Citation Nr: 21015544 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 17-25 476 DATE: March 17, 2021 REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1969 to August 1970. This case comes before the Board of Veteran’s Appeals (Board) on appeal of a July 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a December 2019 hearing before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. 1. Entitlement to service connection for bilateral hearing loss 2. Entitlement to service connection for tinnitus The Veteran contends that his diagnosed hearing loss and tinnitus are caused by his work as a driver/operator of a fire truck and activating sirens on base during a ground or rocket attack without hearing protection. See NOD (May 2015). He testified to hearing a high-pitched sound or ringing under the sirens and after firing M-16 and 50 caliber weapons but could not recall hearing the ringing after the sirens were turned off. See Hearing Transcript (December 2019). STRs reflect no complaints or findings for hearing loss. Audiometric testing was not completed on separation; whisper voice testing was completed on enlistment and separation. See Medical Treatment Record (January 1972). Hearing loss and tinnitus complaints are first documented on the Veteran October 2013 VA disability compensation. See VA 21-526EZ (October 2013). A November 2013 VA examination reflects findings for bilateral sensorineural hearing loss. See CAPRI (November 2013). The Veteran reported occasional, intermittent tinnitus but was unable to specify the date of onset. A June 2014 addendum medical opinion noted the Veteran served as a fireman attached to a local fire station in Da Nang. See Medical Opinion (June 2014). The opinion reflected the Veteran passed both his entry hearing screening and separation screening and found the Veteran had no hazardous/combat noise exposure. It concluded the hearing loss seen was not consistent with the Veteran’s military service history. To ensure that VA has met its duty to assist, the issue of entitlement to service connection for bilateral hearing loss and tinnitus is remanded to obtain a medical opinion supported by an adequate rationale on the etiology of the Veteran’s hearing loss disability and tinnitus. Although VA obtained a June 2014 VA medical opinion, it does not provide an adequate rationale. Indeed, it relies on the absence of documented in-service findings to support the negative conclusion reached. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a Veteran's reports of in-service injury and instead relied on the absence of evidence in a Veteran's service treatment records to provide a negative opinion). Further, it is established that whisper voice testing is an unreliable metric by which to assess damage to hearing and should not alone be relied upon to support a negative medical opinion. See Smith v. Derwinski, 2 Vet. App. 137, 138, 140 (1992) (audiometric evaluation is a more precise indicator of hearing problems than whisper voice testing). Lastly, the medical opinion did clearly address whether any delayed onset hearing loss (or tinnitus) is at least as likely as not etiologically related to his reported in-service noise exposure, including exposure to sirens in the Veteran’s work as a fireman. The VA medical does not support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. See Stefl v. Nicholson, 21Vet. App.102, 124-25. A “medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.” Nieves-Rodriguez v. Peake, 22Vet. App.295, 301 (2008). It is noted that the absence of in-service evidence of hearing loss disability is not fatal to a claim for service connection for hearing loss disability. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing disability (i.e., one meeting the requirements of section 3.385, as noted above) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. See Hensley v. Brown, 5 Vet. App. at 159; 38 U.S.C. § 1154. The Board acknowledges the argument of the Veteran’s representative that VA conceded acoustic trauma on the March 2017 Statement of the Case (SOC). The SOC states that: Although hearing loss is not shown in-service, acoustic trauma or military noise exposure may constitute injury of the ear. As your military personnel records note your primary occupation specialties were an Engineman and Fireman, exposure to acoustic trauma is conceded. Medical expertise is needed to establish a link between your current hearing loss and in-service military noise exposure. See SOC (March 2017). Taken as a whole, the Board finds that noise exposure, but not acoustic trauma, is conceded. Acoustic trauma is defined as “noise induced hearing loss caused by a single loud noise such as a blast injury.” Dorland's Illustrated Medical Dictionary, 825 (32nd ed. 2012). Noise induced hearing loss is defined as “sensorineural hearing loss caused either by a single very loud noise (acoustic trauma hearing loss) or by prolonged exposure to high levels of noise (socioacusis).” Id. In this case, based on the Veteran’s military occupational specialty, in-service noise exposure is conceded, but not acoustic trauma. Lastly, the Board acknowledges that the Veteran submitted a favorable medical opinion in this matter. However, it is inadequate to decide the appeal. While it states that the Veteran’s STRs were reviewed along with all medical record since his leaving the military, both the conclusion reached and supporting rationale are vague and generalized. In this regard, the opinion states that tinnitus and hearing loss “is more likely than not related to the trauma experienced in the military service,” but it does not identify any specific trauma and seems to rely on some other evidence, unidentified, that shows these conditions are the result of his military service. To the extent that it suggests that the Veteran’s hearing conditions are due to service because “no other family members have this issue,” the opinion does not explain how this is dispositive of whether any delayed onset hearing loss is related to in-service injury or disease. The opinion further states that the Veteran’s “history of current illness is consistent with the current diagnosis which is a common secondary condition caused by or aggravated by his service connection disability.” This statement is wholly unclear and untethered from any specific contention or evidence in this appeal. An adequate medical examination report or opinion must “sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion.” Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). In sum, although an examiner need not discuss all potentially favorable or unfavorable evidence in order to render an adequate opinion, see Monzingo, 26 Vet. App. at 105, it must be clear that the examiner was “informed of sufficient facts upon which to base an opinion relevant to the problem at hand.” Nieves-Rodriguez, 22 Vet. App. at 303. As neither the VA nor the private medical opinion is adequate to decide the appeal, remand is necessary. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that it is adequate). In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither his credibility nor any lack thereof should be presumed in this remand. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers seen for symptoms of hearing loss and tinnitus since service discharge, to include Dr. J. Fox. Make two requests for the authorized records from all identified sources, unless it is clear after the first request that a second request would be futile. 2. Schedule the Veteran for a VA examination by an otolaryngologist to ascertain the nature and etiology of the Veteran’s hearing loss and tinnitus. Obtain a detailed medical history as to the symptom onset, progression, and severity. If there is any medical reason to accept or reject the proposition that either hearing loss or tinnitus had its onset in service, this should be noted. The physician must address the following: (a) Whether any hearing loss disability at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) is related to an in-service injury, event, or disease, to include in-service noise exposure. Consider and expressly address the Veteran’s theory that his bilateral hearing loss disability stems from caused by his work as a driver/operator of a fire truck and activating sirens on base during a ground or rocket attack without hearing protection. Explain. (b) Whether any tinnitus at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) is related to an in-service injury, event, or disease, to include in-service noise exposure. Consider and expressly address the Veteran’s theory that his tinnitus stems from caused by his work as a driver/operator of a fire truck and activating sirens on base during a ground or rocket attack without hearing protection. Explain. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints/findings. NOTE (2): A complete explanation is required for rejecting any history by the Veteran of his symptoms, onset, progression, and/or treatment. 3. Ensure that the VA medical opinions obtained includes a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. (Continued on next page) 4. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Edwards 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.