Citation Nr: 21026054 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 14-03 609 DATE: April 29, 2021 REMANDED Entitlement to service connection for a left ear hearing loss disability is remanded. Entitlement to service connection for an acquired psychiatric disorder to include other specified stressor-related disorder and post-traumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1988 to July 1994. The Veteran attended a videoconference hearing before the undersigned Veterans Law Judge in July 2015. A transcript of the hearing is of record. This matter was previously remanded by the Board of Veterans’ Appeals (Board) in November 2015 and January 2020. 1. Entitlement to service connection for a left ear hearing loss disability is remanded. The Veteran contends that he has a left ear hearing loss disability. In accordance with the January 2020 Board remand, a medical opinion regarding the etiology of the Veteran’s claimed left ear hearing loss was obtained in January 2020. The examiner opined that it was less likely than not that the Veteran’s claimed left ear hearing loss was incurred in or caused by his active duty service. The examiner noted that there was no significant shift in thresholds from induction to discharge. The examiner cited the Institute of Medicine and stated that current science indicates that "understanding of the mechanisms and processes involved in the recovery from noise exposure suggests that a delay of many years in the onset of noise-induced hearing loss following an earlier noise exposure is extremely unlikely”. Additionally, the examiner stated that the “evidence from laboratory studies in humans and animals is sufficient to conclude that the most pronounced effects of a given noise exposure on pure-tone thresholds are measurable immediately following the exposure". The Board finds that the January 2020 medical opinion is insufficient. The January 2020 audiologist referenced an Institute of Medicine (IOM) report on noise exposure which noted the lack of scientific support linking delayed onset of hearing loss many years after noise exposure where hearing was normal immediately after the exposure. The examiner relied on the report for the premise that “delayed onset hearing loss due to previous noise exposure are unlikely to occur.” The Board notes that the IOM report has apparently contradictory findings regarding delayed-onset hearing loss. While the VA audiologist relied on the above premise to refute a medical basis for a nexus between the Veteran’s current hearing loss and his military service, the report also indicates that “[t]here is not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one’s lifetime, long after the cessation of that noise exposure” and that “definitive studies to address this issue have not been performed.” See Noise and Military Service: Implications for Hearing Loss and Tinnitus, Institute of Medicine 2006, p. 11, BOX ES-1; see also McCray v. Wilkie, 31 Vet. App. 243 (2019). Accordingly, remand is appropriate to obtain an additional audiological opinion regarding the etiology of the Veteran’s claimed left ear hearing loss disability. 2. Entitlement to service connection for an acquired psychiatric disorder to include other specified stressor-related disorder and PTSD is remanded. The Veteran contends that he has a current acquired psychiatric disorder that is related to his active duty service. The Veteran underwent an examination in December 2015 which indicated that a medical nexus did not exists between an in-service incurrence and a current diagnosis of PTSD, because the Veteran did not have a current diagnosis of PTSD or any other mental disorder. The examiner stated that the Veteran’s diagnosis of adjustment disorder in 1994 was related to difficulties in his marriage. The examiner further stated that one of the criteria of an adjustment disorder is that once the stressor remits there are no symptoms within six months, and that since this stressor was 21 years ago it is less likely than not likely to continue to the time of the examination. Additionally, the examiner stated that the diagnoses of PTSD did not note any specific examples of what types of clinically meaningful social or occupational impairment the Veteran was experiencing at the time of the evaluations. The examiner stated that she was unsure as to how the Veteran met Criterion G necessary for a PTSD diagnosis at those times. Treatment records from August 2020 note that the Veteran has a diagnosis of other specified stressor-related disorder based on the DSM-5 criteria. The Veteran’s physician stated that the Veteran’s symptoms may indeed be related to those experiences but as highly stressful learning experiences rather than trauma experiences. Once VA undertake the effort to provide the Veteran with an examination, it must provide the Veteran with an adequate one, and an adequate examination is sufficiently detailed in order to ensure that VA’s evaluation of the Veteran’s claim is fully formed. Barr v. Nicholson, 21 Vet. App. 303 (2007). Since the December 2015 examiner did not discuss the Veteran’s diagnosed other specified stressor-related disorder the Board finds that a new medical examination is warranted to confirm the Veteran’s diagnosis and to determine whether it is etiologically related to the Veteran’s active duty service. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from a qualified VA medical professional to determine the nature and etiology of any current left ear hearing loss disability. The examiner should review the claims folder, and then respond to the following: Is it at least as likely as not (i.e., probability of 50 percent or greater) that a left ear hearing loss disability is related to the Veteran’s claimed noise exposure during service? In answering this question, review and consider the lay assertions of record, to include his military occupational specialty of light infantryman and the Veteran’s statements regarding live weapons fire of various ordinance while in service. Also, note that the Veteran is competent to describe any symptoms he may have experienced since service discharge, particularly symptoms of hearing loss. The examiner should also address the apparent inconsistencies in the Institute of Medicine (IOM) report Noise and Military Service: Implications for Hearing Loss and Tinnitus, regarding the premise that “delayed onset hearing loss due to previous noise exposure are unlikely to occur”. See McCray v. Wilkie, 31 Vet. App. 243 (2019). Note that the lack of diagnosed hearing loss in service cannot serve as the sole basis for a negative finding. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. Lay contentions must be considered and weighed in making the determination as to whether a nexus exists. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 2. Schedule the Veteran for a VA mental health examination. The examiner is asked to review the pertinent records and obtain a history from the Veteran as to the progression of his mental health symptoms. Upon review of the file, interview of the Veteran and examination, the examiner should address each of the following: (a) The examiner should clearly identify all current psychiatric disabilities. (b) Specifically, if PTSD is diagnosed, please discuss the stressor or stressors upon which the diagnosis is based. The examiner should specifically opine as to whether PTSD is at least as likely as not (50 percent or greater probability) related to his active service including the Veteran’s claimed stressors. (c) Opine on whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran’s other specified stressor-related disorder had onset in, or is otherwise related to his active duty service, to include his claimed in-service stressors.? (d) For any other acquired psychiatric disorder other than PTSD, such as the previously diagnosed adjustment disorder and depression, opine as to whether it is at least as likely as not the disability had onset in, or is otherwise related to his service, to include his claimed in-service stressors. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. Lay contentions must be considered and weighed in making the determination as to whether a nexus exists. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David M. Sebstead, Associate 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.