Citation Nr: 21022361 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 14-16 340 DATE: April 15, 2021 ORDER Entitlement to service connection for tremors of the bilateral upper extremities, to include as secondary to service-connected diabetes mellitus, type II, is denied. Entitlement to service connection for bilateral hearing loss, to include as secondary to service-connected diabetes mellitus, type II, and/or tinnitus, is denied. FINDINGS OF FACT 1. Tremors of the bilateral upper extremities did not have their onset in service and are not otherwise related to the Veteran’s active military service, including exposure to herbicides. 2. Tremors of the bilateral upper extremities are not caused or aggravated by a service-connected disability, to include diabetes mellitus, type II. 3. Bilateral hearing loss did not have its onset in service and is not otherwise related to the Veteran’s active military service. 4. Bilateral hearing loss is not caused or aggravated by a service-connected disability, to include diabetes mellitus, type II, and/or tinnitus. CONCLUSIONS OF LAW 1. Tremors of the bilateral upper extremities were not incurred in or aggravated by the Veteran’s military service, and may not be presumed to have been so incurred. 38 U.S.C. §§ 101, 1101, 1112, 1113, 1116, 1131, 1137, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.307, 3.309. 2. Tremors of the bilateral upper extremities are not proximately due to, or aggravated by, a service-connected disability. 38 U.S.C. §§ 1131, 5017; 38 C.F.R. §§ 3.303, 3.310(a). 3. Bilateral hearing loss was not incurred in or aggravated by the Veteran’s military service, and may not be presumed to have been so incurred. 38 U.S.C. §§ 101, 1101, 1112, 1113, 1116, 1131, 1137, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.307, 3.309, 3.385. 4. Bilateral hearing loss is not proximately due to, or aggravated by, a service-connected disability. 38 U.S.C. §§ 1131, 5017; 38 C.F.R. §§ 3.303, 3.310(a), 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1969 to November 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated September 2012 and November 2012 of the Department of Veterans Affairs (VA) Regional Office (RO). The September 2012 rating decision denied the Veteran’s claim of entitlement to service connection for bilateral hearing loss. He filed a notice of disagreement (NOD) in October 2012. The November 2012 rating decision denied the Veteran’s claim of entitlement to service connection for tremors of the bilateral upper extremities. He filed a NOD in December 2012. A statement of the case (SOC) was issued as to both claims in March 2014; the Veteran perfected a timely substantive appeal in March 2014. In August 2017, the Veteran presented sworn testimony during a videoconference hearing, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran’s VA claims file. In a January 2018 Board decision, the claims were remanded for further evidentiary development. In an August 2019 decision, the Board denied the Veteran’s claim of entitlement to service connection for bilateral hearing loss and remanded the matter of entitlement to service connection for tremors of the bilateral upper extremities. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2020 Order, granting a June 2020 Joint Motion for Partial Remand (Joint Motion), the Court partially vacated the Board’s August 2019 denial of the claim of entitlement to service connection for bilateral hearing loss and remanded the matter for further development in compliance with the directives specified in the Joint Motion. In October 2020, the claim of entitlement to service connection for bilateral hearing loss was remanded for further evidentiary development. As will be discussed below, a review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A supplemental statement of the case (SSOC) was issued as to the matter of entitlement to service connection for bilateral hearing loss in February 2021. A SSOC was issued in November 2020 as to the matter of entitlement to service connection for tremors of the bilateral upper extremities. The Veteran’s VA claims file has been returned to the Board for further appellate proceedings. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or from or aggravation of a pre-existing injury suffered or disease contracted in line of duty. See 38 C.F.R. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board notes that there has been an amendment to the provisions of 38 C.F.R. § 3.310. See 71 Fed. Reg. 52,744 -47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. 1. Entitlement to service connection for tremors of the bilateral upper extremities. The Veteran asserts entitlement to service connection for tremors of the bilateral upper extremities, which he contends were incurred during his military service; specifically, as a result of exposure to herbicides. See the NOD dated October 2012. He alternatively contends that he developed tremors of the upper extremities secondary to diabetes mellitus, type II. See the August 2017 Board hearing transcript. The Veteran’s service treatment records (STRs) do not document complaints of tremors or symptoms possibly indicative of tremors. The Board observes that the Veteran has not asserted that his tremors began in service; rather, he argues that his tremors are due to herbicide exposure and began soon after active duty discharge. See the Board hearing transcript dated August 2017, pg. 15. To this end, service in the Republic of Vietnam is documented in the record. As such, the Veteran’s exposure to herbicide agents, including Agent Orange, is legally presumed. Although tremors are not on the list of diseases that VA has associated with Agent Orange exposure, the regulations also provide that service connection may be granted for any disease diagnosed after discharged, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. §§ 3.303(d), 3.3.09(e); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). VA treatment records dated in August 2012 note that the Veteran had recently been experiencing tremors and had been having difficulty with tedious projects and holding a cup. The Veteran was afforded a VA examination in October 2012 at which time the examiner noted that the Veteran “has developed intermittent incoordination and tremors of [the] upper extremities over [the] last 10 years.” The examiner explained that the claimed tremor disability “was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness.” The examiner explained, “[i]ntention tremor is a problem that largely affects the elderly and has no known etiology. Additionally, there is nothing in the military records which would suggest any sort of neurological problem.” A February 2014 VA medical opinion indicated that the Veteran does not have peripheral neuropathy of the bilateral upper extremities. The examiner confirmed that the October 2012 VA examination was negative for findings of peripheral neuropathy. VA treatment records dated in July 2014 documented tremors in bilateral hands for the past two to three years. A September 2014 neurology consultation noted the Veteran’s report that he initially noticed tremors in 1972, but he attributed those tremors to his alcohol use. However, he stopped drinking alcohol four years ago and continues to experience increasing bilateral upper extremity tremors. The VA neurological treatment provider indicated a diagnosis of essential tremors with no evidence of Parkinson’s disease. The treatment provider stated that the Veteran most likely has benign essential tremors, which will most likely worsen with age. In a September 2015 addendum opinion, a VA neurologist confirmed that the Veteran is diagnosed with essential tremors aggravated by stress and anxiety, which will worsen with time. The Veteran was afforded a VA examination in February 2018 at which time the examiner confirms a diagnosis of benign essential tremor affecting the hands. The examiner indicated that the diagnosed disability “was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness.” The examiner explained that the Veteran’s diagnosis of benign essential tremor of the upper extremities does not have any link to herbicide exposure. In a May 2019 VA addendum opinion, the examiner stated that the “Veteran has been diagnosed with benign essential tremor. There is no causal or aggravated relationship to his service-connected diabetes.” VA treatment records dated in August 2019 documents a continuing diagnosis of essential tremor, both at rest and on activity. A December 2019 VA examination indicated a diagnosis of right upper extremity tremor secondary to diabetic peripheral neuropathy. An additional diagnosis of diabetic peripheral neuropathy was further noted. In a December 2019 VA medical opinion, the examiner reported that “[t]he claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness.” The examiner explained, “[t]he Veteran’s medical records support that any currently diagnosed condition(s) related to the Veteran’s claimed essential tremors of the bilateral upper extremities is less likely than not (less than 50 percent probability) proximately due to or the result of the presumed herbicide exposure.” The examiner continued, “[t]here are currently no studies found related to essential tremors other than a diagnosis of Parkinson’s disease, which the Veteran does not have [that] Agent Orange causes.” Notably, the December 2019 VA examiner determined that the Veteran has diabetic peripheral neuropathy that is at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran’s service-connected condition, diabetes mellitus, type II. The examiner explained, “[t]he Veteran’s HbA1c has steadily increased that reveals a progression of his disease. This progression is also seen with a diabetic peripheral neuropathy that is causing his hand tremors and decreased right hand grip strength and pinch to thumb test on physical exam.” The examiner continued, “[h]is tremors are due to fatigue from neuropathy after actively using his hands in any active task.” The examiner further stated that the Veteran’s records show he has a diagnosis of diabetic peripheral neuropathy that is progressively getting worse. The Veteran was afforded another VA examination in October 2020 at which time the examiner indicated that the Veteran does not have a diagnosis of diabetic peripheral neuropathy of the upper extremities. The examiner explained, “Parkinson’s seems sufficiently ruled out at this time, lacks characteristic gait, tremor at rest, posture or facial changes. Neurologist has apparently also ruled out Parkinson’s and attributed the tremor to the Veteran’s significant drinking history.” The examiner continued, “[t]he Veteran does not have a diabetic peripheral neuropathy condition; however, the findings on examination are instead due to a [central nervous system] condition of essential tremors.” In an October 2020 VA medical opinion, the examiner explained that it is less likely than not (less than 50 percent probability) that the claimed bilateral hand tremors “are proximately due to the Veteran's diabetic peripheral neuropathy. The Veteran's tremors easily predate his diabetes condition. Records vary on the exact date of diagnosis for his diabetes, although all appear to be between 2004 and 2008. The Veteran's STRs indicate that his tremor was present by 1976 and he claimed that the tremor started in the early 1980's, to the best of his recollection.” The examiner continued, “[r]egardless, the Veteran's tremor appears to have predated his diabetes by at least two decades and therefore cannot be attributed to his diabetic peripheral neuropathy in any way, directly or indirectly. Also, there does not appear to be a clear nexus for his tremors to his time in active service.” The Veteran underwent another VA examination in November 2020 at which time he reported that his tremors began in the 1970’s or early 1980’s. He “[n]oticed tremor of both hands initially while working with gun parts, became slightly more frequent shortly after that but he states that the condition has not increased appreciably lately.” The examiner diagnosed the Veteran with an essential tremor. In a separate November 2020 VA medical opinion, the examiner stated that the Veteran’s tremors of the bilateral upper extremities are not at least as likely as not aggravated beyond their natural progression by the diagnosed diabetes mellitus, type II. The examiner explained, “[t]he Veteran’s older medical records only seem to describe the condition as a ‘benign essential tremor’ just referring to it as a mild tremor of the hands, which is essentially consistent with how he has presented in the two encounters this examiner has had with the Veteran.” The November 2020 VA examiner continued, There is no documented objective increase in the Veteran’s tremor symptoms with the onset of his diabetes or his supposed diabetic peripheral neuropathies. Also, diabetic peripheral neuropathies are not classically accepted as suspected etiologies for chronic tremors, regardless of their distribution among the extremities. Unfortunately, there is no commonly accepted scale upon which to grade essential tremor intensity, and the Veteran’s records do not appear to have a qualitative description of his tremors worsening in any manner, regardless of the timeline of his diabetes or peripheral neuropathy. The records do occasionally refer to his tremor as mild, which seem[s] consistent with the subtle shakiness noted of his hands during the examinations. The November 2020 VA examiner additionally explained, Although there is no EMG testing and the diabetic neuropathy work-up from 2012 appears to be negative for a diagnosis, this examiner could eventually find VAMC records of a peripheral neuropathy diagnosis within some routine physicals that stated that he had "chronic neuropathic pain of both feet and chronic left arm numbness." The examiner of this February 8, 2018 note also lists the veteran's essential tremor as a separate diagnosis from these other two neuropathic conditions. Also, diabetic neuropathies are not classically accepted as suspected etiologies for, or contributory to chronic tremors, regardless of their distribution among the extremities. Podiatry notes in the Veteran’s service treatment records do confirm that he suffers from diabetic peripheral neuropathy of the feet, but this examiner cannot find clear involvement of his neuropathies contributing to any upper extremity tremors. The November 2020 VA examiner further opined, The Veteran stated that he did not notice any appreciable change in the degree of his bilateral hand tremors with his diabetes diagnosis or with his neuropathies. He states that the hand tremors "still just come and go" and he denied noticing any appreciable onset of numbness or aggravation of the tremors concurrent with his history of diabetes. Although the diabetes underlying the diabetic peripheral neuropathy might lead to a tremor of the entire body in times of severe hypoglycemic events, this would not be limited to just the hands and the veteran denies having experienced any such hypoglycemic episodes as far as he knows. When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The United States Court of Appeals for Veterans Claims (Court) has held that claims file review, as it pertains to obtaining an overview of a claimant’s medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. “It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion.” See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In this matter, the Board recognizes that the December 2019 VA examiner indicated that the Veteran’s bilateral tremors were a symptom of peripheral neuropathy of the bilateral upper extremities. However, this conclusion is in contrast to the October 2020 and November 2020 VA medical opinions, which specifically determined that the medical evidence does not support a finding that the Veteran has a diagnosis of diabetic peripheral neuropathy of the bilateral upper extremities. Moreover, in the October 2020 and November 2020 medical opinions, the VA examiner explained that the Veteran’s diagnosed essential tremor manifested in mild symptoms of the bilateral upper extremities is not caused or aggravated by service-connected diabetes mellitus, type II, or any complication thereof. To this end, the Board notes that the October 2020 and November 2020 medical opinions were based on a review of the record, including the statements and evidence submitted by the Veteran, and the examiner explained the reasons for their conclusions based on an accurate characterization of the evidence of record. The Board therefore places significant weight on the cumulative findings expressed in the October 2020 and November 2020 VA medical opinions. See Nieves-Rodriguez, supra; see also Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”). The Board notes that the diagnostic findings of the VA examiner expressed in the October 2020 and November 2020 medical opinions are consistent with the findings of the VA neurologist who treated the Veteran in September 2014 and confirmed a diagnosis of benign essential tremor. Accordingly, the Board finds that the competent medical evidence demonstrating the absence of nexus between the claimed tremors of the bilateral upper extremities and the Veteran’s active duty service, as well as his service-connected disabilities, outweighs any medical evidence suggestive of a nexus or aggravation. The Board has carefully considered the contentions of the Veteran that he has tremors of the bilateral upper extremities, which were incurred during service and/or as secondary to his service-connected diabetes mellitus, type II. To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran’s particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011). In this case, the Veteran’s assertions as to etiology concern an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). Questions of competency notwithstanding, the Veteran’s lay theories regarding the onset and etiology of his tremors of the bilateral upper extremities are contradicted by the conclusions of the October 2020 and November 2020 VA examiner who specifically considered the Veteran’s lay statements in rendering the negative opinions. The Board finds the specific, reasoned opinion of the trained health care provider who conducted the October 2020 and November 2020 VA opinions to be of greater probative weight than the more general lay assertions of the Veteran. The Board has considered that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan, supra. Crucially, the October 2020 and November 2020 VA medical opinions specifically considered the lay assertions and inferences contained in the record in rendering the negative nexus opinions. Considering the overall evidence, including the post-service medical evidence, the October 2020 and November 2020 VA medical opinions, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the Veteran’s contentions that he suffers from tremors of the bilateral upper extremities, which is related to his military service and/or secondary to service-connected diabetes mellitus, type II. Thus, the benefit-of-the-doubt rule is not applicable to the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. 2. Entitlement to service connection for bilateral hearing loss, to include as secondary to service-connected diabetes mellitus, type II, and/or tinnitus. In addition to the criteria set forth above, certain enumerated diseases will be service connected on a presumptive basis if they manifested to a compensable degree within one year after active duty service. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). A nexus between the current disability and service may be established by evidence of continuity of symptomatology since service for a listed chronic disability. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). VA deems sensorineural hearing loss to be an organic disease of the nervous system for purposes of 38 C.F.R. § 3.309(a). See Veterans Benefits Administration (VBA) Fast Letter 10-02 (Mar. 18, 2010); Memorandum, Characterization of High Frequency Sensorineural Hearing Loss, Under Secretary for Health, October 4, 1995. Although the Walker case did not expressly address this issue, the Board will deem sensorineural hearing loss as a “chronic” disease for purposes of this decision. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Service connection will be granted for a hearing loss disability where the evidence establishes a nexus between the current hearing loss and a disease or injury suffered while in military service. Godfrey v. Derwinski, 2 Vet. App. 352, 356 (1992). VA regulations do not preclude service connection for a hearing loss which first met VA’s definition of disability after service. Hensley, 5 Vet. App. at 159. In this matter, the Veteran contends that his bilateral hearing loss began during his active military service. See the Board hearing transcript dated August 2017. He has alternatively contended that his bilateral hearing loss is due to service-connected disabilities including diabetes mellitus, type II, and tinnitus. Id. For the reasons set forth below, the Board concludes that service connection is not warranted on either basis. It is undisputed that the Veteran has been found to have current bilateral hearing impairment for VA compensation purposes. See, e.g., the VA examination report dated March 2018. The Veteran’s service treatment records (STRs) include in-service audiological testing completed at the May 1969 enlistment examination, hearing conservation data assessments dated in August 1969, March 1970, and May 1971, as well as the November 1971 separation examination. Because it is unclear from the examination report itself whether such thresholds were recorded using American Standards Association (ASA) units or International Standards Organization-American National Standards Institute (ISO-ANSI) units, the Board considered whether using the recorded metrics under both standards for purposes of considering if one-unit measurement results would be appropriate. However, the March 2018 VA examiner thoroughly reviewed the record and determined that “[n]o conversions are needed as all exams recorded use ISO calibration.” The May 1969 enlistment examination audiometric results are reflected in the record as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 -5 -5 0 LEFT 5 0 0 0 0 The August 1969 hearing conservation data audiometric results are reflected in the record as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 15 10 5 30 LEFT 15 15 10 15 15 The March 1970 hearing conservation data audiometric results are reflected in the record as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 0 0 0 LEFT 0 0 0 0 0 The May 1971 hearing conservation data audiometric results are reflected in the record as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 5 10 10 LEFT 10 5 5 5 10 The November 1971 separation examination audiometric results are reflected in the record as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 5 5 10 LEFT 10 5 5 10 10 In-service noise exposure was conceded by the RO based on the Veteran’s military occupational specialty (MOS) of aircraft maintenance specialist. See the SOC dated March 2014; see also the rating decision dated September 2012. Moreover, as indicated above, the Veteran is currently service-connected for diabetes mellitus, type II, and tinnitus. See the rating decision dated September 2012. Thus, the crucial question in this matter is whether such noise exposure resulted in the current bilateral hearing loss or whether the diagnosed bilateral hearing loss was caused or is aggravated by the service-connected disabilities. The Veteran has neither identified nor submitted any post-service treatment records to demonstrate hearing loss disability at any time prior to his September 2012 VA examination. Although he has described longstanding decreased hearing acuity, there is no competent medical evidence that bilateral sensorineural hearing loss manifested to a compensable degree within one year of his discharge from active service. 38 C.F.R. § 3.307, 3.309. The Veteran was afforded a VA audiological examination in September 2012 at which time the VA examiner documented bilateral hearing loss sufficient for VA compensation purposes. See 38 C.F.R. § 3.385. As to the question of nexus, the VA examiner determined that the Veteran’s bilateral hearing loss was not at least as likely as not caused by or a result of his military service. The examiner stated, “[t]he Veteran’s hearing was normal in both ears at time of enlistment and near separation.” However, as described in the January 2018 Board Remand, the only rationale provided by the examiner for the opinion is that the Veteran’s hearing was normal in both ears at enlistment and near separation. The September 2012 VA examiner’s opinion is therefore of little probative value. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992) (the absence of in-service evidence of a hearing disability is not fatal to a claim of service connection for hearing loss). Pursuant to the January 2018 Board Remand, the Veteran was afforded a VA audiological examination in March 2018 at which time the VA examiner determined that is not at least as likely as not that the diagnosed bilateral hearing loss was caused by or a result of the Veteran’s military service. The examiner recognized that the Veteran was exposed to hazardous noise during his military service. The examiner further noted the Veteran’s report of hearing loss dating from his active duty service. The examiner reviewed the audiometric results documented in the Veteran’s STRs and reported that the August 1969 examination is considered an outlier due to poor reliability. The examiner explained, “hearing was recorded as normal and consistent with entrance exam in three separate exams following the exam on August 11, 1969. There are NO significant threshold changes (equal to or greater than 15dB) noted when thresholds are compared across the other four serial audiograms from 1969-1971.” The examiner noted that “[t]he Veteran’s reliable audiograms in his claims file show no evidence of damage to the hearing mechanisms or auditory system during the Veteran’s time in service.” He continued, “[g]iven the Veteran’s normal thresholds recorded at separation exam and lack of threshold shifts over serial audiograms, it is the opinion of this examiner that the current hearing loss . . . is less likely as not to be due to in-service military noise exposure.” The examiner additionally recognized the research submitted by the Veteran indicating “there is higher incidence of hearing loss, consistent with the Veteran’s high frequency sensorineural hearing loss, among adults with diabetes compared to the adults without diabetes (Bainbridge, Hoffman & Cowie, 2008).” However, the examiner explained, “there is no way to note the possible extent of aggravation of hearing loss due to diabetes mellitus without resorting to speculation.” As indicated above, this matter was the subject of a June 2020 Joint Motion, adopted by a June 2020 Court order, which vacated and remanded the claim of entitlement to service connection for bilateral hearing loss based upon inadequacies in the March 2018 VA medical opinion. Accordingly, in order to comply with the Joint Motion, the issue on appeal was remanded by the Board in October 2020 to obtain a new VA medical opinion to address outstanding questions of nexus and aggravation. Pursuant to the Board Remand, a VA medical opinion was obtained in November 2020 at which time the examiner reviewed the evidence of record and concluded that the diagnosed bilateral hearing loss “was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness.” The examiner explained that the Veteran “served in the Air Force 1969-1971; MOS of Aircraft Maintenance, which had a high probability of hazardous noise exposure. There is no significant permanent shift in hearing thresholds beyond test variability from entrance to separation, which is objective evidence of no permanent auditory damage on active duty from conceded noise. There is no report of complaint/treatment for hearing decrease in STRs or at separation.” The examiner continued, “[a]lthough noise exposure is conceded and the relationship of noise, auditory damage and hearing loss is well-established, auditory damage and hearing loss are not conceded based on noise alone. There must be a nexus of auditory damage to relate current hearing loss to military noise and not another etiology. The evidence is against a nexus in this case; therefore, it is less likely than not that the hearing loss is related to military noise exposure.” As to the question of secondary service connection, the November 2020 VA examiner determined that the Veteran’s bilateral hearing loss “is less likely than not (less than 50 percent probability) proximately due to or the result of Veteran’s service connected condition.” The examiner explained, “[b]oth age and diabetes are known factors that increase the risk of developing hearing loss, establishing a correlation between hearing loss and diabetes, however, current peer reviewed longitudinal studies do not support causation. Unable to establish a nexus at this time.” The examiner additionally concluded that the Veteran’s bilateral hearing loss is less likely than not aggravated beyond its natural progression by his service-connected disabilities. The examiner explained, “[t]here is no significant change in thresholds since the diagnosis of diabetes. Therefore, there is no significant progression of the hearing loss found.” In a separate November 2020 VA medical opinion, the examiner indicated, “[t]here is no medical literature to support tinnitus causing hearing loss or aggravating hearing loss. Although correlation exists between tinnitus and hearing loss, tinnitus causing or aggravating hearing loss is not shown. Etiology of hearing loss can be caused by outer ear, middle or inner ear conditions. A nexus cannot be established.” In a January 2021 VA addendum opinion, the VA examiner clarified that he had thoroughly reviewed the Veteran’s VA claims file including his August 2017 Board hearing testimony as to experiencing noise exposure during service followed by decreased hearing during his military service, which has continued to this day. The VA examiner identified pertinent STRs and post-service treatment records, and concluded, The Veteran’s hearing loss did NOT manifest to a compensable degree within the first post-service year. Lay testimony of Veteran re: noise exposure during service, decreased hearing during service and effects of decreased hearing from Transcript of hearing before the Board of Appeals8/29/2017 was reviewed. Veteran states a subjective complaint of decrease hearing during service; however, the audiograms documented during active duty refute that claim. First diagnosis of hearing loss is noted to be on examination dated 9/17/2012 . . . A nexus cannot be established. When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean, 13 Vet. App. at 448-49. The Court has held that claims file review, as it pertains to obtaining an overview of a claimant’s medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. “It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion.” See Nieves-Rodriguez, 22 Vet. App. at 295. The Board finds the November 2020 and January 2021 VA examiner’s opinions substantially complied the with October 2020 Remand directive. As detailed above, the findings of the November 2020 and January 2021 VA examiner were thoroughly explained and fully supported by the evidence of record. The examiner’s opinions were based on a review of the record, including the lay statements, pertinent medical literature, and thoughtful analysis of the Veteran’s entire history including his August 2017 Board hearing testimony concerning continuity of symptomatology. Moreover, the examiner addressed the Veteran’s contentions of aggravation of bilateral hearing loss by diabetes mellitus and tinnitus. The Board therefore places significant weight on the findings set forth in the November 2020 and January 2021 VA medical opinions. See Nieves-Rodriguez, 22 Vet. App. at 295 (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion); see also Bloom, 12 Vet. App. at 187 (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”). The Board additionally observes that, aside from the Veteran’s lay contentions and one article submitted in support of his appeal, he has offered no evidence in support of his contentions of direct and secondary service connection. The medical evidence in this case has consistently indicated that the Veteran’s diagnosed bilateral hearing loss was not incurred during his military service and is not due to or aggravated by a service-connected disability. See the VA medical opinions dated September 2012, March 2018, November 2020, and January 2021. Accordingly, the Board finds that the competent medical evidence cumulatively demonstrating the absence of nexus between the currently diagnosed bilateral hearing loss and the Veteran’s military service and/or service-connected disabilities outweighs the medical evidence suggestive of a nexus. The Veteran has not produced a medical opinion to contradict the conclusions set forth in the November 2020 and January 2021 VA medical opinions. Thus, these VA medical opinions stand unchallenged as competent medical evidence on the crucial question of medical nexus. The Board has carefully considered the contentions of the Veteran that he suffers bilateral hearing loss, which was incurred during his military service and/or as secondary to a service-connected disability. To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran’s particular disability is the type of disability for which lay evidence is competent. See Davidson, 581 F.3d at 1316; Kahana, 24 Vet. App. at 433, n.4. In this case, the Veteran’s assertions as to etiology concern an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-9; Falzone, 8 Vet. App. 403 (lay person competent to testify to pain and visible flatness of his feet); with Clemons, 23 Vet. App. at 6 (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”); Woehlaert, 21 Vet. App. at 462 (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). See also Colantonio, 606 F.3d at 1382 (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). Questions of competency notwithstanding, the Veteran’s lay theories regarding the etiology of his bilateral hearing loss are contradicted by the conclusion of the November 2020 and January 2021 VA examiner who specifically considered the Veteran’s lay statements in rendering his negative opinions. The Board finds the specific, reasoned opinion of the trained health care provider who conducted provided the November 2020 and January 2021 medical opinions to be of greater probative weight than the more general lay assertions of the Veteran. The Board has considered that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Crucially, however, the Veteran’s contentions in support of service connection, including continuing post-service hearing loss symptomatology are contradicted by the findings set forth in the November 2020 and January 2021 VA medical opinions, which specifically considered the lay assertions and any such inferences contained in the record in the negative nexus opinions. Considering the overall evidence, including the post-service medical evidence, the VA medical opinion, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the Veteran’s claim. Thus, the benefit-of-the-doubt rule is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. K. Buckley, 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.