § 3.159(c) (describing VA’s duty to assist claimants in obtaining evidence). The matters are REMANDED for the following action: 1. Ask the Veteran to clarify the “VA Hospital (medical facility)” where he received treatment for hearing loss on February 28, 1974, as identified in his March 1977 claim. Obtain any outstanding VA medical records pertaining to such treatment. 2. Obtain any outstanding treatment records from the Northern Navajo Medical Center and Tahatchi Health Care Center pertaining to treatment for hearing loss, to include any records dated in October 2013. Efforts to obtain Federal records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. 3. Obtain a medical opinion from an appropriate examiner regarding the nature and etiology of the Veteran’s right and left ear hearing loss. (a) With regard to the pre-existing left ear hearing loss, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the disorder was aggravated by the Veteran’s military service, including any noise exposure and/or injury. (b) With regard to right ear hearing loss, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service, including any noise exposure and/or injury. In providing his or her opinion, the examiner should specifically address whether there was a threshold shift during service and the significance, if any, of the existence or absence of such a shift. The examiner should consider the September 1972, October 1972, and February 1975 audiogram results. The examiner should also address: (1) the lay statements from the Veteran regarding his symptoms of hearing loss both during and after service (see, e.g., June 2011 and December 2012 correspondence); (2) the lay statements from the Veteran regarding an in-service ear injury (see, e.g., December 2012 correspondence); and (3) the December 1974 service treatment record that documented complaints of ear pain. The examiner is advised that the absence of evidence of a hearing loss disability during service is not always fatal to a service connection claim. Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. If there is a medical reason to doubt the history as reported, the examiner should so state. All opinions must be supported by detailed rationale. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Wulff, 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.