Citation Nr: 21029000 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 17-31 962 DATE: May 12, 2021 ORDER Entitlement to service connection for pharyngeal cancer, to include associated residuals, claimed as throat cancer and jaw cancer, is granted. Entitlement to service connection for hearing loss is granted. Entitlement to service connection for tinnitus is granted. FINDINGS OF FACT 1. The Veteran participated in a "radiation-risk" activity, and service connection for pharyngeal cancer, is warranted on a presumptive basis. 2. The evidence of record is at least in equipoise as to whether the Veteran's hearing loss is etiologically related to service. 3. The evidence of record is at least in equipoise as to whether the Veteran's tinnitus is etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for pharyngeal cancer, on a presumptive basis, are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309(d). 2. The criteria for service connection for bilateral hearing loss are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.385. 3. The criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1958 to May 1961. This matter comes before the Board of Veteran's Appeals (Board) from a June 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in January 2019 when the claims of service connection for hearing loss and tinnitus were remanded for development. The Board finds the January 2019 remand directives as to those claims have been substantially complied with, and the matters are again before the Board. Stegall v. West, 11 Vet. App. 268, 271 (1998). In the same January 2019 Board decision, the Board also denied the claims of service connection for throat cancer and jaw cancer, as well as service connection for chronic pain. The Veteran disagreed with the denial as to his claims of service connection for throat and jaw cancer and appealed to the United States Court of Appeals for Veterans Claims (Court). The Board notes the Veteran did not appeal the denial of service connection for chronic pain. In December 2019, the Court granted a Joint Motion for Remand (JMR) where the parties requested vacatur of the January 2019 Board decision as to the issues of service connection for throat cancer and jaw cancer. Those claims have been remanded by the Court pursuant to the JMR for re-adjudication and are now before the Board. The claim of service connection for chronic pain, secondary to cancer, is no longer on appeal as it was decided by the Board in January 2019 and not included in the JMR presented to the Court. Accordingly, the Board has no jurisdiction over the claim of service connection for chronic pain. In October 2020, the Veteran testified via videoconference before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. The Board notes that following the hearing, in October 2020, the Veteran's representative requested a copy of the hearing transcript. The Board acknowledges that in an Appellate Brief, associated with the claims file in November 2020, the Veteran's representative referenced the Hearing Transcript and page numbers. Thus, it is reasonable to conclude that the Veteran's representative had access to the hearing transcript on or before November 2020. Nevertheless, the transcript was provided in April 2021 to the representative, as she requested. See correspondence of April 2021. The Board notes that the letter providing the Veteran's transcript provides 30 days to request changes to the transcript. Those 30 days have not yet expired. However, as the Board is granting the benefits sought in full, there is no reason to further delay the decision on the present appeal, as the fully favorable decision herein results in no prejudice to the Veteran. Service Connection Generally, service connection may be established for a disability resulting from disease or injury in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). To establish service connection for a disability, there must be (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 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). 1. Entitlement to service connection for pharyngeal cancer, to include associated residuals (claimed as throat cancer and jaw cancer) The Veteran seeks service connection for cancer, claimed as jaw cancer and throat cancer. In favor of his claim, the Veteran asserts that he was exposed to ionizing radiation at Camp Hanford and other carcinogenic agents during service. See hearing transcript. The Board has recharacterized the Veteran's claims, for the reasons explained below, as service connection for pharyngeal cancer, to include associated residuals. Generally, service connection for conditions claimed to be due to exposure to ionizing radiation in service can be established in any of three different ways. See Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). First, there are diseases that are presumptively service-connected in radiation-exposed veterans under 38 C.F.R. § 3.309(d). See 38 U.S.C. § 1112(c). Second, service connection can be established under 38 C.F.R. § 3.303(d) with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311, if the condition at issue is a radiogenic disease. Third, direct service connection can be established under 38 C.F.R. § 3.303(d) by showing that the claimed disability was incurred during or aggravated by service without regard to the statutory presumptions and special development procedures outlined in 38 C.F.R. § 3.311. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). Before the Board addresses the claim on the merits, a summary of the Veteran's medical diagnoses as noted throughout the available records is warranted, as to better understand the reasons for the Board's recharacterization of the claims. In September 2010, the Veteran visited his physician for a lesion on the right lower gum, behind the last tooth, characterized by the physician as an exophytic lesion. His physician noted the Veteran was 21 years status post chemoradiation to that same area. See medical records for September 2010. A diagnosis of carcinoma of the lower gum was rendered, confirmed with a biopsy that revealed squamous cell carcinoma in the mouth, specifically the right lower gum. See biopsy report of September 2010. In October 2010, the Veteran underwent a suprahyoid neck dissection with resection of the carcinoma and mobilization of a submental flap. In the surgical reports, the Veteran's diagnosis was noted as oral cancer of the right alveolar ridge. See medical records for October 2010. Following complications with the skin flap used to cover the defect created by the excision of the cancerous tissue, the Veteran was noted to have one area of granulation on the medial aspect of the incision in December 2010. See medical records for December 2010. In March 2011, the Veteran underwent a laryngoscopy and biopsy which revealed keratinizing squamous carcinoma, characterized as "clinically recurrent floor of the mouth cancer." See pathology report of March 2011. A clinical note dated March 2011 noted that this new lesion was a probable recurrence of the resected carcinoma on the right lower floor of the mouth in October 2010. That same month, the Veteran underwent another surgical intervention. The procedure to remove the new lesion was a radical en bloc resection of the tongue, floor of mouth, horizontal mandible and suprahyoid neck on the right side; including reconstruction of the mandible and a free flap to correct the oral defect harvested from the left thigh. See medical records for March 2011. In April 2011, one of the Veteran's private surgeons subscribed a letter wherein he noted that the Veteran had been battling oral/jaw cancer. See letter subscribed by Dr. J, associated with the claims file in May 2014. Another letter, subscribed by Dr. J, in April 2014, noted the Veteran was diagnosed with oral/jaw cancer and his battle with the condition. The surgeon opined that the Veteran's cancers were due to his exposure to ionizing radiation in the 1960's. See letter by Dr. J, dated April 2014, and associated with the claims file in May 2014. VA medical records characterize the Veteran's cancer as malignant neoplasm of the head, face, and neck, in the problem list. See medical records for August 2011 and February 2013. A private medical opinion pertaining to the Veteran's cancer associated with the claims file in November 2020 noted the Veteran's medical history, including the findings disclosed above, and characterized the Veteran's cancer as pharyngeal cancer. The physician, Dr. C, provided no rationale for characterizing the Veteran's cancer as pharyngeal. Nonetheless, the physician after providing an analysis of the environmental exposures the Veteran experienced at Camp Hanford and other relevant social history, opined that the Veteran's pharyngeal cancer was at least as likely as not caused by exposure to radiation and other carcinogenic agents while in service, at Camp Hanford. See medical opinion by Dr. C, dated August 2020 and associated with the claims file in November 2020. The Board finds this medical opinion adequate and assigns it high probative value. The Board notes the "pharynx" is "the musculomembranous passage between the mouth and posterior nares and the larynx and esophagus." Dorland's Illustrated Medical Dictionary 1427 (32d ed. 2012). "Pharyngeal" is the adjective meaning pertaining to the pharynx. Id. The "pharynx," or "throat," has three parts. "The part above the level of the soft palate is the nasopharynx, which communicates with the auditory tube. The lower portion consists of two sections: the oropharynx, which lies between the soft palate and the upper edge of the epiglottis, and the laryngopharynx, which lies below the upper edge of the epiglottis and opens into the larynx and esophagus." Dorland's at 1427. Relevant to this appeal, the oropharynx includes the "[b]ack one-third of the tongue." Oropharyngeal Cancer Treatment, NIH National Cancer Institute, https://www.cancer.gov/types/head-and-neck/patient/adult/oropharyngeal-treatment-pdq (last visited April 27, 2021). Additionally, the Board notes that squamous cell carcinoma has been characterized as "the most common oral or pharyngeal cancer (and the most common at head and neck sites in general)." The Merck Manual 492 (19th ed. 2011). Thus, the record reflects that the Veteran's cancer has been characterized as oral cancer, gum cancer, and pharyngeal cancer. The specific diagnosis is of importance because it determines whether certain presumptions for ionizing radiation exposure apply. Here, the Board affords high probative value to Dr. C's characterization of the Veteran's cancer as pharyngeal cancer in consideration of her expertise, experience, her service as a Radiation Health Officer and her national recognition as an expert on the matter; as contained in the medical opinion dated August 2020. Additionally, the Board notes that Dr. C's characterization of the Veteran's cancer as "pharyngeal" does not seem to arise from ignorance of the record, as she detailed all the findings of "oral cancer" or "gum cancer" in the medical history provided in her opinion. Rather, it seems that in her professional medical judgement, the Veteran's cancer met the requirements to be considered "pharyngeal cancer." It is well established that medical examination reports must be read as a whole. Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012). Accordingly, the Board has recharacterized the Veteran's claims of service connection for jaw cancer and throat cancer, as service connection for pharyngeal cancer, to include associated residuals, as diagnosed in the medical opinion above mentioned- submitted by the Veteran through his representative for consideration. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In arriving at this conclusion, the Board has considered the Veteran's representative's assertions contained in Appellate Brief, associated with the claims file in November 2020. Particularly, the representative argued that the diagnoses of "oral or throat[,] and jaw cancer" are not at issue citing the January 2019 Board decision; which has been vacated by the Court. He also noted the private medical opinion by Dr. C wherein she opined that the Veteran's pharyngeal cancer was at least as likely as not caused by his exposure to radiation and other carcinogenic agents. Here, while the diagnosis of cancer is not at issue, the specific type of cancer the Veteran has been diagnosed with, on the other hand, is not as clear. Thus, the Board has afforded high probative value to Dr. C's characterization of the Veteran's cancer as pharyngeal for the purposes of this decision and recharacterized the claims accordingly. 38 C.F.R. § 3.309(d) lists cancer of the pharynx as a type of cancer for which presumptive service connection is available. Cancer of the jaw and cancer of the mouth are not type of cancers for which presumptive service connection is available under 38 C.F.R. § 3.309(d). Thus, for the presumptions established in 38 C.F.R. § 3.309(d) for pharyngeal cancer to apply in the present case, the Board must determine whether the Veteran qualifies as a "radiation-exposed" Veteran pursuant to 38 C.F.R. § 3.309 (d)(3). Under 38 C.F.R. § 3.309(d)(3), a "radiation-exposed Veteran" is defined as a Veteran who, while serving on active duty, active duty for training, or inactive duty training, participated in a "radiation-risk activity." "Radiation risk activities" include onsite participation in a test involving the atmospheric detonation of a nuclear device; participation in the occupation of Hiroshima or Nagasaki between August 6, 1945, and July 1, 1946; being a prisoner of war in Japan (or service in Japan immediately after internment) with opportunity for exposure comparable to occupation forces in Hiroshima or Nagasaki; service for at least 250 days before 1992 at gaseous diffusion plants in Paducah, Kentucky, or Portsmouth, Ohio, or at K25 area at Oak Ridge, Tennessee; service before January 1, 1974, on Amchitka, Island, if exposed to ionizing radiation during duty related to Long Shot (1965), Milrow (1969) or Cannikin (1971) underground nuclear tests; and service in a capacity which, if performed as an employee of the Department of Energy, would qualify the individual for inclusion as a member of the Special Exposure Cohort under section 3621(14) of the Energy Employees Occupational Illness Compensation Program Act of 2000 (Act). See 38 C.F.R. § 3.309(d)(3)(ii). The Veteran asserts that he participated in a radiation-risk activity due to his service at the Hanford site in Washington. Thus, he contends that his service at the Hanford site in Washington should be considered as "radiation-risk activity" pursuant to 38 C.F.R. § 3.309(d)(3)(ii)(E). Members of the Special Exposure Cohort (SEC) as established in the Energy Employees Occupational Illness Compensation Program Act of 2000, are employees with at least one of the 22 specified cancers prescribed by the statute who worked for a specified period of time at one of the SEC work sites. The statutory SEC classes describe employees who worked at gaseous diffusion plants in Paducah, Kentucky, Portsmouth, Ohio, or Oak Ridge, Tennessee for a total of at least 250 days before February 1, 1992, and were monitored for radiation exposure with dosimetry badges or had jobs with similar exposures to those monitored and/or those who worked before January 1, 1974, on Amchitka Island, Alaska and were exposed to radiation related to the Long Shot, Milrow or Cannikin underground nuclear tests. The Act also authorizes the Secretary of Health and Human Services to add other classes of employees to the SEC. See 42 U.S.C. 7384 (14). In December 2009, the Secretary of Health and Human Services added a new class of employees to the SEC. The new class of employees was defined as: "All employees of the Department of Energy, its predecessor agencies, and its contractors and subcontractors who worked at the Hanford site in Richland, Washington, from October 1, 1943 through June 30, 1972, for a number of work days aggregating at least 250 work days, occurring either solely under this employment or in combination with work days within the parameters established for one or more other classes of employees included in the Special Exposure Cohort." This designation became effective in January 2010. See Notice, 75 Fed. Reg. 3469 (January 21, 2010); see also Department of Labor, EEOICPA Bulletin No.10-04 (2010). Thus, for the Veteran to be found to have participated in a radiation-risk activity, pursuant to 38 C.F.R. § 3.309(d)(3)(ii)(E); the evidence would need to show that he has a type of cancer considered in the statute and that he worked at the Hanford site (or any other site eligible for SEC consideration) for at least 250 work days. The Veteran's service treatment records (STRs) and military personnel records have been associated with the claims file. The Veteran's personnel records show that in February 12, 1960 he was assigned to Camp Hanford for "AIT" or Advanced Individual Training. This training lasted 1 month. These records also show that in March 1960 he was assigned a new duty, reflecting a change in rank after completion of AIT, at Hanford Camp. This new assignment lasted 8 months. See Record of Assignments, contained in the Military Personnel Record, associated with the claims file in July 2014. Thus, the Veteran's military personnel records show that the Veteran was at Hanford for 9 months, from February 12, 1960 until November 28, 1960. In other words, the Veteran was stationed at Hanford for more than 250 days. Additionally, the Veteran's cancer, characterized a pharyngeal cancer, is one of the cancers considered in the regulation. Accordingly, the Board finds that the Veteran participated in a radiation-risk activity pursuant to 38 C.F.R. § 3.309(d)(3)(ii)(E) due to his service at the Hanford site in Washington lasting more than 250 days and his pharyngeal cancer diagnosis. Thus, as the Veteran has been found to have participated of a "radiation-risk activity"; he is to be considered a "radiation-exposed" Veteran and his pharyngeal cancer is subject to presumptive service connection under 38 C.F.R. § 3.309(d). Accordingly, for the reasons explained above, service connection for pharyngeal cancer, to include associated residuals, on a presumptive basis is warranted, as the Veteran has been found to have participated of a radiation risk activity during service pursuant to 38 C.F.R. § 3.309(d)(3)(ii)(E). In reaching this determination, the Board has made no finding as to the current severity of the Veteran's cancer or any associated residual. However, the Board notes that the evidence of record suggests the Veteran has scars pertaining to the surgical interventions for his cancer, difficulty talking due to his surgeries, has experienced disruptions with feeding and has received his nutrition through a feeding tube due to his cancer residuals. 2. Entitlement to service connection for hearing loss The Veteran seeks service connection for hearing loss. In favor of his claim, the Veteran asserts that his hearing loss is related to hazardous noise exposure while in service. See hearing transcript. Hearing loss for VA purposes is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent." 38 C.F.R. § 3.385. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Veteran's DD-214 shows that his military occupational specialty (MOS) was as a guided missile instrument electrician. The Board finds that in-service noise exposure has been established as consistent with the types, places, and circumstances of the Veteran's active service. The Veteran's service treatment records show that he was only administered a hearing whisper test for his induction into service. See Report of Medical Examination for induction, dated January 1958. During his service, the Veteran was administered hearing examinations in May 1958, December 1959, and June 1960. See STRs. Additionally, his report of medical examination for separation, dated April 1961 shows whisper test findings and all audiometer findings show the value "0" for all frequencies. See Report of medical examination for separation, dated April 1961. Pertinently, the Board notes that service department audiometric tests prior to October 31, 1967 were in ASA (American Standard Association) units and require conversion to ISO (International Organization for Standardization) units. The ASA units generally assigned lower numeric scores to hearing loss than do the ISO units. Conversion to ISO units is accomplished by adding 15 dB to the ASA units at 500 Hertz, 10 dB to the ASA units at 1000 Hz, 2000 Hz, and 3000 Hz, and 5 dB to the ASA units at 4000 Hz. See VA Interim Issues 21-66-16, 21-66-17 (June 6, 1966); 10-66-20 (June 8, 1966); DM&S Manual M-2, Part XVIII, Chapter 4, paragraph 4.02, Use of International Standards Organization (ISO) for Audiological Examinations. In March 2013, the Veteran was administered a Hearing Loss and Tinnitus Disability Benefits Questionnaire (Hearing Loss DBQ). In this examination, the Veteran was found to have bilateral hearing loss for VA purposes. Following the examination, the examiner opined that the Veteran's hearing loss was not at least as likely as not related to service. In favor of this opinion, he noted that the Veteran's hearing ability on separation from service in 1961 was normal bilaterally. In January 2019, the Board found this medical opinion inadequate for adjudication purposes and remanded the claim for a new opinion on the matter. In October 2019, the Veteran was re-administered another Hearing Loss DBQ. Following the examination, the examiner opined that the Veteran's hearing loss was less likely than not related to service. In favor of this opinion, the examiner noted having reviewed medical records, and noted that although the Veteran had been exposed to hazardous noise during service, that he separated from service with hearing thresholds well within the normal range. Additionally, the examiner noted the Veteran's cancer treatment and acknowledged that patients who undergo radiation therapy for head and neck cancer appear more likely to experience hearing loss. The examiner determined that the Veteran's hearing loss could be seen as secondary to his cancer condition. See etiology opinions in the Hearing Loss DBQ, dated October 2019. Notably, although this examiner opined that the Veteran separated from service with hearing thresholds within the normal range; the examiner did not convert the ASA units into ISO units for purposes of this opinion. Additionally, the examiner seems to suggest that because the hearing loss did not manifest during a period of service, that there is no relation between the Veteran's service and his hearing loss. He bases this finding on an executive summary, dated 2006, suggesting prolonged delay in the onset of noise-induced hearing loss is unlikely. Further, the examiner seems to suggest or speculate that the Veteran's hearing loss is secondary to his cancer treatment, but does not specify whether the hearing loss was caused by the cancer treatment or aggravated by it; although he noted the Veteran's report of really noticing his hearing difficulty after coming out of a coma in 2011. In November 2020, a private medical opinion was associated with the claims file. The physician noted having reviewed the Veteran's military, VA and civilian medical records. He also noted the Veteran's noise exposure during service and the lack of hearing protection issued to the Veteran. The physician opined that it is at least as likely as not that the Veteran's hearing loss is related to his service and his exposure to acoustic trauma. See medical opinion by Dr. F, dated November 2020. The Board finds this medical opinion adequate and assigns it high probative value. Accordingly, based on the above and for the reasons explained below, the Board finds that the preponderance of the evidence is at least in equipoise as to whether the Veteran's current hearing loss is etiologically related to his service. Resolving doubt in the Veteran's favor, the Board finds that service connection for bilateral hearing loss is warranted. The Veteran has hearing loss in both ears for VA purposes. Accordingly, his claim surpasses the first prong of the Shedden service connection test; a current disability. Further, the Board has already conceded his exposure to hazardous noise during service in view of the Veteran's MOS and his credible and competent lay statements. Thus, his claim also surpasses the second prong of the Shedden service connection test; the in-service incurrence. The only question remaining before the Board is whether there is sufficient evidence linking the Veteran's current hearing loss to his noise exposure during service; the nexus requirement of the Shedden service connection test. Here, the Board notes that as the Veteran was only administered a whisper test for his induction into service, there is no baseline to compare his separation examination audiometric examination. Additionally, there is a positive medical opinion linking the Veteran's hearing loss to his service as well as a negative VA medical opinion indicating the Veteran's hearing loss is not related to his service but could be secondary to his cancer treatment. Thus, there is evidence in favor and against the finding that the Veteran's hearing loss is etiologically related to his service. The Board acknowledges that the VA medical opinion, dated October 2019, suggests the Veteran's hearing loss could be secondary to his cancer, which has been granted service connection in this Board decision. However, as the medical evidence is in relative equipoise as to whether his hearing loss is related to his service on a direct basis, the Board need not explore this alternative theory of entitlement on a secondary basis. As the preponderance of the evidence is in equipoise as to whether the Veteran's current hearing loss is related to service; the Board resolves doubt in the Veteran's favor and finds that service connection, on a direct basis, for hearing loss is warranted. 3. Entitlement to service connection for tinnitus The Veteran seeks service connection for tinnitus. In favor of his claim, the Veteran asserts that his tinnitus is related to his hazardous noise exposure during service. See hearing transcript. In the Hearing Loss DBQ dated March 2013 the Veteran's tinnitus was found to be less likely than not related to service because the Veteran's hearing ability was normal at separation. In favor of this opinion the examiner reasoned that tinnitus is associated with hearing loss. See Hearing Loss DBQ of March 2013. The examiner did not opine whether the Veteran's tinnitus could be directly related to his service, but rather only opined that the Veteran's tinnitus is associated with his hearing loss. In the Hearing Loss DBQ dated October 2019, the examiner opined that the Veteran's tinnitus is less likely than not related to service because the evidence of record does not show that tinnitus was present during or immediately after his service period. See Hearing Loss DBQ dated October 2019. The Board finds this medical opinion inadequate for adjudication purposes as it relied on the absence of contemporaneous medical evidence of an in-service incurrence to provide a negative opinion. In November 2020, a private physician opined that the Veteran has tinnitus and that is it as likely as not that his tinnitus originated in service, due to his exposure to acoustic trauma. See private medical opinion of November 2020. The Board finds this medical opinion adequate and assigns it high probative value. Based on the above, the Board finds that the evidence is at least in equipoise as to whether the Veteran's tinnitus is related to service; resolving doubt in his favor, the Board finds that service connection for tinnitus is warranted. The Board notes that tinnitus is "a sensation of noise (as a ringing or roaring) that is caused by a bodily condition (as wax in the ear or a perforated tympanic membrane"). Butts v. Brown, 5 Vet. App. 532, 540 (1993). The Board observes that in Charles v. Principi, 16 Vet. App. 370, 374-375 (2002), the Court specifically held that tinnitus is a condition which is capable of lay observation. See also Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). As the Veteran has reported he currently suffers from tinnitus, the Board finds that the first prong of the Shedden service-connection test has been surpassed; a current disability. The Board has also conceded the Veteran's in-service hazardous noise exposure. Thus, his claim also surpasses the second prong of the Shedden service-connection test; the in-service incurrence. The remaining question before the Board is whether there is sufficient evidence of record linking the Veteran's current tinnitus to his service, the third prong of the Shedden service connection test- the nexus requirement. Here, the Board finds that the evidence is at least in equipoise as to whether the Veteran's tinnitus is related to his service. Particularly, the Board notes that VA medical opinions of record note that the Veteran's tinnitus is related to his hearing loss and not his service, while a private medical opinion links the Veteran's tinnitus to his service. Thus, as there is evidence for and against the finding that the Veteran's tinnitus is related to his service; the Board finds that the preponderance of the evidence is at least in equipoise. Resolving doubt in the Veteran's favor, the Board finds that service connection for tinnitus is warranted, on a direct basis. As the Board has found that there is sufficient evidence to grant the benefit sought on a direct basis, the Board will not address the theory of entitlement on a secondary basis, raised by the evidence of record. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Gonzalez-Maldonado 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.