Citation Nr: 21023480 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 15-21 170 DATE: April 20, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for a cervical spine disorder is denied. REMANDED Entitlement to an initial rating in excess of 10 percent prior to February 3, 2017, and thereafter, in excess of 20 percent for peripheral neuropathy of the right upper extremity disability is remanded. Entitlement to an initial rating in excess of 10 percent prior to February 3, 2017, and thereafter, in excess of 20 percent for peripheral neuropathy of the left upper extremity disability is remanded. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy, sciatic nerve, left lower extremity disability is remanded. Entitlement to an initial rating in excess of 10 percent for peripheral neuropathy, sciatic nerve, right lower extremity disability is remanded. Entitlement to a compensable rating prior to February 13, 2017, and thereafter, a rating in excess of 10 percent for peripheral neuropathy, femoral nerve, left lower extremity, is remanded. Entitlement to a compensable rating prior to February 13, 2017, and thereafter, a rating in excess of 10 percent for peripheral neuropathy, femoral nerve, right lower extremity, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder, is remanded. FINDINGS OF FACT 1. Any hearing loss that the Veteran experienced during service in Vietnam did not develop into a permanent or chronic disability at that time; there was no diagnosis or manifestations to a compensable degree within one year after service discharge or continuity of hearing loss symptomatology after service; and the current hearing loss disability has not been linked to an in-service injury, disease, or incident. 2. The evidence of record does not support a finding that the Veteran’s tinnitus had its onset in service or within one year after service discharge, or that there was continuity of tinnitus symptomatology after service; and the current tinnitus has not been linked to an in-service injury, disease, or incident. 3. The evidence of record does not support a finding that the Veteran’s cervical spine symptomatology had its onset in service or within one year after service discharge, or that there was continuity of cervical spine symptomatology after service; and the current cervical spine symptomatology has not been linked to an in-service injury, disease, or incident. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1112, 1154 (b), 5107 (b); 38 C.F.R. §§ 3.102, 3.303, 3.304(d), 3.307(a)(3), 3.309 (a), 3.385. 2. The criteria for entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 1133, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for a cervical spine disorder have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1967 to April 1970. These matters come before the Board of Veterans Appeals (Board) on appeal from a February 2015 Rating Decision by a Department of Veterans Affairs (VA) Regional Office (RO). On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA). This law creates a new framework for Veterans dissatisfied with VA’s decision on their claim to seek review. Here, the Veteran has not opted-in to VA’s test program, the Rapid Appeals Modernization Program (RAMP). Although the AMA was implemented effective February 19, 2019, the Rating Decision on appeal was issued prior to that date. Accordingly, the Board will review his appeal under the existing Legacy Appeals System. Pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, and 5126 (2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2018); see also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Here, neither the Veteran nor his representative has raised any issues with regard to the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). These issues were previously before the Board in January 2021, at which time they were remanded in order to obtain additional VA examinations and opinions. Such examinations and opinions were obtained and associated with the claims file in February 2021. Thus, with respect to the issues adjudicated herein, the Board finds that there has been substantial compliance with its previous remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a remand request is required). Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 C.F.R. §§ 3.303, 3.304. Service connection may 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). Generally, in order to prove service connection, a veteran must show: (1) a present disability; (2) an 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, or the “nexus.” See Shedden v. Shinseki, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, including sensorineural hearing loss and arthritis, are subject to presumptive service connection if they manifest to a compensable degree within one year from separation from service, even if there is no evidence of the disease during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Additionally, such chronic diseases may use the alternative method of continuity of symptomatology to establish the second and third Shedden elements if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a); see 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2014). Additionally, 38 U.S.C. § 1154(a) requires that VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim for disability or death benefits. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence is considered to be competent and sufficient for establishing a diagnosis of a condition when (1) a layperson is competent to identify the medical condition; (2) a lay person is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed Cir. 2007). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Entitlement to service connection for bilateral hearing loss The Veteran seeks entitlement to service connection for bilateral hearing loss. Specifically, he has asserted that he developed bilateral hearing loss secondary to in-service acoustic trauma during military operations. A hearing loss disability is defined for VA compensation purposes with regard to audiologic testing involving puretone frequency thresholds and speech discrimination criteria. 38 C.F.R. § 3.385. For 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 of 500, 1,000, 2,000, 3,000, or 4,000 Hertz (Hz) is 40 decibels (dB) or greater; or when the auditory thresholds for at least three of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hz are 26 dB or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. Id. Audiology testing standards were set by the American Standards Association (ASA) until November 1, 1967. After that date, audiometric tests were conducted using International Standards Organization (ISO) or American National Standards Institute (ANSI) measurement. Current VA regulations that define hearing loss for VA purposes are based on the dB measurement recorded in the ISO-ANSI units. Accordingly, VA uses a system to convert ASA units to ISO-ANSI units that adds 15 dB to 500 Hz, 10 dB to 1000, 2000, and 3000 Hz, and 5 dB to 4000 Hz. Here, the Veteran’s DD Form 214 indicates that he was a Stock Control and Accounting Specialist, and served in Vietnam from March 1968 to April 1970. His service personnel records reveal participation in several counter offensives in the Republic of Vietnam as well as the receipt of the Bronze Star. As such, the Board will concede the Veteran’s exposure to in-service acoustic trauma. A review of the Veteran’s service treatment records reveals that he was underwent audiometric testing at the time of his April 1966 pre-induction Report of Medical Examination. At that time, pure tone auditory thresholds were as follows (with ISO-ANSI conversions in parentheses): HERTZ 500 1000 2000 3000 4000 RIGHT 0 (15) 0 (10) 0 (10) 0 (10) 0 (5) LEFT 0 (15) 0 (10) 0 (10) 0 (10) 0 (5) The Veteran again underwent audiometric testing at the time of his September 1967 Report of Medical Examination at induction. At that time, pure tone auditory thresholds were as follows (with ISO-ANSI conversions in parentheses): HERTZ 500 1000 2000 3000 4000 RIGHT 5 (20) 0 (10) 0 (10) 0 (10) 10 (15) LEFT 25 (40) 0 (10) 0 (10) 0 (10) 10 (15) The Veteran again underwent audiometric testing at the time of his December 1967 Report of Medical Examination for Airborne Physical. At that time, pure tone auditory thresholds were as follows (with ISO-ANSI conversions in parentheses): HERTZ 500 1000 2000 3000 4000 RIGHT 5 (20) 5 (15) 5 (15) -- 5 (10) LEFT 5 (20) 5 (15) 5 (15) -- 5 (10) At the time of the Veteran’s April 1970 Report of Medical Examination at separation from service, he scored 15/15 on the whispered voice test, bilaterally. The Board emphasizes that this discharge hearing screening was limited to the whisper voice test and did not include an audiometric evaluation. Whispered voice tests can be inaccurate and insensitive to the types of hearing loss most commonly associated with noise exposure. See Smith v. Derwinski, 2 Vet. App. 137, 138, 140 (1992) (noting that audiometric evaluation is a more precise indicator of hearing problems than whispered voice testing). However, on his corresponding April 1970 Report of Medical History at separation, the Veteran denied hearing loss; running ears; or ear, nose or throat trouble. A June 2014 correspondence from private internal medicine physician C. E. Mora Quesada, M.D, indicated that the Veteran referred earaches, vertigo, tinnitus and severe bilateral hearing loss to in-service noise exposure during military operations. Although Dr. Mora Quesada diagnosed the Veteran as having tinnitus and bilateral hearing loss at that time, he did not include any audiometric findings or provide an etiological opinion with respect to hearing loss. The Veteran was provided with a VA Hearing Loss and Tinnitus examination in November 2014, at which time pure tone auditory thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 20 50 40 LEFT 25 15 10 40 35 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and 100 percent in the left ear. The Veteran was diagnosed as having bilateral sensorineural hearing loss. However, the examiner opined that the Veteran’s diagnosed hearing loss was less likely than not incurred in or caused by an in-service injury, event, or illness. In support of this conclusion, the examiner explained that: VBMS records and VA medical files were carefully reviewed. No audio test results were found for service period. VA medical records are silent as to any audiological treatment/care for hearing loss until present exam. It is well established in the medical literature that exposure to high levels of noise causes either immediate hearing loss, such as in cases of noise/acoustic trauma, or progressive hearing deficits during prolonged periods of exposure during military service. However, retroactive effects in hearing are expected so many years after exposure to military noise. Another VA opinion was obtained in April 2019. At that time, the examiner again opined that the Veteran’s diagnosed hearing loss was less likely than not incurred in or caused by an in-service injury, event, or illness. In support of this conclusion, the examiner explained that: The electronic C-File and VA CPRS was carefully reviewed. Veteran was in active duty between 09/14/1967 to 04/18/1970. Audiometric charts in records dated after 11/01/1967 are presumed to be ISO-ANSI units, in this case the hearing test dated April 1966 are presumed to be ASA. When changes the values to ISO-ANSI, the results available in the pre-induction test on 04/08/1966 and Induction on 09/06/1967 are normal hearing in both ears. The hearing tests (ISO-ANSI units) on 12/07/1967 through 04/18/1970 show normal hearing in both ears. There is no evidence of complains of hearing loss and tinnitus in the C-File for more than 40 years after service. Medical literature indicates that exposures to high intensity noise levels, like security force, industrial/construction noise, printing work, music, or military noise, can causes permanent or progressive hearing loss during prolonged periods of exposure. No retroactive hearing effects are expected after years of being exposed to high intensity noise. It is highly probable that VA evaluations show a bilateral high frequencies hearing loss that is due to presbycusis or hearing loss expected as a normal aging process or a combination of both factors (aging process and noise exposure). It is reasonable to conclude that the bilateral hearing loss and tinnitus is less likely as not related to the military service. In its January 2021 Remand, the Board noted that it was unclear from the Veteran’s in-service audiometric testing reports whether the thresholds were recorded using ASA units or ISO-ANSI units. Additionally, the Board reiterated that it was Board policy to assume metrics conducted prior to January 1, 1967, were made using ASA units, and to consider the recorded metrics under both standards for all audiograms conducted between January 1, 1967, to December 31, 1970, relying on the unit measurements most favorable to the Veteran’s appeal. As the April 2019 VA examiner did not consider the conversions from ASA to ISO standards for the December 1967 audiometric results, and did not address the slight threshold shifts from the April 1966 pre-induction examination to the December 1967 induction examination, the Board remanded the matter for an adequate opinion. Pursuant to the Board’s January 2021 Remand, the Veteran was afforded another VA Hearing Loss and Tinnitus examination in February 2021, at which time pure tone auditory thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 25 55 55 LEFT 15 10 20 60 50 Speech audiometry revealed speech recognition ability of 92 percent in the right ear and 92 percent in the left ear. The Veteran was diagnosed as having bilateral sensorineural hearing loss. However, the examiner opined that the Veteran’s diagnosed hearing loss was less likely than not incurred in or caused by an in-service injury, event, or illness. In support of this conclusion, the examiner explained that: Veteran was active during the following dates at the ARMY- EOD: 09/14/1967; RAD: 04/18/1970. Veteran's electronic VBMS and CPRS folder were reviewed and it was observed that the different hearing test performed during service measured bilateral normal hearing. The analysis of the different test performed during service was utilizing the ASA to ANSI hearing threshold conversion units- on the following date test: 04/08/1966 and on 09/06/1967. The one performed on and after 12/07/1967 already are in ANSI units. Veteran's electronic record is silent to tinnitus complain. After the analysis a mild drop at 500Hz was observed at the audio test performed on 09/06/1967 but improve to normal hearing thereafter till today. Therefore, the clinician consider that the temporary hearing threshold shift could be secondary to a transitory event such as any conductive situation that was resolved. It is well known that prolonged exposure to high intensity noise such as military type noise may cause damage to auditory structures resulting in hearing loss. Damage to the auditory system after a single extremely intense acoustic event is immediate after the noise trauma, or hearing loss can appear gradually, during the noise exposure period. Medical literature does not support that a delayed onset or retroactive effect is expected to be evidenced as a hearing loss so many years after being exposed to military noise. Therefore, based on the available evidence of hearing tests conducted during service, and veteran's current audiological assessment, the association between hearing loss and noise exposure or other event during service cannot be assumed to exist. It is highly probable that hearing loss evidenced is due to the combined effect of occupational noise exposure as an presbycusis, or hearing loss expected as a normal aging process, and the exposure to post service occupational and/or recreational noise. Based on the above, hearing loss and tinnitus is less likely as not related to hazardous noise exposure while in active military service. The Board finds the February 2021 VA opinion to be the most probative evidence of record as to whether the Veteran’s current bilateral hearing loss is related to his active service. The examiner’s rationale is logical, well-reasoned, thorough, and relied upon consideration of the entire record, including the Veteran’s service treatment records and post-service treatment records. In sum, the Board finds the following facts from the record especially persuasive: the Veteran denied experiencing hearing loss on his April 1970 Report of Medical History at separation in his service treatment records; the only time that his hearing acuity dropped to the level of a hearing loss disability, as defined by VA, at any time during his period of active duty service, even after converting to ISO-ANSI units, was on his September 1967 Report of Medical History upon induction into service; and the mild drop at 500Hz observed in the left ear on the September 1967 audiometric test later improved to normal hearing by the time of the December 1967 audiometric test, which was described as a temporary hearing threshold shift secondary to a transitory event by the January 2021 VA examiner. Given the presence of this highly probative, specific evidence that contradicts the Veteran’s claim that he suffered chronic hearing loss in service, there is clear and convincing evidence against the contention that the Veteran incurred hearing loss in combat service. Thus, the combat presumption is rebutted in this regard. See 38 U.S.C. § 1154(b). After a review of all the lay and medical evidence of record, the Board finds that symptoms of hearing loss were not chronic in service, were not continuous since service separation, and did not manifest to a compensable degree within one year of separation from active service in April 1970. Service treatment records do not reflect any in service complaints, symptoms, diagnosis, or treatment for a hearing loss disability in either ear during service, other than a mild drop at 500Hz observed in the left ear on the September 1967 audiometric test at induction into service. Accordingly, the above evidence does not demonstrate chronic symptoms of hearing loss during active service. The lay and medical evidence weighs against findings of in-service onset and/or continuous symptoms of hearing loss since service separation; therefore, presumptive service connection under the provisions of 38 C.F.R. § 3.303(b) is not warranted based on either “chronic” in-service or “continuous” post service symptoms. As discussed above, the Veteran reported that he did not experience hearing loss or ear trouble at the time of his April 1970 Report of Medical History at separation. The Board finds that the weight of the evidence shows that hearing loss did not have its onset during service and is not otherwise etiologically related to service. Although in-service noise exposure is conceded, all VA clinicians who examined the Veteran concluded that it was less likely than not that his hearing loss was caused or otherwise related to his period of active duty service. The record does not contain a competent medical opinion to the contrary. Because there is clear and convincing evidence against service connection for bilateral hearing loss, it logically follows that the preponderance of evidence is against a finding that the Veteran’s current bilateral hearing loss was caused by his active service. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. 2. Entitlement to service connection for tinnitus The Veteran also seeks entitlement to service connection for tinnitus. A review of his service treatment records does not reveal and complaints of or treatment for tinnitus. Significantly, as discussed above, the Veteran denied or ear, nose or throat trouble on his April 1970 Report of Medical History at separation. Also as discussed above, a June 2014 correspondence from private physician Dr. Mora Quesada indicated that the Veteran referred earaches, vertigo, tinnitus and severe bilateral hearing loss to in-service noise exposure during military operations. Although Dr. Mora Quesada diagnosed the Veteran as having tinnitus and bilateral hearing loss at that time, he did not include any audiometric findings or provide an etiological opinion with respect to tinnitus. The Veteran was provided with a VA Hearing Loss and Tinnitus examination in November 2014, at which time he was diagnosed as having tinnitus. Significantly, at that time, the Veteran did not report an initial onset of tinnitus in service; rather, the Veteran indicated that he experienced bilateral constant tinnitus for many years, but could not be specific about circumstances of its onset. The examiner opined that the Veteran’s tinnitus was less likely than not incurred in or caused by an in-service injury, event, or illness. In support of this conclusion, the examiner explained that: Veteran is also requesting service connection for tinnitus after 44 years since released from service. The Veteran has a diagnosis of clinical hearing loss, and tinnitus is known to be a symptom associated with hearing loss. After reviewing all available records it is my opinion that claimed hearing loss and tinnitus conditions are less likely as not caused by noise exposure or acoustic trauma during military service. At the Veteran’s February 2021 VA Hearing Loss and Tinnitus examination, he was again diagnosed as having tinnitus. Again, however, the Veteran reported that the onset of his tinnitus occurred “years ago,” although the circumstances of this onset were unknown. The examiner opined that the Veteran’s tinnitus was less likely than not incurred in or caused by an in-service injury, event, or illness. In support of this conclusion, the examiner explained that the Veteran’s tinnitus was at least as likely as not (50 percent probability or greater) a symptom associated with the Veteran’s hearing loss, as tinnitus is known to be a symptom associated with hearing loss. After a review of all the lay and medical evidence of record, the Board finds that symptoms of tinnitus were not chronic in service, were not continuous since service separation, and did not manifest to a compensable degree within one year of separation from active service in April 1970. Service treatment records do not reflect any in service complaints, symptoms, diagnosis, or treatment for tinnitus in either ear during service. Accordingly, the above evidence does not demonstrate chronic symptoms of tinnitus during active service. The lay and medical evidence weighs against a finding of continuous symptoms of hearing loss and tinnitus since service separation; therefore, presumptive service connection under the provisions of 38 C.F.R. § 3.303(b) is not warranted based on either “chronic” in-service or “continuous” post service symptoms. As discussed above, the Veteran reported that he did not experience ear trouble at that time of his April 1970 Report of Medical History at separation, and he did not discuss the circumstances regarding the onset of tinnitus at any of his VA examinations. The Board finds that the weight of the evidence shows that tinnitus did not have its onset during service and is not otherwise etiologically related to service. Although in-service noise exposure is conceded, all VA clinicians who examined the Veteran concluded that it was less likely than not that his tinnitus was caused or otherwise related to his period of active duty service. The record does not contain a competent medical opinion to the contrary. Based on the foregoing evidence, the Board finds that a preponderance of the evidence is against the Veteran’s claim of service connection for tinnitus, and the claim must be denied. 3. Entitlement to service connection for a cervical spine disorder The Veteran also seeks entitlement to service connection for a cervical spine disorder. Specifically, he contends that his current cervical spine disorder is a result of injuries sustained while participating in parachute jumps during active service. The Veteran’s DD Form 214 confirms that he earned a Parachutist Badge. Additionally, his service personnel records confirm that he participated in Basic Airborne Training at Fort Benning Georgia, in January 1968, and that he was attached to the 173rd Airborne Brigade of the U.S. Army in March 1968. A review of the Veteran’s service medical records does not reveal any complaints of or treatment for cervical spine symptomatology in service. Significantly, on his April 1970 Report of Medical History at separation from service, the Veteran indicated that he never suffered from arthritis or rheumatism; history of broken bones; bone, joint, or other deformity; or back trouble of any kind. Similarly, the corresponding April 1970 Report of Medical Examination at separation indicated that the Veteran’s head, face, neck, and scalp, as well as his spine and other musculoskeletal groups, were within normal limits. The Veteran’s post-service VA treatment records indicate that he complained of cervical pain in December 2014. X-rays conducted in April 2015 revealed multiple degenerative changes in the cervical spine. Magnetic resonance imaging (MRI) of the cervical spine conducted in January 2016 was suggestive of cervical spondylosis. The Veteran was provided with a VA Neck (Cervical Spine) Conditions examination in February 2021, at which time he was diagnosed as having degenerative arthritis as well as degenerative disc disease other than intervertebral disc syndrome (IVDS) of the cervical spine. However, the VA examiner opined that the Veteran’s cervical spine condition was less likely as not a result of his period of service, to include injury from parachute jumps. In support of this conclusion, the examiner explained that: As seen at the cervical imaging studies 08/03/2015 MRI, 11/23/2015 cervical X-ray and whole body bone scan 08/03/2016, there are objective findings that correlate with the atraumatic changes that occur as part of normal aging process. All available evidence for this evaluation is silent for trauma of the cervical area related to parachute jumps. The cervical area is not a weight bearing joint area and usually is not associated to musculoskeletal sequela in relation to the activities of parachute jumps unless there was a direct trauma to the cervical spine related to a bad landing; which in this case there is no evidence os such injury and the veteran did not verbalized that type of incident during his military service at this medical history interview as lay statement. Additionally, the examiner opined that the Veteran’s cervical spine arthritis less likely than not began during active service, or manifested within a year after discharge from service, or was noted during service with continuity of the same symptomatology since service. In support of this opinion, the VA examiner explained that: The Veterans cervical spine condition is related to atraumatic changes of aging process as seen at objective evidence (imaging studies) as described above. The Veteran served form 09/14/1967 to 04/18/1970 so his age during service was 19y/0 to 21y/o, medical literature does not support the concept of degenerative osteoarthritis at that age range, so it is less likely that the present spine degenerative changes had onset during the Veterans active service dates or one year after separation. Based on the above evidence, the Board finds that service connection for a cervical spine disorder is not warranted. There are no service treatment records reflecting cervical spine symptomatology in service or chronic pain since service, there are no clinical records for many years after separation from service reflecting a cervical spine disability, and there is no competent credible opinion that the Veteran has a current cervical spine disability causally related to active service, or that he has a cervical spine disability which manifested within a year of service such that service connection on a presumptive basis is warranted. Based on the foregoing evidence, the Board finds that a preponderance of the evidence is against the Veteran’s claim of service connection for a cervical spine disorder, and the claim must be denied. REASONS FOR REMAND The Veteran also seeks entitlement to higher initial ratings for his service-connected peripheral neuropathy of the bilateral upper and lower extremities, as well as entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder. Unfortunately, the Board finds that additional development must be undertaken before these claims can be adjudicated on the merits. With respect to the claims of entitlement to higher ratings for peripheral neuropathy of the bilateral upper and lower extremities, the Board’s January 2021 Remand noted that VA treatment records indicated the Veteran’s neurologic impairment had worsened since his disabilities were last evaluated by VA in March 2017. Specifically, the Board referenced VA diagnostic testing which revealed evidence of bilateral carpal tunnel syndrome, and indicated that it was unclear from the medical evidence whether his bilateral carpal tunnel syndrome was associated with his diabetic peripheral neuropathy, and if not, whether his symptomatology could be separated between his service-connected disabilities and non-service connected disabilities. Indeed, a June 2016 VA Primary Care Note indicated that electromyography (EMG) / nerve conduction velocity (NCV) studies were being ordered to investigate bilateral hand numbness and suspected carpal tunnel; August 2016 NCV studies revealed evidence of “bilateral moderate on left median entrapment neuropathy at wrist level and severe on right side”; and a July 2019 VA Physical Medicine Rehab Attending Note indicated that the Veteran should consider a hand surgeon for reevaluation of his carpal tunnel syndrome, but that additional NCV studies should be performed before evaluation by a surgeon. As such, the claims were remanded so that additional VA examinations and opinions could be obtained. Pursuant to the Board’s January 2021 Remand directives, the Veteran was provided with a VA Diabetic Sensory-Motor Peripheral Neuropathy examination in February 2021, at which time he was diagnosed as having diabetic peripheral neuropathy of both the bilateral upper and lower extremities. However, no mention was made of the Veteran’s diagnosed carpal tunnel syndrome, as explicitly requested by the Board’s January 2021 Remand directives. Curiously, the examiner also indicated that EMG studies had not been performed, and that there were no other significant findings or diagnostic test results available. The Board finds that these examination results do not substantially comply with its prior Remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) (the Board errs as a matter of law when it fails to ensure compliance to remand directives). As such, on Remand, an addendum opinion should be obtained which discusses the diagnostic test results of record, to include NCV studies, and which addresses the Veteran’s diagnosed carpal tunnel syndrome. If the examiner finds that additional diagnostic testing, to include EMG and/or NCV studies are needed, then such testing should be conducted. With respect to the issue of entitlement to service connection for an acquired psychiatric disorder, a June 2014 correspondence from private internal medicine physician Dr. Mora Quesada diagnosed the Veteran as having generalized anxiety disorder, major depression disease, and posttraumatic stress disorder (PTSD), and opined that the Veteran had psychiatric disorders that were “more probable than not secondary to his military service performance.” Thereafter, a December 2014 VA treatment note diagnosed the Veteran as having major depression. As recently as January 2020, VA treatment records have diagnosed the Veteran as having either “major depression” and/or “major depressive disorder.” In its January 2021 Remand, the Board noted that a November 2014 VA PTSD examination report concluded that the Veteran did not have any current diagnosed mental health disorder in accordance with DSM-V criteria, and no medical opinion was provided on the etiology of the Veteran’s previously diagnosed anxiety and depression. As such, given that subsequent VA treatment records included diagnoses of major depressive disorder, the Board found that a remand was necessary to obtain a VA medical opinion on whether the Veteran has an acquired psychiatric disorder related to his period of service. Pursuant to the Board’s Remand, the Veteran was provided with a VA Mental Disorders examination in February 2021; however, the examiner simply stated that: This examiner cannot furnish any opinion since there is no diagnosis on Axis I. There is no medical evidence in E-file, CPRS chart or current mental evaluation that fullfil any DSM-V diagnostic criteria at this moment. No neuropsychiatric condition was found at this time. Therefore, since there is no evidence of a mental illness at the present time, all the above presumptions are invalid. Regarding [Dr. Mora Quesada’s] June 25, 2014 report: it is worth mentioning that the practice of psychiatry, and psychology, is regulated in P.R. and USA. Given that, the report above mentioned, was completed by a primary physician, not trained, not certified, for the treatment or proper diagnosis of the mental illness. Therefore, he reach to opinions, and conclusion, beyond his expertise and qualifications. The Board finds that the January 2021 VA Mental Disorders examination to be inadequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one). Significantly, the examiner stated that, “the Veteran without history of psychiatric complaints, findings or treatment at the San Juan VA or any other mental health institution”; yet the Veteran’s VA treatment records have listed “major depression” and/or “major depressive disorder” among his active problems as recently as January 2020, and periodically comment upon the Veteran’s mood and any suicidal/homicidal ideation. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that an opinion based on an inaccurate factual premise has no probative value). The Board emphasizes that the requirement of a current disability is satisfied if the disability exists: (a) just prior to the filing of the claim; (b) when the claim is filed; or (c) during the pendency of the claim, even if the disability resolves prior to completion of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Furthermore, VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). As such, on remand, an addendum opinion must be obtained which specifically acknowledges the inclusion of “major depression” and “major depressive disorder” as diagnoses in his VA treatment records and discusses whether that inclusion was based on a correct psychiatric diagnosis that has since resolved, based on an incorrect psychiatric diagnosis, or merely based on medical history provided by the Veteran without a psychiatric diagnosis rendered by VA. If it is the examiner’s opinion that one or more of the diagnoses documented in the record since July 2014 is inaccurate, then he or she should note that fact and provide reasons for the conclusion. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination to determine the current severity of his service-connected diabetic peripheral neuropathy in his bilateral upper and lower extremities. Such an examination should include all necessary diagnostic testing, to include electromyography (EMG) and/or nerve conduction velocity (NCV) studies. The examiner should provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran’s service-connected diabetic peripheral neuropathy under the rating criteria. Additionally, the examiner should indicate whether carpal tunnel syndrome (which has been diagnosed in the Veteran’s VA treatment records) is also found upon current examination, and specify which signs and symptoms are attributable to carpal tunnel syndrome alone. If the examiner is unable to distinguish between the symptoms associated with the service-connected left and right upper extremity diabetic peripheral neuropathy and any symptoms associated with a nonservice-connected disorder (such as carpal tunnel syndrome), then he or she should so state in the report. However, if separate and distinct symptoms attributable to carpal tunnel syndrome alone are identified, then the examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s carpal tunnel syndrome was caused or aggravated by his service-connected diabetic peripheral neuropathy. Aggravation is defined as any increase in severity that is proximately due to or the result of a service-connected disease or injury and not due to the natural progress of the disease. The determination of aggravation due to a service-connected disability or disabilities should be made independent of any additional non-service connected disabilities that may cause aggravation. If aggravated, the VA examiner should specify the baseline of disability prior to aggravation, and the permanent, measurable increase in disability resulting from the aggravation. The examiner must provide a rationale for all opinions provided. 2. Obtain an addendum opinion to determine the likely nature and etiology of any psychiatric disorder diagnosed during the rating period on appeal (i.e., from July 2014 to the present), to include major depression / major depressive disorder. If it is determined that another examination is needed to provide the required opinions, then the Veteran must be afforded the appropriate VA examination. Following a review of all pertinent evidence (to include VA treatment records listing major depression / major depressive disorder among the Veteran’s diagnoses as recently as January 2020), the examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s psychiatric disorder had its onset in service or is otherwise related to his period of service. If not, then the examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s psychiatric disorder was caused or aggravated by any of his service-connected disabilities. Aggravation is defined as any increase in severity that is proximately due to or the result of a service-connected disease or injury and not due to the natural progress of the disease. The determination of aggravation due to a service-connected disability or disabilities should be made independent of any additional non-service connected stressors/disabilities that may cause aggravation. If aggravated, the VA examiner should specify the baseline of disability prior to aggravation, and the permanent, measurable increase in disability resulting from the aggravation. If the examiner finds that the Veteran has not met the DSM-V criteria for a psychiatric diagnosis at any time during the rating period on appeal (i.e., from July 2014 to the present), then the examiner must discuss whether the notations of major depression / major depressive disorder among the Veteran’s diagnoses in his VA treatment records as recently as January 2020 were based on a correct psychiatric diagnosis that has since resolved, based on an incorrect psychiatric diagnosis, or merely based on medical history provided by the Veteran without a psychiatric diagnosis rendered by VA. If it is the examiner’s opinion that one or more of the diagnoses noted since July 2014 is inaccurate, then he or she should note that fact and provide reasons for the conclusion. The examiner must provide a rationale for all opinions provided. The term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. If the examiner is unable to provide the requested opinion without resorting to speculation, then the examiner must provide an explanation for the basis of that determination. Notify the examiner that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, then the examiner should indicate this in the examination report and provide a rationale for that determination. 3. Thereafter, after undertaking any additional development deemed necessary, issue a Supplemental Statement of the Case if any issue on appeal remains denied. After the Veteran and his representative are given opportunity to respond, the case should be returned to the Board, if otherwise in order. T. V. CASEY Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Anthony M. Flamini 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.