Citation Nr: 21021760 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 16-23 614 DATE: April 13, 2021 REMANDED Entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran had active service from September 1999 to September 2003. He served in Iraq and was awarded the Combat Action Ribbon. Entitlement to service connection for bilateral hearing loss is remanded. Service connection may also be granted for disability which is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service connected disorder has aggravated a nonservice connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection has been established for traumatic brain injury (TBI) residuals, tinnitus associated with TBI, migraine headaches associated with TBI, posttraumatic stress disorder (PTSD), irritable bowel syndrome, and hemorrhoids. The report of an August 2012 Department of Veterans Affairs (VA) psychiatric examination states that the Veteran was diagnosed with TBI residuals including hearing loss. The report of an October 2019 auditory examination conducted for VA states that the Veteran complained of being unable to understand conversations in noisy places; at work; and on the telephone. The examiner found that the Veteran exhibited normal hearing on audiometric evaluation. She did not address the August 2012 VA psychiatric examination report. Therefore, the Board finds that the examination report is of limited probative value. The report of an October 2020 traumatic brain injury (TBI) examination conducted for VA does not note the August 2012 VA psychiatric examination report or address whether the Veteran’s subjective hearing loss is a component of or otherwise related to the service connected TBI residuals. Therefore, the Board finds that the examination report is of limited probative value. 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). Clinical documentation dated after October 2020 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). This matter is 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 hearing loss disability. 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 October 2020. 3. Schedule the Veteran for an appropriate VA examination to assist in determining the current nature and etiology of any identified hearing loss disability and the relationship, if any, to active service and/or a service connected disability. The examiner must review the record, including the August 2012 VA psychiatric report, and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all hearing loss disability found. If such disability is identified, the examiner should specifically state whether it is a symptom of the service connected TBI residuals. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified hearing loss disability had its onset during active service or is related to any incident of service, including the Veteran’s combat experiences in Iraq. (Continued on the next page)   (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified hearing loss disability is due to the TBI residuals and the other service connected disabilities. The examiner should specifically discuss the August 2012 VA psychiatric report. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any identified hearing loss disability has been aggravated (permanently increased in severity beyond the natural progress of the disorder) by TBI residuals and the other service connected disabilities. The examiner should specifically discuss the August 2012 VA psychiatric report. J. T. HUTCHESON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Andrew Ledman II 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.