Citation Nr: 21022098 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 18-25 810 DATE: April 14, 2021 ORDER Entitlement to service connection for residuals of a traumatic brain injury (TBI) is denied. Entitlement to service connection for a psychiatric disability, claimed as posttraumatic stress disorder (PTSD), is denied. REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that claimed residuals of a TBI were incurred in or aggravated by service. 2. The preponderance of the evidence is against finding that the Veteran has a psychiatric disability that began during service or is otherwise related to any event, injury, or disease during service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for residuals of a traumatic brain injury (TBI) have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 2. The criteria for entitlement to service connection for a psychiatric disability, to include PTSD, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran was a member of the National Guard. The Veteran had active duty for training (ACDUTRA) from May 15, 1976, to May 29, 1976. That period of service is characterized as honorable. He subsequently served on active duty from January 1979 to August 1979, and that period of service is characterized as under other than honorable conditions and has been found to be a bar to VA benefits. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a July 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). Service Connection In general, service connection may be established for disability or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be established for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303(d). The term active military, naval, or air service includes active duty, any period of active duty for training during (ACDUTRA) which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a). To establish a service connection for a disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163(Fed. Cir. 2004). A disability may be service-connected if the evidence of record shows that the Veteran currently has a disability that was chronic in service or was chronic as defined by regulation with continuity of symptomatology demonstrated after service. 38 C.F.R. § 3.303; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for residuals of a traumatic brain injury (TBI) The Veteran claims to presently have residuals of a TBI from a vehicle accident that occurred during a period of ACDUTRA in 1976 at Yakima Firing Center. The Veteran contends that his head was slammed against an open tank hatch which rendered him unconscious for an extended period. A Worksheet for Accident Report for All Oregon National Guard Vehicles shows that on May 17, 1976, an accident occurred. The report indicates that the damage to the vehicle consisted of damage to the right front and rear shocks. The report shows that there were two injuries: N.S. had a chest injury and was taken to the hospital, and the Veteran had a mouth injury and was treated by a medic. The narrative read, “I was returning to tank compound driving on tank trail. I was driving at or about 25MPH following a APC M113 coming down a small slope and I ran over a rut in the tank trail. It bounced once before I got it stopped, then I heard my assistant driver. That’s when I knew he got hurt. I went into the passenger hold and helped him on to the table and called for help.” A May 17, 1976, medical examination and duty status report states that the Veteran “was driving the Command Track 11577 back to the tank park after functioning as a commo relay station for this unit. When the track was enroute to the tank park XX he hit a rut causing him to hit his mouth on the XXXXX edge of the driver’s hatch directly resulting in a cut lip.” The duty status report shows that the Veteran was on ACDUTRA at the time of the accident, and the report was signed by D.J.L., 2LT, AR. The attending physician specifically noted that the Veteran was mentally sound and that further treatment was not anticipated. The examining physician indicated that the disability resulting from the accident was temporary. The physician further wrote, “trauma to anterior lower jaw with minor laceration of mucosa and very slight loosening of the two lower incisor teeth which should firm up without problem.” The attending physician was D.W.M., COL, MC, and the attending physician signed the report. In a May 18, 1976 statement, N.D.S., SP5, states that he “was functioning as vehicle commander in a command track M566 and was standing in the TC hatch. As we (the driver and myself) were in convoy returning from the days training area to the tank compound along the tank trail, traveling at or about 25 MPH when we came over a rise in the road and came down into a ditch type spot in the road. The driver, not being able to stop in time, hit the ditch and I was slammed into the ridge of the TC hatch several times before the driver was able to bring the track to a halt, injuring primarily my rib cage area.” Another May 18, 1976, statement states “On May 17, 1976 at about 1300 hours I was driving a command track vehicle M577 back to the unit tank compound. I was driving about 25 miles per hour and I ran into a small drainage rut in the tank trail. I didn’t see until I was right next to it and I couldn’t stop in time. I hit the rut and the vehicle bounced once before I stopped it and that’s when I heard my assistant driver yell and I knew he had been hurt. I went back and helped him up on the table in the vehicle. I told him I would try and drive the rest of the way in because it was only a little ways. I started driving again when I noticed the track had been damaged and it would not make it back it’s condition. I saw another tank coming but before the tank got close enough I saw an MP vehicle coming and I waved at him to stop. He looked at me and drove on down the road a little ways and stopped. I kept signaling him to come back to our vehicle. In the meantime the other tank had reached my position, I was able to stop him. I told them I had an injured man and I needed help. That’s when the MP vehicle drove back to where we were. During this time, before I could get the MP vehicle to come back, I was radioing back to my home base for help. When the MP’s realized the situation he called for the post medics and they came and evacuated him.” The signature on that statements reads as by the Veteran. The statement also shows that it was sworn to and subscribed before D.J.L., 2LT, AR, at the Yakima Firing Center, Yakima, Washington, on May 18, 1976. The Board notes that the Veteran has claimed that he did not sign that May 18, 1976, statement. He has submitted a July 2018 affidavit from W.C. in which she asserts that the signature on this May 18, 1976, statement was made by an individual other than the Veteran. W.C. presented herself as a forensic document examiner and handwriting expert. However, no allegations have been made regarding the May 18, 1976, statement from N.D.S.; the May 17, 1976, medical examination and duty status report; or the Worksheet for Accident Report for All Oregon National Guard Vehicles. The May 18, 1976 statement from N.D.S.; the May 17, 1976, medical examination and duty status report; and the Worksheet for Accident Report for All Oregon National Guard Vehicles were all created by individuals other than the Veteran. Even assuming for the sake of argument that the signature on the May 18, 1976, statement was not made by the Veteran, the Board has no reason to question the other official documents relating to the May 1976 accident. A July 1977 Report of Medical Examination shows that the Veteran had a normal head, face, neck, and scalp. The report also shows that the Veteran was psychiatrically normal. On a July 1977 Report of Medical History, the Veteran marked that he did not experience and had not experienced dizziness, head injury, loss of memory or amnesia, or periods of unconsciousness. A June 1979 mental status evaluation report shows that the Veteran was fully alert, fully oriented, exhibited normal behavior, had clear thinking process, normal thought content, and good memory. The examiner indicated that the Veteran was mentally responsible, able to distinguish right from wrong, able to adhere to the right, and had the mental capacity to understand and participate in board proceedings. A June 1979 Report of Medical Examination shows that the Veteran had a normal head, face, neck, and scalp. The report also found that the Veteran was psychiatrically normal. On a June 1979 Report of Medical History, the Veteran marked that he did not experience dizziness, head injury, loss of memory, amnesia, or periods of unconsciousness. An April 2016 VA MRI found no acute intracranial process. There were cystic changes in the right cerebellum that the interpreter stated may be related to an old infarction. A February 2017 VA emergency room note shows that the Veteran had headache and dizziness after a recent trauma. It was noted that the Veteran was hit in the head with a steel pipe two days previously. The Veteran had a loss of consciousness at the time with vomiting afterwards. He was seen at St. Thomas and had been unsteady on his feet and had difficulty concentrating. A June 2016 Review PTSD Disability Benefits Questionnaire (DBQ) completed by private examiner, C.M., Psy.D. indicated that the Veteran did not have a diagnosed TBI. At a June 2017 VA examination, the examiner specified that he was a neurologist. The examiner recorded the Veteran’s self-report that while on active duty, he was driving a tank at 60 miles per hour with his head out of the hatch. The Veteran stated that he hit something and felt like they went airborne. The Veteran stated that his head went back and hit the back of his helmet, and then he hit his mouth on the hatch ring. The Veteran reported that he lost consciousness for four to five hours before regaining consciousness. The Veteran stated that he made an emergency call several times on the radio before someone answered. The Veteran stated that he felt the cut in his lip, and he said he could put his tongue through the cut. He recalled that the others did not take him to the hospital for the cut on his lip but left him at the scene. He stated that the torsion bars were snapped in half on the driver’s side of the tank track, and the track was removed. He stated that his next memory was driving the vehicle at about 10:40 that night, and he stated he went unconscious again. He next remembered being outside of the vehicle at 1:40 A.M. He stated that he had another loss of consciousness, and his next memory was at 10:45 the next morning. He stated that he did not go to the hospital. The VA examiner noted that neuropsychological testing had been performed. After performing an in-person examination, the examiner stated that the Veteran did not have nor had he ever had a traumatic brain injury (TBI) or any residuals of a TBI. The examiner also opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran’s history of the in-service event was not consistent with the clear documentation of record. The examiner stated that the acute in-service documentation of the accident did not indicate a diagnosis of concussion or TBI and also did not show injuries or symptoms consistent with a brain injury. The examiner further detailed that the documentation of record was in conflict with the Veteran’s self-reported history of prolonged loss of consciousness following the incident. The examiner specified that the subsequent treatment records in the service medical records and the Veteran’s own self-reports of medical history in service following the accident were negative both for a head injury and signs or symptoms consistent with postconcussion residuals or postconcussion syndrome. In an April 2020 letter, B.V., Ph.D., opined that it was more likely than not that the Veteran’s TBI was due to or caused by a head injury with loss of consciousness while in service. Dr. V. stated that he reviewed the medical and treatment notes, and emailed statements from the Veteran. Dr. V. also conducted a video interview with the Veteran. Dr. V. stated that it was not typical or a normal development for a man of the Veteran’s age to have the cognitive and memory impairments that the Veteran had developed. Dr. V. opined that the Veteran had an undiagnosed TBI from service. The examiner reiterated that he was a psychologist and not a M.D.. The Board has carefully considered the April 2020 letter from B.V., Ph.D. That letter was written by a medical examiner who had the education and training to offer a competent medical opinion. However, the April 2020 letter did not provide the level of in-depth discussion of the nature of the Veteran’s claimed symptoms as the June 2017 VA examiner. Dr. V. did not perform neuropsychological testing or comment on the neuropsychological testing results of record. Notably, while Dr. V. recounted the Veteran’s self-report of the May 1976 vehicle accident, Dr. V. offered no discussion of the documentation of record that was in conflict with the Veteran’s self-reported history. For example, although Dr. V. discussed the Veteran’s statements regarding a head injury in May 1976, Dr. V. did not discuss the Veteran’s own notations on July 1977 and June 1979 Reports of Medical History in which the Veteran marked that he did not experience dizziness, head injury, loss of memory, amnesia, or periods of unconsciousness. Those are among the reasons that the Board finds the opinion offered by Dr. V. to be of less probative weight and outweighed by the other evidence of record. The Board finds the June 2017 VA examiner’s opinion to be the most probative evidence of record. The June 2017 VA examination report outlines the reasons why the examiner opined that the Veteran’s claimed symptoms were less likely to be related to service. The examiner considered the Veteran’s self-report, the service treatment records, the post-service records, and explained the factors behind the determinations that the Veteran’s claimed disability was less likely to be related to service. The Board finds the June 2017 VA examination report to be the most persuasive evidence of record. Among the factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion. Hayes v. Brown, 5 Vet. App. 60 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence); Wood v. Derwinski, 1 Vet. App. 190 (1992). The probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion the examiner reaches. As is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Concerning the Veteran’s own statements, the Board again notes that on two separate Reports of Medical History completed in July 1977 and June 1979, the Veteran specified he did not experience dizziness, head injury, loss of memory or amnesia, or periods of unconsciousness. Those Reports of Medical History, both completed after the May 1976 accident, appears to contradict his current assertions that he had experienced a continuity of symptoms from the time of the May 1976 accident. The Board finds the Veteran’s remarks on the July 1977 and June 1979 Reports of Medical History to be more probative than his current assertions regarding the presence or lack thereof of symptoms during service, as the July 1977 and June 1979 Reports of Medical History were completed in connection with service examinations that was more contemporaneous to the time of the accident. Therefore, the Board finds that the Veteran’s statements are of less probative value and outweighed by the other evidence of record. Accordingly, as the probative medical evidence is against a finding that the Veteran’s claimed symptoms are etiologically related to any aspect of honorable service, service connection is not warranted. As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107. 2. Entitlement to service connection for a psychiatric disability, claimed as posttraumatic stress disorder (PTSD) The Veteran claims to have a psychiatric disability as a result of three separate stressors. First, he claims that he has a psychiatric disability as a result of the vehicle accident discussed previously in connection with the TBI claim. Second, he claims that he has a psychiatric disability as a result of witnessing a helicopter crash with mutilated crewmen. Third, he claims that he has a psychiatric disability as a result of a hospitalization in connection with a hernia surgery. However, the claimed helicopter crash and hernia surgery hospitalization both occurred during a period of service that is characterized as other than honorable and has been found to be a bar to VA benefits. Therefore, only the first stressor of the tank accident can be considered in connection with the claim for service connection for a psychiatric disability. A July 1977 Report of Medical Examination shows that the Veteran had a normal head, face, neck, and scalp. The report also shows that the Veteran was psychiatrically normal. On a July 1977 Report of Medical History, the Veteran marked that he did not experience dizziness, head injury, loss of memory, amnesia, or periods of unconsciousness. A June 1979 mental status evaluation report shows that the Veteran was fully alert, fully oriented, exhibited normal behavior, had clear thinking process, normal thought content, and good memory. The examiner indicated that the Veteran was mentally responsible, able to distinguish right from wrong, able to adhere to the right, and had the mental capacity to understand and participate in board proceedings. A June 1979 Report of Medical Examination shows that the Veteran had a normal head, face, neck, and scalp. The report also shows that the Veteran was psychiatrically normal. On a June 1979 Report of Medical History, the Veteran marked that he did not experience dizziness, head injury, loss of memory, amnesia, or periods of unconsciousness. The Veteran began receiving mental health treatment from VA in March 2016. A March 2016 VA mental health treatment record contains the Veteran’s self-report that he was offered the chance to go to West Point and become an officer because he had the highest aptitude test in military history. The Veteran stated that he taught others about cryptic codes at West Point and even went to a party where he met the Pope. The Veteran stated that the Pope was telling dirty jokes. The Veteran also stated that when he was a decoder he could pick up a phone and could talk directly with the president. The Veteran was subsequently given a diagnosis of other psychotic disorder. In June 2016, the Veteran underwent VA neuropsychological testing. It was noted that the Veteran had been diagnosed with unspecified schizophrenia spectrum and other psychotic diagnosis. The Veteran was administered an extensive test battery, and his performance was deemed clearly non-credible and broadly within normal limits. The test provider indicated that almost all of the Veteran’s scores on standard cognitive tests were within normal limits, with very few exceptions, which made it highly unlikely that the Veteran was exhibiting any actual cognitive decline. The Veteran’s scores on psychological testing were not considered valid, as the examiner said that the Veteran had some content-inconsistent responding as well as a tendency to overreport memory symptoms. The examiner indicated that the Veteran did not appear to meet criteria for any sort of cognitive disorder and had a very complicated diagnostic picture otherwise. The examiner noted that the Veteran had a possible history of cerebellar stroke, but it was unlikely that the stroke would have caused the Veteran’s current profile. The examiner found that the Veteran’s report of cognitive symptoms was most consistent with significant attentional difficulties that are not uncommon in severe PTSD. The examiner found that the Veteran’s diagnostic picture was complicated by possible somatic delusions. On a Review Posttraumatic Stress Disorder Disability Benefits Questionnaire (DBQ) completed in June 2016 by a private examiner, C.M., Psy.D. indicated that the Veteran had diagnoses of PTSD and possible personality disorder. At a June 2017 VA examination, the examiner diagnosed other specified mental disorder. The examiner stated that the Veteran had a complex presentation, and the diagnosis was complicated by multiple factors. The examiner noted that prior to service, the Veteran had problems functioning in the school system, and behavioral issues had resulted in at least two arrests. The Veteran reported two primary stressors. The examiner noted that the stressor that was best documented, the tank accident, was a minor accident pursuant to the records of the time. The Veteran’s other primary stressor involved a nine-day hospital stay during which the Veteran stated he was roused every two hour and administered morphine. The examiner stated that considering the Veteran’s poor reliability on other points, it was difficult to take his dramatic assertions at face value. The examiner found clear and convincing evidence of delusions and strong indications of somatizations. The examiner opined that the discrepancy between the Veteran’s recall of his traumas and the available evidence may be due to delusions. The examiner specified that it was quite possible that a delusional disorder interfered with the Veteran’s recall of the events of service, as it seemed to sporadically influence the Veteran’s interactions with healthcare providers. It was noted that psychosis can lead to preoccupation with certain events, intrusive images, and the other symptoms the Veteran endorsed. The examiner specified that at present it was impossible to provide clearer guidance about the Veteran’s diagnosis, the onset of symptoms, and the true relationship to military service without resorting to significant speculation. The examiner found that the Veteran was not a reliable historian as indicated by (1) the discrepancy between his report of one of his primary stressors, the tank accident, and the various records of that era, and (2) the unlikely nature of some of the Veteran’s claims, such as a helicopter flipped upside down then rotated upside down for an hour or more. The examiner also noted that objective assessment of both the Veteran’s cognitive and psychological testing was invalid. In a July 2017 letter, C.M., Psy.D., referred to a July 2016 psychological interview with the Veteran. That psychologist stated that the Veteran related his symptoms to two experiences in service. The Veteran described a vehicle accident during a training exercise and vividly described seeing and hearing his fellow soldiers suffering from serious injuries. The Veteran also described a second traumatic event about a year later in which he witnessed a helicopter crash. Dr. M. opined that the Veteran had PTSD more likely than not related to service. In a November 2018 letter, B.V., Ph.D., opined that the Veteran’s PTSD was at least as likely as not incurred in or caused by trauma stressors in service. The stressors cited were the Veteran’s documented tank accident and the Veteran’s report of witnessing a helicopter crash and mutilated crewmen. Dr. V. stated that he reviewed the medical and treatment notes and emailed statements from the Veteran. In reviewing the evidence of record, the Board finds that the preponderance of the evidence is against finding that the Veteran has a psychiatric disorder that is related to honorable service. In reviewing the medical opinions of record, the Board has carefully considered the June 2017 letter from C.M., Psy.D., and the November 2018 letter from B.V., Ph.D.. However, neither examiner gave any rationale to support the etiology opinions. Significantly, neither examiner perform neuropsychological testing or commented on the neuropsychological testing results of record. Notably, while both examiners recounted the Veteran’s self-reports, neither examiner offered any discussion of the documentation of record that was in conflict with the Veteran’s self-reported history. For example, neither examiner discussed the Veteran’s own notations on July 1977 and June 1979 Reports of Medical History in which the Veteran marked that he did not experience dizziness, head injury, loss of memory or amnesia, or periods of unconsciousness, or the conflicting evidence of the circumstances of the tank accident during service. Additionally, neither examiner discussed the Veteran’s documented psychoses. These are among the reasons that the Board finds the opinions offered by Dr. M. and Dr. V. to be of less probative weight and outweighed by the other evidence of record. Those examiners also considered events during the Veteran’s period of service that is a bar to VA benefits. The Board finds the June 2017 VA examiner’s opinion to be the most probative evidence of record. The June 2017 VA examination report outlines the reasons supporting the examiner’s opinion. The examiner considered the Veteran’s self-report, the service treatment records, the post-service records, and explained the factors behind the opinions. The Board finds the June 2017 VA examination report to be the most persuasive evidence of record. Among the factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion. Hayes v. Brown, 5 Vet. App. 60 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence); Wood v. Derwinski, 1 Vet. App. 190 (1992). The probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion the examiner reaches. As is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). The Board has considered the Veteran’s lay statements but assigned the Veteran’s opinion regarding his psychiatric disability less probative weight. Although the Veteran can competently relate the presence of symptoms observable through his senses, the Board finds that the Veteran’s statements are outweighed by the report of the June 2017 VA examiner. The VA examiner was a clinical psychologist who had the education and training necessary to competently offer the given opinion. The Veteran has not been shown to have such knowledge. In addition, the evidence strongly suggests that the Veteran is a poor historian. Finally, the Board has considered that service incurrence will be presumed for certain chronic diseases, to include psychoses, if manifest to a compensable degree within the year after active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. In this case, the medical evidence of record does not show that a psychosis was manifest to a compensable degree within one year of honorable active service, to include ACDUTRA. Accordingly, as the preponderance of the evidence is against a finding that a psychiatric disability is etiologically related to any aspect of qualifying service, service connection is not warranted. As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C. § 5107. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea In May 2016, the Veteran underwent a sleep study which resulted in a diagnosis of severe obstructive sleep apnea syndrome. In a January 2017 letter, A.M.E., Jr., M.D. indicated that the veteran had a nasal injury and that the Veteran’s sleep apnea was at least contributory to high nasal airway breathing. A July 2018 letter from a private treatment facility indicates that the Veteran’s nasal deviation complicated his sleep apnea. The treatment provider thought that it was more likely than not that the deviated nasal septum contributed to the difficulty breathing at night and obstructive sleep apnea. The Veteran has not been provided a VA examination in connection with the claim for service connection. The service records show that the Veteran received a mouth and facial injury in a tank accident in May 1976 during ACDUTRA. Medical evidence of record suggests a possible connection between currently diagnosed obstructive sleep apnea and a facial injury. Remand is required to provide the Veteran a VA examination for an etiology opinion concerning any connection between obstructive sleep apnea and the Veteran’s qualifying service that is supported by sufficient rationale. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 2. Entitlement to service connection for bilateral hearing loss is remanded. 3. Entitlement to service connection for tinnitus The Veteran’s service personnel records show that his military occupational specialty was 05B10, voice radio operator. In an October 2016 VA audiology note, the Veteran reported that he first noticed tinnitus in both ears during service. He stated that his tinnitus was worsened after being involved in a tank accident. On VA examination in June 2017, pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 15 35 55 LEFT 15 15 40 55 65 Speech discrimination scores were 94 percent for the right ear and 92 percent for the left ear using the Maryland CNC Test. The Veteran told the examiner that he first noticed hearing loss and tinnitus in 1976 after a tank accident during service. The examiner stated that the Veteran had normal hearing sensitivity at separation in 1979. The examiner stated that because the Veteran’s hearing was normal at separation, there was no evidence the noise exposure in service caused a permanent noise injury affecting hearing sensitivity. Therefore, the examiner opined that the Veteran’s current hearing loss was deemed less likely as not caused by or a result of service noise exposure. The examiner noted the Veteran’s report that his tinnitus began in 1976, which was not during a period of active duty service. The examiner stated that it was widely accepted that noise-induced tinnitus occurred at the time of the noise exposure and did not develop years later. The examiner opined that the Veteran’s tinnitus was less likely than not caused by or a result of service noise exposure. The Board appreciates the efforts made by the VA examiner. However, the rationale given by the examiner to support the opinion is inadequate. While the examiner gave an opinion regarding the Veteran’s hearing loss and tinnitus and service noise exposure, the examiner did not give an opinion regarding any possible connection between the Veteran’s hearing loss, tinnitus, and the documented tank accident. Notably, the tank accident occurred during a period of ACDUTRA. Additionally, an opinion that relies only on the absence of symptoms or treatment during or since service is not adequate. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Remand is necessary for an adequate etiology opinion regarding bilateral hearing loss and tinnitus. VA attention has been directed to a sponsored Institute of Medicine (IOM) report on delayed onset hearing loss. While the report states that “based on the anatomical and physiological data available on the recovery process following noise exposure, it is unlikely” that the onset of hearing loss begins years after noise exposure occurs, that statement does not reflect the full extent of the report’s findings pertinent to the matter. Comm. on Noise-Induced Hearing Loss and Tinnitus Assoc’d with Military Service from World War II to the Present, Inst. of Medicine, Noise and Military Serv.: Implications for Hearing Loss and Tinnitus, at 47 (Larry E. Humes, Lois M. Joellenbeck, and Jane S. Durch eds., 2005). While a portion of the IOM report found there is no evidence of delayed onset hearing loss due to noise exposure, another portion of the same IOM report found that “an individual’s awareness of the effects of noise on hearing may be delayed considerably after the noise exposure.” Comm. on Noise-Induced Hearing Loss and Tinnitus Assoc’d with Military Service from World War II to the Present, Inst. of Medicine, Noise and Military Serv.: Implications for Hearing Loss and Tinnitus, at 203-04 (Larry E. Humes, Lois M. Joellenbeck, and Jane S. Durch eds., 2005. Therefore, the IOM report’s language may support a theory of service connection involving delayed onset of a Veteran’s perception of hearing loss such that a VA examiner’s citation of the report should contemplate all of the pertinent aspects of its findings. Lemmons v. McDonald, No. 15-3043, 2016 LEXIS 1646 (Vet. App. October 28, 2016) (non-precedential). The matters are REMANDED for the following action: 1. Obtain all pertinent VA and private medical records not yet associated with the record. 2. Schedule the Veteran for a VA examination to determine the etiology of diagnosed obstructive sleep apnea. The examiner must review the record and must note that review in the report. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. The examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that sleep apnea was caused by any incident during the Veteran’s period of honorable service, to include as due to a facial injury during the May 1976 tank accident during a period of ACDUTRA. The examiner should review the service records regarding the accident in making the opinion. If it is determined that there is another likely etiology for sleep apnea, that should be stated. A complete rationale for all opinions expressed should be clearly provided. 3. Schedule the Veteran for a VA audiology examination and obtain an opinion on the etiology of bilateral hearing loss and tinnitus. Following a review of the record, to include the Veteran’s lay statements concerning noise exposure in service, a May 1976 tank accident while on ACDUTRA, hearing loss symptoms, tinnitus, and the IOM report concerning an individual’s delayed awareness of the effects on hearing from noise, and the onset of current symptomatology, the examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s bilateral hearing loss or tinnitus had its onset during, or is otherwise related to service, to include as due to the documented May 1976 tank accident during a period of ACDUTRA. The examiner should review the records regarding the tank accident during service. A clearly stated rationale for any opinion offered should be provided and must not be based solely on the lack of any record of hearing loss or tinnitus during service. The examiner must consider the Veteran’s lay statements regarding symptoms of hearing loss and tinnitus during and since service. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Layton, 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.