Citation Nr: 21029772 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 18-43 733 DATE: May 17, 2021 ORDER New and material evidence having been presented, the claim of entitlement to service connection for a left ankle disorder is reopened. New and material evidence having been presented, the claim of entitlement to service connection for a right ankle disorder is reopened. New and material evidence having been presented, the claim of entitlement to service connection for bilateral hearing loss is reopened. New and material evidence having been presented, the claim of entitlement to service connection for tinnitus is reopened. New and material evidence having been presented, the claim of entitlement to service connection for posttraumatic stress disorder (PTSD) is reopened. The claim of entitlement to service connection for PTSD is granted. The claim of entitlement to service connection for bilateral hearing loss is denied. REMANDED The claim of entitlement to service connection for a left ankle disorder is remanded. The claim of entitlement to service connection for a right ankle disorder is remanded. The claim of entitlement to service connection for obstructive sleep apnea is remanded. The claim of entitlement to service connection for tinnitus is remanded. FINDINGS OF FACT 1. A June 2015 rating decision denied the claim to reopen the issue of entitlement to service connection for a left ankle disorder; the Veteran did not appeal the decision or submit any pertinent evidence within the appeal period and the decision is now final. 2. Evidence received subsequent to the expiration of the appeal period is not cumulative or redundant of the evidence previously of record and relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a left ankle disorder. 3. A June 2015 rating decision denied the claim to reopen the issue of entitlement to service connection for a right ankle disorder; the Veteran did not appeal the decision or submit any pertinent evidence within the appeal period and the decision is now final. 4. Evidence received subsequent to the expiration of the appeal period is not cumulative or redundant of the evidence previously of record and relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a right ankle disorder. 5. A June 2015 rating decision denied the claim to reopen the issue of entitlement to service connection for bilateral hearing loss; the Veteran did not appeal the decision or submit any pertinent evidence within the appeal period and the decision is now final. 6. Evidence received subsequent to the expiration of the appeal period is not cumulative or redundant of the evidence previously of record and relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for bilateral hearing loss. 7. A June 2015 rating decision denied the claim of entitlement to service connection for tinnitus; the Veteran did not appeal the decision or submit any pertinent evidence within the appeal period and the decision is now final. 8. Evidence received subsequent to the expiration of the appeal period is not cumulative or redundant of the evidence previously of record and relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for tinnitus. 9. A May 2016 rating decision denied the claim to reopen the issue of entitlement to service connection for PTSD; the Veteran did not appeal the decision or submit any pertinent evidence within the appeal period and the decision is now final. 10. Evidence received subsequent to the expiration of the appeal period is not cumulative or redundant of the evidence previously of record and relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for PTSD. 11. The probative evidence is at least in relative equipoise as to whether the Veteran's PTSD is etiologically related to his active duty service. 12. A bilateral hearing loss disability has not been present during the pendency of the claim. CONCLUSIONS OF LAW 1. New and material evidence has been presented to reopen the claim of entitlement to service connection for a left ankle disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. New and material evidence has been presented to reopen the claim of entitlement to service connection for a right ankle disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. New and material evidence has been presented to reopen the claim of entitlement to service connection for bilateral hearing loss. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. New and material evidence has been presented to reopen the claim of entitlement to service connection for tinnitus. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. New and material evidence has been presented to reopen the claim of entitlement to service connection for PTSD. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 6. The criteria for establishing entitlement to service connection for PTSD have been met. 38 U.S.C. §§ 1110; 38 C.F.R. §§ 3.102, 3.303, 3.304. 7. The criteria for establishing entitlement to service connection for a bilateral hearing loss disability have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service in the United States Air Force from December 1996 to March 2001. The claim of entitlement to service connection for sleep apnea was originally characterized as a claim that required the submission of new and material evidence before the claim could be considered on the merits. The Board finds, however, that new and material evidence has been submitted within one year of the February 2017 rating decision that originally denied the claim. Specifically, a September 2017 medical opinion, which will be discussed below is new and material to the sleep apnea claim. Thus, this evidence is considered as having been filed in connection with the claim that was pending at the beginning of the appeal period. 38 C.F.R. § 3.156 (b). Accordingly, this claim has been recharacterized as a service connection claim. New and Material Evidence Generally, if a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. "New" evidence is defined as existing evidence not previously submitted to agency decision-makers. "Material" evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative, nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The threshold to reopen a claim is low. Shade v. Shinseki, 24 Vet. App. 110 (2010). 1. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for a left ankle disorder. Please see discussion in paragraph 5. 2. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for a right ankle disorder. Please see discussion in paragraph 5. 3. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for bilateral hearing loss. Please see discussion in paragraph 5. 4. New and material evidence has been presented to reopen the claim of entitlement to service connection for tinnitus. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Please see discussion in paragraph 5. 5. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for PTSD. The Regional Office (RO) initially denied service connection for a bilateral ankle disorder and bilateral hearing loss in a February 2009 rating decision. The RO confirmed and continued the denials in a July 2009 rating decision. The RO determined that the evidence did not show in-service incurrence of the bilateral ankle disorder or bilateral hearing loss. In a June 2015 rating decision, the RO initially denied service connection for tinnitus and PTSD. The RO also continued to deny the claims of entitlement to service connection for a left ankle disorder, a right ankle disorder, and bilateral hearing loss. The RO determined that the medical evidence did not contain a diagnosis of PTSD. It was also determined that his tinnitus was not related to service. In a May 2016 rating decision, the RO continued the denial of the claim for service connection for PTSD. The Veteran did not appeal the denials or submit any pertinent evidence within the appeal periods. Therefore, the decisions are final. See 38 U.S.C. § 7105; 38 C.F.R. § § 20.201, 20.302, 20.1103. Thereafter, the Veteran filed a claim to reopen the issues of entitlement to service connection for a left ankle disorder and tinnitus in November 2016. In September 2017, he filed a claim to reopen the issues of entitlement to service connection for a left ankle disorder, a right ankle disorder, bilateral hearing loss, and PTSD. Evidence received since the June 2015 rating decision includes September 2017 medical opinions by P.Y., D.C. Dr. Y. opined that his bilateral ankle disorder, bilateral hearing loss, and tinnitus are related to service. The Veteran also submitted a private psychological assessment completed by R.O., Ph.D. Dr. O. diagnosed PTSD caused by the military sexual trauma. Accordingly, reopening of the claims of service connection for a left ankle disorder, a right ankle disorder, bilateral hearing loss, tinnitus, and PTSD is warranted. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease, injury, or event and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). For the purpose of applying the laws administered by VA, impaired hearing will be considered a disability when the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a) (2018); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the in-service stressor occurred. 38 C.F.R. § 3.304 (f). If PTSD is based on an in-service personal assault, evidence from sources other than a veteran's service records may corroborate his or her account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted disease; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be used to corroborate the stressor. In addition, VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304 (f)(5). Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. 38 C.F.R. § 3.304 (f)(5). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (finding service connection presupposes a current diagnosis of the condition claimed). The requirement that a current disability be present is satisfied, "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim... even though the disability resolves prior to the Secretary's adjudication of the claim." McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). 6. Entitlement to service connection for PTSD. The Veteran seeks service connection for PTSD. He asserts that he developed PTSD as a result of an in-service sexual assault. In multiple statements provided during the appeal period, the Veteran reported that he was sexually abused by his supervisor's wife, who has also in the military. In April 2016, he stated that the sexual abuse occurred from June 1997 to June 2000. It began when he was 20 years old and his abuser was 34 and occurred in various locations, such as at her home, work, and other places around town. She threatened to disclose the sexual encounters to her husband if the Veteran did not continue. The Veteran was fearful of retaliation. In March 2020, he explained that he endorsed feelings of worry, guilt, and embarrassment, and that he tried to get help from a military psychologist. He did not discuss the abuse with the psychologist and instead concentrated on his job stress. He felt that his military career was over and separated from service following the years of sexual abuse. Following service, his mother recognized that he was isolated. Service treatment records showed that the Veteran received behavioral health treatment in January 2000. He presented with complaints of stress secondary to worry and rumination on occupational problems. He stated that he had problems with his former supervisor that resulted in reprimands. He subsequently switched supervisors and was doing well, however, he continued to dwell on the past because of the potential impact on his career. He reported decreased concentration, social activity, energy, interest, and appetite. The diagnosis was rule out adjustment disorder with depressed mood. A February 2000 service treatment record note that he attended stress management class and denied significant stressors at that time. The Veteran reported that the problems in his workplace were resolving. The Veteran no longer wanted to continue with treatment. Post-service VA treatment records included negative PTSD screens in November 2008, January 2010, May 2013, and January 2015. In May 2014, the Veteran reported depression symptoms for 5 years. His symptoms were found to be consistent with major depressive disorder, but not PTSD. The Veteran was afforded a VA psychiatric examination in June 2015. The examiner found that the Veteran did not have a mental disorder diagnosis. The examiner noted that the Veteran's August 1996 enlistment examination referenced a letter from his mother that confirmed one session for behavior problems when he was younger. The examiner also noted the Veteran's two mental health sessions during service in January 2000 and February 2000. During the VA examination, the Veteran continued to describe his in-service sexual abuse by his superior. The examiner determined that the stressor was not adequate to support a diagnosis of PTSD. The examiner explained that the diagnostic criteria for PTSD are not met due to the lack of symptoms reported. In September 2017, the Veteran submitted a PTSD disability benefits questionnaire (DBQ) and medical opinion provided by R.O., Ph.D. The diagnoses were PTSD, as well as depressive disorder due to another medical condition. His clinical symptoms were consistent with the criteria of DSM-V. The Veteran continued to describe his in-service stressor involving his Sergeant's wife. He reported that she threatened to tell her husband if the Veteran didn't continue the sexual encounters. There were rumors of the sexual relationship and the Sergeant became suspicious. The Veteran stated that he "was quite frightened of retribution" and feared that the Sergeant would become violent. The result was severe anxiety. He reported a long history of poor interpersonal relationships with women. Dr. O. noted that the Veteran had physiological and psychological reactivity to both internal and external events that symbolize or represent aspects of the original trauma. It was found that the Veteran was caught between two ranking non-commissioned officers which accounted for his emotional and physical internalizations of stress. The Veteran was afforded a VA examination in December 2017. The examiner determined that the Veteran did not meet the criteria for a diagnosis of PTSD, but that he did meet the criteria for a diagnosis of unspecified anxiety disorder. His stressor was adequate to support a PTSD diagnosis. Following a review of the medical records, the examiner opined that the Veteran's anxiety disorder was less likely than not related to service. The examiner noted that the Veteran continued in the National Guard after the reported trauma. He also denied psychiatric symptoms when he was seen at the VA from 2008 to 2012, when he reported stress related to balancing work and school. The examiner stated that VA records were negative for PTSD/psychiatric symptoms until 2013 when he reported depression secondary to abdominal symptoms. It was also noted that in 2014, the Veteran was seen by a mental health treatment provider and that it was found that his symptoms were not consistent with PTSD. In October 2018, a VA psychiatrist, G.M., M.D., found that the Veteran's psychological issues were most likely related to the unwanted, traumatic experiences he was exposed to and suffering from during military service. Dr. M. stated that he/she had one to two brief interviews with the Veteran and found him to be a credible historian. Dr. M. noted review of the Veteran's in-service mental health treatment records, as well as the September 2017 private medical opinion. The Veteran submitted a May 2020 private psychological assessment completed by S.H., Psy.D. Dr. H. disagreed with the June 2015 and December 2017 VA examiners and concluded that the Veteran's symptoms clearly aligned with a PTSD diagnosis. Dr. H. explained that an essential feature of PTSD is the development of characteristic symptoms following exposure to one or more traumatic events. It was also explained that military sexual trauma includes any sexual activity where a servicemember is involved against his/her will and whereby the veteran is pressured into sexual activity either through threats or by taking advantage of someone when they are unable to consent. It was noted that his service treatment records showing complaints of anxiety were consistent with a PTSD diagnosis. Dr. H. explained that although the Veteran was diagnosed with a rule-out of adjustment disorder with depressed mood during service in January 2000, he did not disclose the sexual trauma, which decreased the accuracy of the diagnosis. His VA treatment records also noted psychiatric symptoms, including anxiety, nervousness, worry, restlessness, nightmares, flashbacks, trouble concentrating, irritability, and negative mood alterations, all of which are consistent with a PTSD diagnosis. In light of the above, the Board finds that the evidence is at least in equipoise as to whether the Veteran has a diagnosis of PTSD caused by an in-service stressor. The Board acknowledges that the VA examiners concluded that the Veteran did not meet the diagnostic criteria for PTSD. However, the September 2017 DBQ and May 2020 psychological assessment included a diagnosis of PTSD. In addition, the Board finds that there is credible supporting evidence that the military sexual assault occurred. The Board points to the January 2000 service treatment record showing that the Veteran presented with complaints of worrying and ruminating on occupational problems, including conflict with his former supervisor and his concerns that it would impact his career. In March 2020, the Veteran reported that the sexual trauma caused significant worry, guilt, and isolation. He stated that the abuse destroyed his hopes of a military career. He also reported that following his separation from service, he noticed difficulty forming personal relationships. In October 2018, the Veteran's treating psychiatrist stated that the Veteran was a credible historian and that his psychiatric symptoms were related to the in-service traumatic experiences. Similarly, the September 2017 and May 2020 private medical opinions relate his PTSD to the military sexual trauma. Accordingly, the Board concludes that the medical evidence establishes that the Veteran's PTSD is related to his military sexual trauma. Accordingly, resolving the benefit of the doubt in the Veteran's favor, the Board finds that the Veteran's PTSD is causally related to service. Therefore, service connection for a psychiatric disorder is warranted. Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 7. Entitlement to service connection for bilateral hearing loss. The Veteran seeks entitlement to service connection for bilateral hearing loss. Initially, the Board must examine whether the Veteran has had a hearing loss disability as defined by VA regulation at any time during the pendency of this claim. The Veteran was afforded a VA examination in June 2015. Speech discrimination was measured at 100 percent in each ear. Speech discrimination scores and pure tone thresholds, in decibels (dB), were as follows: June 2015 HERTZ 500 1000 2000 3000 4000 CNC RIGHT 15 10 15 20 30 100% LEFT 5 5 10 15 20 100% Upon consideration of the evidence above, the Board finds that that the competent evidence of record does not establish the presence of a bilateral hearing loss disability, as defined by 38 C.F.R. § 3.385, at any time during the pendency of this claim. Significantly, the June 2015 audiology findings did not show a hearing loss disability for VA purposes. Therefore, the Board must conclude that service connection for bilateral hearing loss is not warranted because the competent evidence does not show a hearing loss disability for VA compensation purposes. See 38 C.F.R. § 3.385. Without a finding of a current disability, service connection is not warranted. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). REASONS FOR REMAND 1. The claim of entitlement to service connection for a left ankle disorder is remanded. Please see discussion in paragraph 2. 2. The claim of entitlement to service connection for a right ankle disorder is remanded. The evidence of record includes three medical opinions addressing the etiology of his bilateral ankle disorder. Unfortunately, the Board finds that all three medical opinions are inadequate for adjudication purposes. The May 2015 VA examiner found that the Veteran's currently diagnosed bilateral ankle sprains were less likely than not related to service. The rationale was that the reported injuries during service would not be expected to result in a chronic ankle condition. In September 2017, Dr. Y. opined that the Veteran's bilateral ankle disorder was at least as likely as not causally related to the documented in-service ankle injury. The rationale was that the disorder is permanent and progressive. The December 2017 VA examiner opined that the bilateral ankle disorder was less likely than not related to service. The examiner stated that it was difficult to determine whether his current bilateral ankle disorder was the result of decondition and aging, or rather, from the in-service injuries. The Board finds that the medical opinions did not contain sufficient rationale. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion that contains only data and conclusions without any supporting analysis is accorded no weight). In addition, while the December 2017 VA examiner provided a negative nexus opinion, the supporting rationale essentially indicated that a determination could not be made, which does not support the conclusion that the bilateral ankle disorder is not due to service. Opinions stating that an opinion cannot be rendered without resorting to speculation must be supported by a rationale. Jones v. Shinseki, 23 Vet. App. 382 (2010). Here, the examiner did not explain why he could not determine if the bilateral ankle disorder was due to service or due to aging/deconditioning. As such, the medical opinions are inadequate, and a remand is necessary so that a new opinion may be obtained. 3. The claim of entitlement to service connection for obstructive sleep apnea is remanded. The claim of entitlement to service connection has been granted herein. In September 2017, Dr. Y. opined that the Veteran's sleep apnea was at least as likely as not directly and causally related to his PTSD. However, sufficient rationale was not provided. The Veteran has not been afforded a VA examination with respect to his claim for service connection for sleep apnea. Generally, VA must provide a medical examination or obtain a medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2), 38 C.F.R. § 3.159 (c)(4)(i). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, disease or injury is a low threshold. McLendon, 20 Vet. App. at 83. The Board finds the low threshold necessary to provide an examination has been established in this case. 4. The claim of entitlement to service connection for tinnitus is remanded. The Veteran asserts that his currently diagnosed tinnitus was caused by in-service noise exposure. A December 2008 VA treatment record documented the Veteran's report of occasional ringing in the ears since service. He denied post-service occupational noise exposure. He was afforded a VA examination in June 2015. The Veteran reported that he worked on the flight line within an office and that the noise that came in when the door opened caused damage to his hearing. The examiner noted that the Veteran did not work directly on the front line. The examiner opined that the Veteran's tinnitus was less likely than not related to military noise exposure. The rationale was that his tinnitus may be related to his current hearing loss. However, his hearing loss is not due to his time in service. The Board finds that the opinion is inadequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Specifically, the examiner did not provide sufficient rationale to support the opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 124. Accordingly, a remand is required to obtain an addendum opinion. The matters are REMANDED for the following action: 1. The AOJ should undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 2. Then, the AOJ should obtain a VA medical opinion by a physician(s) with sufficient expertise to determine the nature and etiology of his bilateral ankle disorder. All pertinent evidence of record must be made available to and reviewed by the examiner. Another examination of the Veteran should only be performed if deemed necessary by the person providing the opinion. All pertinent evidence of record must be made available to and reviewed by the examiner. Following a review of the relevant records and lay statements, the examiner must provide an opinion as to the whether it is at least as likely as not (50 percent or greater degree of probability) that the Veteran's bilateral ankle disorder began in or is otherwise related to the Veteran's active duty service. In so opining, the examiner must consider the May 2015, September 2017, and December 2017 medical opinions of record addressing this matter. The examiner must also consider and discuss the March 2020 statement provided by the Veteran. The rationale for all opinions expressed must also be provided. If the examiner is unable to provide any required opinion, she or she should explain why. If an opinion cannot be provided without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, examiner should identify the additional information that is needed. 3. Thereafter, the AOJ should afford the Veteran a VA examination by a physician with sufficient expertise, to determine the nature and etiology of his sleep apnea. All pertinent evidence of record must be made available to and reviewed by the examiner. Any necessary tests and studies should be accomplished. Following a review of the relevant records and lay statements, the examiner must provide an opinion as to the following: (a) Whether it is at least as likely as not (50 percent or greater degree of probability) that the Veteran's sleep apnea began in or is otherwise related to the Veteran's active duty service. (b) Whether it is at least as likely as not (50 percent or greater degree of probability) that the Veteran's sleep apnea was caused or aggravated by his service-connected PTSD. In so opining, the examiner must consider the September 2017 favorable medical opinion. The rationale for all opinions expressed must also be provided. If the examiner is unable to provide any required opinion, she or she should explain why. If an opinion cannot be provided without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, examiner should identify the additional information that is needed. 4. Then, the AOJ should obtain a VA medical opinion by a physician with sufficient expertise to determine the nature and etiology of his tinnitus. All pertinent evidence of record must be made available to and reviewed by the examiner. Another examination of the Veteran should only be performed if deemed necessary by the person providing the opinion. All pertinent evidence of record must be made available to and reviewed by the examiner. Following a review of the relevant records and lay statements, the examiner must provide an opinion as to the whether it is at least as likely as not (50 percent or greater degree of probability) that the Veteran's tinnitus began in or is otherwise related to the Veteran's active duty service. In so opining, the examiner must consider and discuss the Veteran's reports of occasional ringing in the ears since service. The rationale for all opinions expressed must also be provided. If the examiner is unable to provide any required opinion, she or she should explain why. If an opinion cannot be provided without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, examiner should identify the additional information that is needed. 5. Then, the AOJ should readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. McKinley, 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.