Citation Nr: 21028108 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 17-11 996 DATE: May 10, 2021 REMANDED Entitlement to an increased rating for bilateral hearing loss is remanded. Entitlement to service connection for lumbar spine condition is remanded. Entitlement to service connection for bilateral shoulder condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from December 1983 to September 1991 and from September 2001 to May 2003, with additional service in the Air Force Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran filed a Notice of Disagreement in September 2014. The Veteran testified before the undersigned Veterans Law Judge in September 2020. A transcript of the hearing is of record. At the hearing, the Veteran testified that his hearing had worsened. Additionally, he testified that his shoulders and back have bothered him since service but that he self-treated with motrin, ice, and physical therapy exercises. The Veteran indicated that after a back strain in the 1980s during service, he would periodically strain his back. He testified that his work as a security forces member required strenuous work, and that he continued to strain his back as a result. The Veteran also described an in-service injury to his right shoulder that required hospitalization, which was ultimately diagnosed as peripheral neuropathy. He testified that the tingling in his fingers and elbows persists, and that it affects his civilian occupation as a federal law enforcement officer, as the injury has affected his grip strength. 1. Entitlement to an increased rating for bilateral hearing loss is remanded. The Veteran is service connected for bilateral hearing loss. He testified at the September 2020 hearing that his hearing has worsened since he was last examined. He was afforded a VA examination in December 2016. Because of the passage of time and the indication of worsening, the Veteran should be provided a VA examination to ascertain the current severity and manifestation of his service-connected disability on appeal. See Snuffer v. Gober, 10 Vet. App. 400 (1997). 2. Entitlement to service connection for lumbar spine condition is remanded. The Veteran submitted relevant private treatment records that indicate that he was treated for back injuries and strains since his last period of active duty, including a right lumbar strain. While the Veteran was afforded a VA examination in November 2016, the Board finds that remand is necessary to afford the Veteran another evaluation. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The examiner noted that there was a 21-year gap between muscle spasm complaints in service and later complaints. However, the Veteran was treated several times in service for back pain, and reported swollen, painful joints in 1991 before the end of his first period of active service. The Veteran's private treatment records do indicate low back pain following a 2008 car accident; however, the records showed that he had a prior history of back pain, as indicated in a 2006 private treatment note. The Veteran submitted a September 2020 letter from his private treatment provider indicating that she believed the Veteran's current back condition was the result of his military service. Its rationale, however, was vague. He also submitted additional private treatment records as noted above. Remand is needed to obtain another opinion that addresses the private treatment records, the letter from the Veteran's private treatment provider, and the lay statements from the Veteran concerning the nature of his service. 3. Entitlement to service connection for bilateral shoulder condition is remanded. The Veteran's private treatment records also indicate ongoing treatment for a bilateral shoulder condition, which was diagnosed as shoulder impingement syndrome with partial rotator cuff tear as well as degenerative joint disease. The November 2016 VA examiner indicated that the Veteran was only diagnosed with bilateral rotator cuff tendonitis. The examiner did not note the Veteran's diagnosis of impingement syndrome, which was diagnosed during his first period of active duty and which he continues to be treated for per private treatment records. Additionally, the examiner relied on the lack of continuity of care since the Veteran's 1991 period of service in reaching the conclusion that the Veteran's condition was not service connected. However, the Veteran was again treated for shoulder pain during a period of active duty in April 2003, and he was treated by his private treatment provider shortly after release from his second period of active service beginning in 2005. Thus, remand is needed to obtain another opinion. See Id. The matters are REMANDED for the following action: 1. Afford the Veteran a VA examination to determine the current severity of his bilateral hearing loss. In addition to dictating objective test results, the examiner's report should describe the effects of the Veteran's disability on his occupational functioning and daily activities. A complete rationale should be given for all opinions and conclusions expressed. 2. Provide the Veteran's entire claims file to an appropriate examiner. The examiner's attention is directed particularly to the lay statements of record as well as the Veteran's hearing testimony regarding the onset of symptomatology. If the examiner cannot provide the below requested opinions without examining the Veteran, that should be arranged. The examiner should provide an opinion concerning the nature and etiology of any lumbar spine condition. The examiner should opine as to whether it is at least as likely as not that the Veteran's back disability is related to an in-service injury or disease, to include his lumbar strain shown in service. The examiner should provide an opinion concerning the nature and etiology of any bilateral shoulder disability. The examiner should opine as to whether it is at least as likely as not that the Veteran's bilateral shoulder disability is related to an in-service injury or disease, to include impingement syndrome as noted in service (Continued on the next page) The reports should include reasons for any opinion expressed. If the clinician completing the report is unable to provide an opinion without resort to speculation, he or she should state whether the inability is due to the limits of the person's knowledge, the limits of medical knowledge in general, or there is additional evidence that would permit the needed opinion to be provided. 3. After completing the above actions, to include any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V. Geer, 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.