Citation Nr: 21026315 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 11-08 670 DATE: April 30, 2021 REMANDED Entitlement to service connection for right ear hearing loss is remanded. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to April 15, 2014, is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from May 1968 to September 1969, and he had a period of active duty for training from February 1966 to July 1966. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from August 2010 and October 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at hearings in April 2017 and December 2020. This case was previously before the Board in April 2014 and January 2018, when it was remanded for development. The case has been returned to the Board for further appellate review. A May 2020 rating decision granted entitlement to service connection for left ear hearing loss and a right knee disorder. This action represents a total grant of the benefits sought on appeal with respect to these issues, and they are no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). 1. Entitlement to service connection for right ear hearing loss is remanded. In October 2019, the Veteran was afforded a new VA audiological examination in order to address the inadequacies identified in the January 2018 Board remand. The examiner noted the results of five pre-service and in-service audiograms, where the Veteran was found to have normal hearing in the right ear, and appears to base the negative etiology opinion solely on this evidence. The examiner also noted a career in construction after service, and stated that the right ear hearing loss is most likely attributed to years working in that field, but did not reconcile this conclusion with the finding elsewhere in the examination report that the Veteran did not experience noise exposure after service. The Board notes the Veteran testified at the December 2020 Board hearing that his time on-site in his post-service construction career was relatively low compared to his time spent performing office work. Finally, the examiner did not discuss the lay statements in the record from the Veteran and his spouse regarding onset of hearing loss symptoms during service, beyond noting that hearing loss and tinnitus worsened over the years as the Veteran aged. The examiner impermissibly dismissed the Veteran’s reports of continuous hearing problems since service solely because these complaints were not documented in the service treatment records, as well as his reports that his career in construction consisted largely of office work. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (that reports of symptomatology are not supported by contemporaneous clinical evidence does not render them inherently not credible). Therefore, the examination is inadequate, and a remand is necessary to obtain a new opinion, as the Board has previously found the other opinions in the record to be inadequate as well. 2. Entitlement to an initial evaluation in excess of 50 percent for PTSD is remanded. At the December 2020 Board hearing, the Veteran testified that his PTSD has worsened since the last evaluation in August 2017. Therefore, a new VA examination is necessary to determine the current severity of the Veteran’s PTSD. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The Board notes the Veteran reported at the April 2017 Board hearing that all of his PTSD treatment is through VA. The most recent VA treatment records in the claims file are from 2019. On remand, any outstanding VA treatment records should be associated with the record. 3. Entitlement to a TDIU prior to April 15, 2014, is remanded. The TDIU issue is intertwined with the PTSD issue remanded above and is also remanded at this time. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Obtain any and all VA treatment records from the Salt Lake City VA Medical Center, and/or any other VA medical facility that may have treated the Veteran, and associate those documents with the claims file. 2. Forward the claims file to an appropriate clinician to determine whether the current right ear hearing loss is related to the Veteran’s military service. Following review of the claims file, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the right ear hearing loss began in or is otherwise caused by the Veteran’s active service. The examiner must specifically address the Veteran’s and his spouse’s lay statements regarding onset of hearing loss symptoms during service and continuing since. The examiner should also address the Veteran’s December 2020 testimony regarding noise exposure in his post-service construction career. The examiner is instructed that a finding of normal hearing acuity during service is not, without further discussion of the facts of the Veteran’s particular circumstances and the medical community’s understanding of hearing loss, sufficient to support a negative etiology opinion. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. (Continued on next page)   3. Schedule the Veteran for an examination with an appropriate clinician to determine the current severity of the Veteran’s service-connected PTSD. The examiner should provide a full description of the disorder and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to the service-connected PTSD alone. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Josey, 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.