Citation Nr: 21022379 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 18-21 578 DATE: April 15, 2021 ORDER Service connection for bilateral hearing loss is dismissed. The previously denied claim for service connection for depression and anxiety disorders is reopened. Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) with depression and anxiety, is granted. REMANDED Service connection for a low back disorder is remanded. Service connection for a neck/cervical spine disorder is remanded. Service connection for a left knee disorder is remanded. Service connection for a right knee disorder is remanded. Service connection for a left ankle disorder is remanded. Service connection for a right ankle disorder is remanded. Service connection for tinnitus is remanded. Service connection for erectile dysfunction is remanded. Entitlement to special monthly compensation based on loss of use of creative organ is remanded. Service connection for scars on the scalp is remanded. Service connection for scars on the left ankle is remanded. FINDINGS OF FACT 1. In January 2021, during the Board hearing and prior to promulgation of a decision in the appeal, the Veteran explicitly, unambiguously, and with a full understanding of the consequences, withdrew his appeal for entitlement to service connection for bilateral hearing loss. 2. In an unappealed rating decision dated in March 2003, the RO denied service connection for depression and anxiety finding no evidence of in-service incurrence or that a current condition was caused by service. 3. Additional evidence received since March 2003 is not cumulative or redundant of the evidence of record at the time of that rating decision, relates to an unestablished fact necessary to substantiate the claim for service connection for depression and anxiety, and raises a reasonable possibility of substantiating the claim. 4. The evidence is in equipoise as to whether the Veteran’s PTSD with comorbid depression and anxiety is related to his military service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the Veteran’s appeal of the claim for service connection for bilateral hearing loss have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The March 2003 rating decision denying service connection for depression and anxiety is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 3. New and material evidence having been received, the criteria for reopening the previously denied claim of service connection for depression and anxiety have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. The criteria for service connection for an acquired psychiatric disorder, to include PTSD with depression and anxiety, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(f), 4.125. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from April 1982 to April 1986, and from March 1987 to October 1989. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision issued by a VA Regional Office (RO). In January 2021, the Veteran testified at a Board Hearing before the undersigned. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). 1. Service connection for bilateral hearing loss is dismissed. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 19.55. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. In DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011), the Court held a valid oral withdrawal must be: (1) explicit, (2) unambiguous, and (3) done with a full understanding of the consequences of such action by the appellant. During the January 2021 Board hearing, the Veteran’s representative stated, and the Veteran reiterated, on the record, that the Veteran was withdrawing his appeal for service connection for hearing loss. The Veteran’s representative indicated, “I’ve discussed the ramifications associated…with the Veteran to include the fact that, Your Honor will not be issuing decision on that… And should he wish to file that in the future the effective date will only be from the date in the future.” The undersigned again asked the Veteran if he understood the consequences of withdrawing the hearing loss claim, and the Veteran indicated he did understand and still wished to withdraw the claim. The Board finds that the Veteran’s withdrawal of the appeal was “explicit, unambiguous, and done with a full understanding of the consequences of such action on the part of the claimant.” DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011); see also Acree v O’Rourke, 891 F.3d 1009 (Fed. Cir. 2018). Thus, the Board finds the Veteran’s withdrawal of this issue at the hearing meets the requirements of DeLisio and, therefore, is dismissed because there remains no allegation of error of fact or law for appellate consideration. 38 U.S.C. § 7105. 2. The previously denied claim for service connection for depression and anxiety disorders is reopened. The Veteran contends his depression and anxiety began during service. In a rating decision dated in March 2003, the RO denied the claims on the grounds that there was no record of any complaints, treatment, or diagnosis in the STRs (although the RO did note that STRs from the Veteran’s first enlistment were missing). No new evidence or notice of disagreement was received by VA within one year of the issuance of the March 2003 rating decision. Thus, it became final. A claimant may reopen a finally adjudicated legacy claim by submitting new and material evidence. New evidence is evidence not previously part of the actual record before agency adjudicators. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110 (2010). In October 2013, the Veteran filed a new claim for service connection for depression/a psychiatric disorder and, in a rating decision dated in July 2014, the RO “confirmed and continued” the previous denial of service connection. Regardless of what the RO did, the Board has the jurisdictional responsibility to consider whether it was proper to reopen the claim. The Board will therefore determine whether new and material evidence has been received and, if so, consider entitlement to service connection on the merits. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). At the time of the March 2003 rating decision, the record included service treatment records from the Veteran’s second period of service. These records showed at the time of separation, in August 1989, the Veteran reported “trouble sleeping.” His personnel records also indicated he was undergoing proceedings associated with drug abuse “misconduct” during his second period of service. He was given an August 1989 mental status evaluation. At that time the Veteran was evaluated as having normal behavior and fully alert and having the mental capacity to participate in the proceedings. The record also indicated the Veteran’s service treatment records for his first period of service, from April 1982 to April 1986, were unavailable. The Veteran did not provide any contentions or context as to why he believed he had depression or anxiety related to service. There was also no medical evidence indicative of a current diagnosis. On review of the record the Board finds that new and material evidence has been submitted since the RO’s March 2003 denial of these claims. Initially, it is worth noting the Veteran’s character of discharge for his second period of service has been characterized as “under honorable conditions.” However, as long as a veteran is discharged or released under conditions other than dishonorable, he is eligible for VA compensation. 38 U.S.C. § 38 U.S.C. § 101(2); 38 C.F.R. §§ 3.12(a), 3.4(a). In 2014, the Veteran’s spouse submitted a lay statement noting various post-military changes of behavior she observed, to include misuse of drugs, suicidal ideation, angry outbursts, sleep disturbances, trouble concentrating, depression, and changes in appetite that she believed were indicative of a mental health issue. The Veteran also provided statements of in-service stressors in support of his claim related to parachute jump accidents and an explosion in Germany that resulted in casualties of friends. A search was able to confirm that on January 11, 1985, a U.S. Army vehicle accident occurred in a Pershing Missile exploding resulting in US casualties assigned to the Veteran’s unit. VA outpatient treatment records from 2013 to 2015 also reflect various diagnoses, to include depression, anxiety, an adjustment disorder, and PTSD, related to an incident in Germany where an explosion accident occurred that killed the Veteran’s friend. The record also contains conflicting nexus opinions from a VA examiner and a private opinion, but at a minimum the lay statements, the confirmed stressor, and the medical evidence showing current diagnoses that may be associated with in-service incidents (none of which were of record at the time of the March 2003 rating decision) are material as it raises a reasonable possibility of substantiating the claim. The previously denied claim of service connection for depression and anxiety is thus reopened and the Board will address the merits of the claim. 3. Service connection for PTSD with depression and anxiety is granted. As outlined above, the Veteran contends he has PTSD, depression, and/or anxiety, due to various in-service stressful events during his military service, to include an incident in Germany where a vehicle was involved in a missile explosion resulting in casualties of friends. In view of the commonality of these disorders in this case, Board has consolidated these separately claimed and adjudicated issues into a single claim for service connection for a psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (holding that a claimant without medical expertise cannot be expected to precisely delineate the diagnosis of his mental illness; he filed a claim for the affliction that his mental condition, whatever it is, causes him). Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. “To establish a right to compensation for a present 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”—the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). In addition to service connection on a direct basis, service connection may also be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For a grant of service connection, the diagnosis of a mental disorder must be made in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 38 C.F.R. § 4.125(a); see also Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020) (holding that with respect to psychiatric disabilities VA has expressly limited compensation to disabilities conforming to a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis and the Court lacks jurisdiction to review the Secretary’s decision to require such a diagnosis as set out in the schedule of ratings). Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran contends various stressors that include a parachute jump gone wrong resulting in a friend’s death and a vehicle missile explosion in Germany resulting in other fellow servicemen deaths. The Veteran’s personnel records confirm that he served as a Pershing Missile Crewman during his first enlistment, and as a Paratrooper during his second enlistment, and the service department was able to verify that on September 26, 1988 a fellow serviceman in the Veteran’s unit was killed in a jump-related incident. The service department, additionally, also verified that on January 11, 1985, a US Army vehicle accident occurred resulting in a Pershing Missile exploding resulting in US casualties assigned to the Veteran’s unit. See June 2014 responses from the service department. In short, a verified stressor has already been conceded. There are, however, varying opinions as to diagnoses and whether these conditions are related to the Veteran’s is military service or due to personality disorder traits. On review of the record, the Board finds that the evidence is at least in relative equipoise. The Veteran’s service treatment records do not contain any specific complaints, treatment, or diagnoses related to a psychiatric disorder, but the Veteran’s complained of “frequent trouble sleeping.” The Veteran had recently (in May and June of 1989) undergone military proceedings related to drug use. A mental health evaluation in August 1989 was within normal limits. After service, the Veteran’s wife stated that she saw significant changes in the Veteran’s behavior, to include misuse of drugs, trouble sleeping, suicidal ideation, depression, trouble concentrating, angry outbursts, and other mental health issues. See statement from Veteran’s spouse dated in April 2014. Additionally, VA and private treatment records do confirm various current diagnoses of depression, anxiety, adjustment disorder, and PTSD. The evidence also shows that the Veteran has participated in psychotherapy, including VA PTSD group therapy in February 2014. See also VA psychotherapy records dated in July 2016. The evidence is in conflict, however, with regard to diagnosis and nexus. In July 2014, a VA examiner diagnosed the Veteran with persistent depressive disorder but stated that the criteria for a diagnosis of PTSD were not met. The examiner asserted that the Veteran’s strong personality disorder traits interfered with the examiner’s ability to offer any opinion regarding PTSD with any level of scientific certainty. The examiner further found that the Veteran’s depression was secondary to his personality disorder as “much of the Veteran’s depression appears to be driven by his chronic social, interpersonal and occupational difficulties.” The examiner found that while the Veteran attributed all his problems to his military service, it appeared that many of his issues were unrelated to the military. The examiner also found it unlikely that the Veteran’s personality disorder was “permanently aggravated” by anything, to include the in-service stressors. According to this evidence, the Veteran’s depression is secondary to, and not superimposed upon, a personality disorder. This weighs against the claim, as personality disorders may not be service connected except where there is disability resulting from a mental disorder that is superimposed upon a personality disorder. See 38 C.F.R. § 4.127. The examiner also stated that the Veteran’s personality disorder was not aggravated by the Veteran’s service. Thereafter, in September 2014 the Veteran submitted a statement from a private physician, Dr. J.R., who said that he had been the Veteran’s primary care provider since 2005 and had discussed the Veteran’s military experiences with the Veteran. According to Dr. J.R., the Veteran was being treated for PTSD, depressive disorder, and anxiety disorder. Dr. J.R. added that he himself had prescribed “a mild anxiety medication” for the Veteran. Dr. J.R. did not, however, render an opinion himself, but rather just reported the Veteran’s pertinent medical history based on the Veteran’s self-report. In November 2014, the Veteran underwent a VA MH PTSD Clinic Intake evaluation. During the evaluation the Veteran reported that he was still trying to cope with memories of events, including the deaths of follow soldiers, that occurred when he was in Germany “working with nukes” and while stateside during his time in the 82nd Airborne. He complained of nightmares, panic attacks, and flashbacks. The physician commented that the Veteran’s responses were sometimes evasive or lacking in detail but at other times they were full of detail. The diagnosis, which the physician stated was “based upon DSM 5 criteria” was r/o PTSD; r/o personality disorder; Persistent Depressive Disorder; and Unspecified Anxiety Disorder.” The physician added that “at this point, it is not possible to verify the accuracy of his reports regarding the deaths of soldiers in the military. He has several stories about soldier’s deaths, which combined, seemed somewhat unlikely (though not impossible).” The Board notes, however, that at the time of this assessment, the reported in-service stressors related to the jump and the Pershing explosion had been confirmed by the service department. Subsequently, the Veteran was hospitalized by VA for psychiatric care secondary to suicidal ideation. During that time he was diagnosed by appropriate clinicians as suffering from unstable PTSD with flashbacks and “severe depression and anxiety accompanying it.” See VA inpatient psychiatric treatment records dated in December 2015, in which the psychiatrist averred : “Patient has a diagnosis of PTSD. This occurred from an incident with his friends dying in West Germany. He has a lot of flashbacks about this and has been through numerous treatments.” According to this evidence, the Veteran’s depression and anxiety are part and parcel of his PTSD, and this PTSD with comorbid depression and anxiety is related to the Veteran’s service. The Board notes, however, that the diagnosis was vaguely associated with “friends dying in West Germany” and not a specifically confirmed stressor. Conversely, in July 2016 the Veteran was afforded a VA Initial Post Traumatic Stress Disorder examination. The examiner “deferred” diagnosis of PTSD noting that while stressors had been confirmed, the Veteran’s description of these events “differed in part from the verified stressor report” and, therefore, the examiner had credibility concerns. The examiner elaborated that given the discrepancies in the Veteran’s reports with the verified traumatic incidents, a diagnosis of PTSD was not able to be made with any level of scientific certainty as it was not clear how much of the Veteran’s report “is true versus representation of some type of delusional process for representative of even some other psychological process.” This evidence, which suggests that the diagnosis of PTSD is not valid, opposes the claim. However, since that time a couple of private psychologists have not only endorsed a diagnosis of PTSD but relate it to the Veteran’s service. In July 2016, the Veteran underwent a private psychological evaluation by Dr. J.L.R., which was done via “computer video-teleconference interface.” Dr. J.L.R. noted that the Veteran was “significantly depressed and anxious.” Dr. Dr. J.L.R. discussed the in-service traumatic incidents as relayed to him by the Veteran, including the incident in which a comrade was killed by an exploding missile [which the service department has verified]. Dr. J.L.R. stated that the Veteran’s emotional problems began to emerge around January 1985, after he saw a missile explode during assembly. Dr. J.L.R. added that “all of [the Veteran’s] emotional difficulties appear to stem from life experiences related to his time in military service, resulting from the memories of killings, death, the sights of dead bodies, destruction, carnage, mortar attack and fearing for his own life while stationed in Germany.” Dr. J.L.R. then asserted that “based on the American Psychiatric Association’s Diagnostic Statistical Manual, the Veteran meets the criteria for the DSM-V diagnoses of PTSD and Persistent Depressive Disorder/Dysthymia.” Dr. J.L.R. added that “given the stress from his memories of the missile explosion that skilled some of his friends, the experiences of seeing people shot and killed, and given the common and usual stressors of military service in a war-zone, it is my professional opinion that his psychological disability is at least as likely as not to have originated during his time in military service and is, in fact, more likely to be related to these experiences than not.” Additionally, in July 2018 the Veteran underwent a “TeleMed evaluation” by another private psychologist (Dr. R.A.S.), who stated that he had reviewed the Veteran’s file “in total.” Dr. R.A.S. discussed the Veteran’s in-service experience and post-service symptoms, including the Veteran’s multiple suicide attempts, homicidal ideation, and hostility, irritability, and agitation. Dr. R.A.S. then averred that the Veteran was suffering from recurrent major depressive disorder, chronic post-traumatic stress disorder, and intermittent explosive disorder that is “at least as likely to have begun during his time in the US Army while stationed in Germany and serving in the 82nd Airborne Division.” In January 2021, the Veteran testified before the undersigned in a Board hearing. Of particular note, the Veteran claimed his mental health issues were more related to generally being in the military and knowing his life was on the line every day. He acknowledged turning to drugs and alcohol to deal with stressful military life. While he also gave some information related to the missile explosion incident and the parachute jump incident, the Veteran’s testimony mostly focused on the stress of being in an environment of always feeling he was “under constant threat of sniper fire” or that his life was on the line in some other way. Thereafter, in a letter received by VA in February 2021, Dr. R.A.S. sought to clarify his opinion, stating that while he had previously opined that the Veteran’s presentation “is at least as likely as not to have begun during his time in the US Army while stationed in Germany,” his opinion was based on the Veteran’s report of having witnessed a Pershing missile explosion that resulted in two casualties. Dr. R.A.S. then made a subtle distinction to his previous opinion, stating “Thus, it is ‘at least as likely as not’ [the Veteran’s] diagnosed posttraumatic stress disorder is secondary to witnessing the aforementioned traumatic incident while in service.” Although Dr. R.A.S. seems to be suggesting that the Veteran’s PTSD did not begin during service, his opinion that the Veteran’s PTSD is related to the Veteran’s having witnessed the exploding missile incident still favors the claim. In short, the Veteran currently has diagnoses of psychiatric conditions, to include PTSD, depression, and anxiety. However, there are varying contrasting opinions as to whether these conditions are related to his military service or due to personality disorder traits. The Board also finds noteworthy that the Veteran’s description of the in-service stressors have varied throughout time and, indeed, the July 2016 VA examiner outlined legitimate, significant concerns related to the Veteran’s credibility and reporting of in-service stressors, which varied in detail compared to the verified events confirmed by the state department. Similar to the July 2016 VA examiner’s concerns, the Board similarly notes some disparity in the reporting of these events during the January 2021 hearing with the undersigned. At the same time, it is clear the Veteran’s service as a whole had a significant impact on him whether it be because he felt fear for his life or because he witnessed casualties. Given the complexities of this case, the varying medical opinions, and the confirmed stressors during his military service, the Board finds that the evidence is at least in equipoise on whether the Veteran has a current psychiatric disorder that is related to service. Accordingly, resolving doubt in the Veteran’s favor, the Board finds that service connection for an acquired psychiatric disorder, to include PTSD with comorbid depression and anxiety, is warranted and the appeal is granted. REASONS FOR REMAND In February 2018, the RO issued a Statement of the Case (SOC). Thereafter, and prior to certification of the case to the Board, relevant VA medical records were associated with the claims file, but a Supplemental Statement of the Case was not issued. Before any of the remaining claims can be resolved, compliance with 38 C.F.R. § 19.31(b)(1) is required. The Board also notes that there may be extant STRs. According to documentation in the claims file, on November 14, 2002 the RO requested the STRs from the Veteran’s first (April 1982-April 1986) enlistment, and on November 26, 2003 received the response “there are no additional SMRS on file at Code 13.” The RO then sent a letter on January 9, 2003 to the Commander, U.S. Army Reserve Personnel Command, asking for the Veteran’s STRs, and there is a January 16, 2003 responsive notation on a VA Form 21-3101 that “Record Located at Code 13.” The RO subsequently prepared a March 2003 Memorandum of Unavailability of Service Medical Records. However, the RO did not first make a follow up request to Code 13, after its initial request in November 2002, to see if the STRs are, as implied by the service department, now located at Code 13. The RO then stated, in its February 2018 SOC, that the evidence consisted of STRs dating from April 1982 to April 1986. However, no additional STRs have been associated with the claims file since the RO’s March 2003 Memorandum of Unavailability of Service Medical Records. In accordance with 38 C.F.R. § 3.159(c), additional action should be taken to obtain the extant STRs. Additionally, and before the claims are readjudicated, the following development should also be undertaken. 1. – 6. Service connection for low back, neck/cervical spine, left and right knee, and left and right ankle disorders is remanded. The Veteran seeks service connection for current neck, back, knee, and ankle disorders, which he attributes to the many jumps that he completed as a Paratrooper in the 82nd Airborne Division. During his Board Hearing he testified that he completed “ at least 100 jumps or more.” See Board Hearing Transcript, pp. 22-25. In June 2014, the Veteran was afforded a VA examination, during which the Veteran reported that he was treated for neck, back, knee and ankle pain during service. Diagnoses for all complaints except the right ankle were provided. The examiner then stated that the disorders were less likely related to service because the Veteran denied symptoms during his separation examination. However, the Board notes that the STRs that are of record do in fact show that the Veteran complained of and was treated for knee, ankle and back pain during service; and that the Veteran clearly complained of joint pain during his 1989 separation examination. Moreover, the examiner did not discuss whether the Veteran’s current back, neck, knee, and ankle disorders may nevertheless be related to the Veteran’s parachute jumps, or state whether the Veteran’s undiagnosed right ankle pain is nonetheless productive of functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability if it reaches the level of a functional impairment of earning capacity). The evidence also includes an opinion from a private physician regarding the Veteran’s neck issues. In July 2014, Dr. J.R. stated that he had been the Veteran’s primary care provider since 2005 and had discussed the Veteran’s military experiences with the Veteran. Dr. J.R. then declared “patient had several injuries to his upper extremities and neck during service,” and advised that the Veteran has a current diagnosis of spinal stenosis in his cervical spine. Dr. J.R. then stated: “It is my opinion considering every possible sound medical etiology principle to at least the 75% level of probability that his current neck problem, are due to his experiences/trauma that the patient had during military service.” Although the Veteran did indeed serve as a Paratrooper during service, it does not appear that Dr. J.R. reviewed the claims file. This is significant since there is no record of neck injuries in the Veteran’s military records. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (holding that a bare transcription of lay history... is not competent medical evidence merely because the transcriber is a health care professional). See also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (holding that the examiner “must consider the records of prior medical examinations and treatment in order to assure a fully informed examination”). The Board is consequently unable to favorably resolve the claim for a cervical spine disability based solely on this evidence. However, and in view of the inadequacies of the June 2014 VA examination, the Veteran should be afforded a new one regarding the claims for service connection for cervical spine, back, knee, and ankle disabilities. 7. Service connection for tinnitus is remanded. The Veteran is also requesting service connection for tinnitus, which he thinks began in the 1980s. During his recent Board Hearing he testified that he first noticed it towards the end of 1985, and particularly described being daily exposed generator engine noise that he described as “jet engines basically, running jet turbines.” See Board Hearing Transcript, pp. 15, 17. There is no record of any complaints of tinnitus during service. However, the Veteran complained of ear/nose/ throat trouble and hearing loss during his August 1989 separation examination. Additionally, STRs show that the Veteran was provided ear plugs during service. In June 2014 the Veteran was afforded a VA examination, during which he complained of constant tinnitus as far back as he could remember. However, the ensuing examination report is unclear, as the examiner appears to have returned a diagnosis, but then talked about the unreliability of the audiometric portion of the examination. The examiner then said she was unable to provide a nexus opinion regarding the tinnitus without resorting to speculation. Remand for clarification/a nexus opinion regarding the distinct issue of service connection for tinnitus is needed. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board’s duty to return an inadequate examination report “if further evidence or clarification of the evidence... is essential for a proper appellate decision”). In this regard the Board notes that in September 2014, the Veteran’s private primary care physician opined that the Veteran’s tinnitus “is due to his exposure to loud noise while in service as his records do not contain another more likely etiology for his advanced for age... tinnitus.” Although the Veteran was indeed exposed to loud noise during his service, the Board is unable to favorably resolve this claim based solely on this evidence since it has not been shown that this physician has the requisite competence to opine on the etiology of hearing disorders and the rationale provided is too speculative. See Sklar v. Brown, 5 Vet. App. 140, 146 (1993) (holding that a specialist’s opinion as to a medical matter outside of his or her specialty is to be given little weight). See also Bloom v. West, 12 Vet. App. 185, 187 (1999) (holding that statements favorable to the veteran’s claim that do little more than suggest a possibility are too speculative to establish the required nexus for service connection). 8. Service connection for scars on the scalp is remanded. The Veteran also seeks service connection for residual scars on his scalp from wounds that he says occurred while landing in trees during his parachute jumps. See Board Hearing Transcript, pp. 30-31. As stated before, military records confirm that the Veteran trained for and served as a Paratrooper during service; however, there is thus far no record of any head wounds or scars in the STRs. There is, however, evidence which suggests that scars on the Veteran’s scalp were incurred during service. In a letter dated in September 2014, the Veteran’s primary care provider (Dr. J.R.) noted that there were scars on the back of the Veteran’s head, and indicated that these could have been caused by “hitting foreign objects in the lz” like trees and the ground. Unfortunately, there is no indication that Dr. J.R. reviewed the STRs, which is significant since he did not mention the absence of evidence in the Veteran’s August 1989 separation examination report or the other STRs. The Board is consequently unable to favorably resolve this claim based solely on this evidence. See Caffrey, 6 Vet. App. 377, 381 (holding that the examiner “must consider the records of prior medical examinations and treatment in order to assure a fully informed examination”). However, the evidence is sufficient to warrant further development. After the RO has completed steps to obtain extant STRs, the Veteran should be afforded a VA examination. See 38 C.F.R. § 3.159(c)(4). See also McLendon, 20 Vet. App. 79. 9. Service connection for scars on the left ankle, is remanded. The Veteran is also requesting service connection for residual scars from left ankle surgery after service in 2004. See Board Hearing Transcript, pp. 28-29. As this issue is inextricably with the pending claim for service connection for a left ankle disorder, the Board’s review of this matter is postponed pending resolution of the primary claim for service connection. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered). The matters are REMANDED for the following action: 1. Renew efforts to obtain the STRs from the Veteran’s first (April 1982-April 1986) period of enlistment. Document all efforts taken to obtain these records. If, after renewed action to obtain these records has been taken and they are not found and it is determined that further efforts to obtain them would be futile, make a Formal Finding for the record. 2. After completion of step 1, schedule the Veteran for a new VA examination regarding the claim of service connection for neck, back, bilateral knee, and bilateral ankle disorders. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a.) provide the diagnosis for the Veteran’s neck, back, knee, and ankle complaints and symptoms. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. (b.) opine, for each diagnosed neck, back, knee and ankle disorder (or, if there is no diagnosis, any discernible functional impairment of earning capacity of the neck, back, knees and ankles) as to whether it is at least as likely as not (50/50 probability) that the disorder i. began during active duty service. ii. began (for degenerative disease/arthritis), within the year after the Veteran’s separation from active duty service. iii. is related to some incident of the Veteran’s active duty service, such as the parachute jumps that the Veteran completed during his military training and ensuing military service (which the Veteran estimates to be well over 100), and the incidents of back, knee, and ankle pain chronicled in STRs. A discussion of the facts and the medical principles involved will be of considerable assistance to the Board. All conclusions or opinions offered must be accompanied by a complete medical rationale, citing to established medical principles and relevant medical evidence, such as examination findings, service treatment records, VA and private treatment records, the Veteran’s contentions, or other pertinent evidence in the record to support the conclusions reached. 3. Return the issue of service connection for tinnitus to the July 2014 VA examiner for clarification. The examiner is asked to provide a response to the following: (a.) Whether the Veteran’s complaints meet the criteria for a diagnosis of tinnitus; and, if so, (b.) Opine as to whether it is at least as likely as not (50/50 probability) that the Veteran’s tinnitus is related to the Veteran’s noise exposure during service, such as the Veteran’s exposure to very high-powered jet turbine generators; an exploding missile; and other weapons/field artillery fire during service. The examiner should consider the Veteran’s lay description of in-service noise exposure and focus on whether the noise exposure in service caused the Veteran’s tinnitus. Facts and medical principles relied upon to arrive at an opinion should be set forth. In considering lay statements of record, the clinician should note that the Veteran is competent to attest to matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the clinician should provide a reasoned explanation. The clinician should consider all medical and lay evidence of record and offer a complete rationale for each opinion expressed. If the clinician concludes that either of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so should be provided. 4. Schedule the Veteran for a VA examination regarding the issue of service connection for head scars. The examiner must review the claims file. The examiner must also measure and take color photographs of the scars on the Veteran’s head and neck. The examiner is asked to provide a response to the following: (a.) Describe the scars on the head and neck, including the dimensions of each scar, the total combined area of the head and neck scars, and the characteristics of each scar. (b.) Associate unretouched color photographs of the head and neck scars with the examination report. (c.) Opine as to whether it is at least as likely as not (50/50 probability) that any one or more of the claimed scars on the Veteran’s head or neck is the result of any incident during active duty service, including landing in trees during parachute jumps. In formulating this opinion, the examiner must consider the Veteran’s lay account of landing in trees during his parachute jumps and his contention that the head/neck scars are the residuals of respective injuries. In considering the Veteran’s lay assertions, the examiner should note that the Veteran is competent to attest to matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a reasoned explanation. A discussion of the facts and the medical principles involved will be of considerable assistance to the Board. Any conclusions or opinions offered must be accompanied by a complete medical rationale, citing to established medical principles and relevant medical evidence, such as examination findings, service records, VA and private treatment records, or other pertinent evidence in the record to support the conclusions reached. (Continued on the next page)   If the examiner concludes that the requested opinion cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so should be provided. 5. After completion of the above directives and any other necessary action, re-adjudicate the claims based on all of the evidence of record. Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Childers, 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.