Citation Nr: 21020801 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 17-62 437A DATE: April 8, 2021 REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to total disability due to individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1969 to August 1971. In May 2020, the Veteran testified at a Board hearing. The transcript is of record. 1. Entitlement to service connection for bilateral hearing loss Once VA undertakes the effort to provide an examination, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran underwent an audiological examination in March 2016. The examiner opined that hearing loss is less likely than not related to military service as there is a lack of evidence in the claims file. The Board finds this opinion inadequate for adjudication. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Furthermore, a VA examiner may not generally rely on the absence of evidence as negative evidence. Fountain v. McDonald, 27 Vet. App. 258, 272-75 (2015). 2. Entitlement to a rating in excess of 50 percent for PTSD VA has a duty to make reasonable efforts to assist Veterans in securing evidence necessary to substantiate their claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). The evidence indicates that there may be outstanding relevant VA treatment records. A May 2020 correspondence from the Veteran’s VA provider stated that he has regualr appointments at the mental health clinic; however, the most recent VA treatment records are from 2016. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issues on appeal. As such, a remand is required to allow VA to obtain them. Additionally, the Veteran last underwent a VA examination in October 2012 for his PTSD. At the hearing in May 2020, the Veteran testified that his symptoms have increased since his last VA examination. Based on the contention that his symptoms worsened, a new VA examination is warranted to determine the current severity of the Veteran’s PTSD. 3. TDIU In the case of Rice v. Shinseki, 22 Vet. App. 447, 455 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim for a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is part and parcel of an increased rating claim when such claim is raised by the record. The Board finds the issue of TDIU has been raised. The Veteran's entitlement to a TDIU is inextricably intertwined with the PTSD claim on appeal. Therefore, the claim for a TDIU must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). The matters are REMANDED for the following action: 1. Obtain updated VA and/or private treatment records from 2016 to present. If such records are unavailable, the Veteran’s claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. 3. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s bilateral hearing loss is related to his active service or is caused by or aggravated by military service. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms of bilateral hearing loss from in-service to the present and to describe his in-service exposure to acoustic trauma. The examiner must specifically consider and discuss the Veteran's testimony regarding his in-service exposure to weapons firing and concussion grenades and continuity of symptomology since service. The opinion and rationale should reflect such consideration. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner 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). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. Schedule the Veteran for a VA medical examination to determine the current severity of his service-connected PTSD. The electronic claims file should be made available to the examiner, and the examiner is requested to review the claims file and indicate that such was accomplished in the examination report. The examiner must address the following: (a.) The examiner should indicate the current level of occupational and social impairment; and (b.) The examiner must also provide an assessment of the Veteran's functional limitations due to PTSD, including how they may relate to his ability to function in a work setting and to perform work tasks. The examiner should refrain from commenting on whether the Veteran is employable. The examiner should elicit a full medical history. The Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. A complete rationale for all medical opinions is required. The examiner should 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). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 5. Provide the Veteran with a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability and issue a VCAA notice letter to the Veteran concerning a claim for a TDIU. Any additional development deemed necessary to adjudicate the issue of entitlement to TDIU should be completed. 6. Finally, readjudicate the appeal G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. A. Prinsen 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.