Citation Nr: 21021317 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 16-56 461 DATE: April 12, 2021 REMAND Entitlement to service connection for a recurrent ear disability, to include ear infection residuals, is remanded. REASONS FOR REMAND The Veteran had active service from August 1979 to August 1982; from September 1982 to September 1992; and from February 2003 to July 2003. She served in Iraq. The Veteran had additional duty with the Army Reserve. Entitlement to service connection for a recurrent ear disability to include ear infection residuals, is remanded. In its December 2018 Remand instructions, the Board of Veterans’ Appeals (Board) directed that the Veteran was to be scheduled for an examination “by an appropriate clinician to determine the nature and etiology of any disability productive of ear pain.” The examiner was requested to provide an opinion as to whether “it is at least as likely as not (50 percent or greater probability) that the Veteran has a current disability productive of ear pain that is related to an in service injury, event, or disease, including exposure to loud noise on the shooting range, and in-service ear infection.” The report of a June 2019 ear examination conducted for the Department of Veterans Affairs (VA) states that the Veteran was diagnosed with tinnitus. The examining nurse practitioner did not address whether the “Veteran has a current disability productive of ear pain.” In light of such omission, the Board finds that the examination report is of essentially no probative value. Service connection for tinnitus has been established. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Agency of Original Jurisdiction’s compliance with the Board’s remand instructions is neither optional nor discretionary. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, the Board finds that further VA ear evaluation is necessary. Clinical documentation dated after April 2019 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any recurrent ear disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records including those pertaining to treatment after April 2019. 3. Schedule the Veteran for a VA ear examination conducted by a medical doctor to assist in determining the current nature of any identified recurrent ear disability, including ear infection residuals, and the relationship, if any, to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all recurrent ear disabilities found. If a recurrent ear disability, other than tinnitus, is not identified, the examiner must specifically state that fact. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified recurrent ear disability had its onset during active service or is related to any incident of service, including the documented in service ear pain and earaches. . J. T. HUTCHESON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board F. Lanton, 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.