Citation Nr: 21029848 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 16-25 776 DATE: May 17, 2021 ORDER Entitlement to an initial compensable rating for residuals of left foot ingrown toenails disorder is denied. Entitlement to an initial 10 percent rating for right knee disability is granted from May 3, 2013. Entitlement to a separate 10 percent rating for left knee instability is granted from June 7, 2012. REMANDED Entitlement to an initial rating in excess of 10 percent for lumbar strain with degenerative arthritis is remanded. Entitlement to an initial rating in excess of 10 percent for left hip sprain with degenerative arthritis remanded. Entitlement to a rating in excess of 10 percent for residuals of left knee injury is remanded. Entitlement to a rating in excess of 10 percent rating for left knee instability is remanded. Entitlement to an initial rating in excess of 10 percent for right knee disability is remanded. Entitlement to an initial rating in excess of 10 percent for residuals of left thumb injury is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for a left ankle disorder is remanded. Entitlement to service connection for insomnia as secondary to service-connected left knee disorder or other musculoskeletal disorders is remanded. Entitlement to service connection for tobacco abuse as secondary to service-connected left knee disorder or other musculoskeletal disorders is remanded. Entitlement to service connection for substance abuse as secondary to service-connected left knee disorder or other musculoskeletal disorders is remanded. FINDINGS OF FACT 1. The Veteran's left foot ingrown toenails disability is not manifested by a moderate foot injury. 2. From May 3, 2013, the Veteran right knee disability has been manifested by at least painful motion. 3. From June 7, 2012, the Veteran's left knee disability is productive of at least slight instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial compensable rating for residuals of left foot ingrown toenails disorder are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code (DC) 5284. 2. The criteria for an initial 10 percent rating for a right knee disability from May 3, 2013 are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.40, 4.59, 4.71a, DCs 5003-5260. 3. The criteria for a10 percent rating for a left knee instability from June 7, 2012 are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.40, 4.59, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1987 to June 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from March 2013, September 2014, and October 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this matter in November 2018 for additional development. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the evidence demonstrates distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. 1. Entitlement to an initial compensable rating for residuals of left foot ingrown toenails disorder is denied. The Veteran asserts that his recurrent left ingrown toenails are more severe than that contemplated by the noncompensable rating currently assigned. The Board finds that a review of the relevant medical and lay evidence of record, to include the August 2014 and November 2019 VA examinations, shows that the left ingrown toenails disability does not manifest to a severity that can be considered "moderate," or of medium severity that is greater than mild, in terms of intensity, and therefore, does not warrant a higher, compensable, disability rating. Therefore, the claim must be denied. The left ingrown toenail disability is currently rated noncompensable under DC 5284. Under DC 5284, other foot injuries are rated 10 percent disabling when moderate, 20 percent disabling when moderately severe, and 30 percent disabling when severe. With actual loss of use of the foot, a 40 percent rating is assigned under Diagnostic Code 5167. DC 5284 refers to other foot injuries and applies to foot disabilities for which there is not already a specific diagnostic code, such as in this case. When a disability is specifically listed in the Schedule, it may not be rated by analogy under DC 5284. Copeland v. McDonald, 27 Vet. App. 333 (2017). The period on appeal begins on May 3, 2013, the date service connection was established. In August 2014, the Veteran underwent a VA foot examination, at which time the examiner confirmed a diagnosis of left ingrown toenails. The Veteran stated that he developed left foot ingrown toenails due to poor posture and wearing heavy boots while performing military physical training and work related duties post-service, in 2003, which were treated with excision. He reported occasional pain in the left foot with prolonged walking, standing or bending, with symptoms relieved with rest and/or medication. The Veteran reported pain as 0/10 at the examination, and denied any flare-ups or functional loss. The examiner noted mild residuals of ingrown toenails of the left foot, hallux valgus with no symptoms on examination, and mild degenerative changes of the first metatarsophalangeal (MTP) joint. However, the examiner also noted moderate impairment. Although the examiner does not clarify these contradictory statements, the examiner clearly stated that the Veteran had a history of ingrown toenails in 2003 and 2005 (which the Board emphasizes is prior to the appeal period), now with no symptoms or dysfunction of the left foot, no pain on physical examination, and no functional impairment, to include during flare-ups and as a functional equivalent of amputation with prosthesis. The August 2014 VA examiner determined that the left foot condition caused no impact on the Veteran's ability to work. In November 2019, the Veteran underwent an additional VA foot examination, at which time the examiner diagnosed left ingrown toenails and mild degenerative arthritis of the left foot. The Veteran reported that he has not had an ingrown toenail in years. He reported that the last time that he went a specialist, he was taught how to cut his toenails and that his ingrown toenails have not returned since. He received no treatment for the condition. The examiner specifically opined that the Veteran's left foot degenerative arthritis was separate and unrelated to the Veteran's service-connected ingrown toenails, and instead attributed arthritis to the aging process and obesity. The November 2019 VA examiner determined that the left foot condition caused no impact on the Veteran's ability to work. VA treatment records are negative for any complaints, diagnosis, or treatment of ingrown toenails. Based on a careful review of all the lay and medical evidence, the Board finds that throughout the initial rating period on appeal, the Veteran's service-connected left ingrown toenails do not warrant a compensable rating. Rather, the medical evidence reveals that the Veteran had either mild or no signs or symptoms associated with the ingrown toenails, as they have resolved and only caused occasional pain on prolonged exertion. Furthermore, the Veteran did not report any recurring ingrown toenail during his November 2019 VA examination and the August 2014 VA examiner's findings are equivalent to no or only slight/mild impairment associated with the service-connected disability. Therefore, the Board finds that there is no basis upon which to award a compensable rating for left ingrown toenails under DC 5284. The Board notes that the United States Court of Appeals for the Federal Circuit (Federal Circuit) in Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019), the Federal Circuit held that when rating foot conditions not listed in the Rating Schedule, VA must consider analogous ratings under DC 5284, for other foot injuries, even when other listed, service-connected foot disabilities are present. In this case, the Board has considered whether any other relevant diagnostic codes, may afford the Veteran a compensable evaluation for his ingrown toenails. However, given that the clinical evidence found no pathology to support a diagnosis of ingrown toenail and there was no other symptomatology identified, the Board finds that there are no other applicable diagnostic codes. In this regard, the Board also finds that a separate rating is not warranted for hallux valgus under DC 5281, which the Board notes the more recent 2019 VA examiner did not even diagnose, as it has not required surgery and is not characterized as severe, but instead asymptomatic. 38 C.F.R. § 4.71a, DC 5281. 2. An initial 10 percent rating for a right knee disability is granted. The Veteran asserts that he is entitled to a higher rating for his right knee disability. When evaluating musculoskeletal disabilities based on limitation of motion, the Veteran is entitled to at least the minimum compensable evaluation if motion is accompanied by pain. See 38 C.F.R. § 4.59 ; Burton v. Shinseki, 25 Vet. App. 1 (2011). Additionally, pain is also relevant to assignment of a rating in excess of the minimum compensable rating, but only if that pain results in demonstrated functional impairment. Mitchell v. Shinseki, 25 Vet. App. 32, (2011); see 38 C.F.R. §§ 4.40, 4.45. Functional impairment as contemplated by 38 C.F.R. §§ 4.40 and 4.45 includes less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell, 25 Vet. App.at 44. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. See generally Mitchell, 25 Vet. App. at 32. The period on appeal begins on May 3, 2013, the date service connection was established. The Veteran's right knee disability is currently rated as noncompensable under DCs 5003-5260 for arthritis and limitation of flexion. See 38 C.F.R. § 4.27 (hyphenated diagnostic codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned). Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). The Board notes that the criteria under which the Veteran's right knee is currently rated, 38 C.F.R. § 4.71a, DC 5260, was not affected by the February 7, 2021, amendments. Further, because his disability was rated based on evidence of degenerative arthritis, the criteria under DC 5003 also was not affected as pertains to the Veteran. Under the pre-amended criteria, degenerative arthritis as shown by x-ray studies is rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DCs 5003. When, however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. A rating of 20 percent may be applied where there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DCs 5003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Under DC 5260, flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. Turning to the evidence of record, the Veteran was afforded VA examinations in August 2014 and November 2019. During the August 2014 VA examination, the Veteran reported onset of right knee pain due to poor posture and limping. The Veteran reported right knee pain with prolonged walking, standing, and bending. The examiner determined that the Veteran was able to do all activities of daily living with some difficulties. Thus, the Board finds the Veteran's right knee disability warrants at least a ten percent rating for the entire appeal period, as it has resulted in functional impairment manifested by painful motion. See Burton, supra; 38 C.F.R. § 4.59. 3. A 10 percent rating for left knee instability is granted from June 7, 2012. The Veteran asserts that he is entitled to an increased rating for his left knee disability. By way of background, the current appeal period begins on June 7, 2012, the date VA received the Veteran's claim for an increased rating for the left knee disability, plus the one-year "look back" period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). The Veteran's left knee disability is currently rated 10 percent under DC 5259 for symptomatic residuals of meniscal surgery. The Board finds that a separate, compensable rating is warranted for subluxation or lateral instability of the left knee under 38 C.F.R. § 4.71a, DC 5257. Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. VA thus must consider the claim for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. The Board observes that former regulation 38 C.F.R. § 19.9(b)(2) (now renumbered as 38 C.F.R. § 20.904(d)(2)) provided that the Board has the authority to consider appeals in light of laws, including but not limited to statutes, regulations and court decisions that were not previously considered by the AOJ. In Disabled American Veterans v. Sec of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) specifically upheld the validity of 38 C.F.R. § 19.9(b)(2) (now as noted renumbered as 38 C.F.R. § 20.904(d)(2)). Id. at 1349. As such, pursuant to 38 C.F.R. § 20.904(d)(2), the Board will proceed to adjudicate the Veteran's claim. Under the pre-amended criteria, DC 5257 evaluates recurrent subluxation or lateral instability of a knee, and provides for a 10 percent disabling for a slight impairment; a 20 percent disabling for a moderate impairment; and a 30 percent disabling for a severe impairment. Under DC 5259, a 10 percent evaluation is assigned for symptomatic removal of semilunar cartilage. Effective February 7, 2021, DC 5257 was amended to provide ratings for recurrent subluxation or lateral instability. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribing both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribing a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribing either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. DC 5257 also provides for ratings based on patellar instability. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. Note [1] to DC 5257 states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note [2] to DC 5257 states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration. At the March 2013 VA examination, the Veteran reported that his left knee slips out of place. During the November 2019 VA examination, the Veteran reported that his left knee comes out a place and that he wears a brace. In December 2019, the Veteran was prescribed a knee brace. However, upon testing, the March 2013, August 2014, and November 2019 VA examinations show no instability. A rating based on instability may be warranted even in the absence of objective testing. See English v. Wilkie, 30 Vet. App. 347 (2018). Resolving all reasonable doubt in the Veteran's favor, the Board finds the Veteran has instability of the left knee that is slight in severity. In Lyles v. Shulkin, 29 Vet. App. 107 (2017), the United States Court of Appeals for Veterans Claims held that evaluation of a knee disability under DCs 5257 or 5261 or both does not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under DC 5258 or 5259, and vice versa, so long as manifestations of disability for which a separate evaluation is being sought have not already been compensated by an assigned evaluation under a different DC. To this end, the Board notes that the December 1994 rating decision awarded service connection following his in-service arthroscopic anterior cruciate ligament reconstruction and medial meniscus repair. The rating decision noted limitation of flexion of the left knee without evidence of subluxation or lateral instability. Thus, the Board finds that the Veteran's meniscus condition was manifested by symptomatology separate and distinct from his instability. Accordingly, a separate rating of at least 10 percent for left knee instability is warranted. REASONS FOR REMAND 4. Entitlement to an initial rating in excess of 10 percent for lumbar strain with degenerative arthritis is remanded. 5. Entitlement to an initial rating in excess of 10 percent for left hip sprain with degenerative arthritis is remanded. 6. Entitlement to a rating in excess of 10 percent for residuals of left knee injury is remanded. 7. Entitlement to a rating in excess of 10 percent rating for left knee instability is remanded. 8. Entitlement to an initial rating in excess of 10 percent for a right knee disability is remanded. 9. Entitlement to an initial rating in excess of 10 percent for residuals of left thumb injury is remanded. Review of the record reveals that the Veteran underwent VA back, hip, bilateral knee, and left thumb examinations in August 2014; however, the examinations do not comply with Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) (the examiner should "estimate the functional loss that would occur during flares."). In accordance with the November 2018 Board remand directives, the Veteran was afforded VA examinations in November 2019. The November 2019 VA examination report relates that the Veteran denied flare-ups but also reflects that he essentially identified and described flare-ups while discussing his current symptoms, to include aggravated back pain caused by overuse, left hip pain caused by moving or prolonged walking, intermittent knee pain and swelling, and intermittent thumb pain with writing and typing. Thus, a remand is required for an addendum opinion that is complaint with Sharp. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 10. Entitlement to service connection for hypertension is remanded. The November 2018 Board decision determined that the Veteran's in-service blood pressure readings were consistent with elevated blood pressure as defined by the American Heart Association. See Health Topics, High Blood Pressure, Understanding Blood Pressure Readings (Nov. 30, 2017) available at http://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings. A November 2019 VA examiner opined that the Veteran's current hypertension is less likely than not related to service. In rendering this opinion, the examiner noted that the Veteran's hypertension diagnosis was rendered many years after service discharge. The examiner failed to address the Veteran's in-service elevated blood pressure readings. Thus, an addendum opinion must be obtained on remand. 11. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran asserts that his bilateral hearing loss is due to the significant amount of hazardous noise exposure during service due to his duties of his military occupational specialty (MOS) as a Power Generation Equipment Repairer. The November 2019 VA audiologist opined negatively as to a relationship between the Veteran's bilateral hearing loss and service, relying on the absence of significant threshold shifts in the audiograms in the Veteran's STRs and the fact that his hearing was normal at service separation. However, the examiner did not address the Veteran's report regarding hearing problems beginning in 1993 due to his duties of his MOS or the possibility of delayed-onset hearing loss. Thus, an addendum opinion is warranted on remand. Hensley v. Brown, 5 Vet. App. 155, 159. 12. Entitlement to service connection for a left ankle disorder is remanded. 13. Entitlement to service connection for insomnia as secondary to service-connected left knee disorder or other musculoskeletal disorders is remanded. 14. Entitlement to service connection for tobacco abuse as secondary to service-connected left knee disorder or other musculoskeletal disorders is remanded. 15. Entitlement to service connection for substance abuse as secondary to service-connected left knee disorder or other musculoskeletal disorders is remanded. Any outstanding VA and private treatment records should be secured on remand. Finally, as the record does not demonstrate the presence of a current disability or functional impairment in the left ankle, insomnia, tobacco abuse, or substance abuse, action on these claims is deferred pending this development. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain all outstanding private treatment records. If any records are unavailable, notify the Veteran pursuant to 38 C.F.R. § 3.159(e). 3. Then obtain an addendum opinion addressing the severity of the Veteran's back, left hip, bilateral knee, and left thumb disabilities during a flare-up. No additional examination is necessary, unless the examiner determines otherwise. The examiner is asked to address the following: (a). Considering the Veteran's reported history, to include the March 2013, August 2014, and November 2019 VA examination reports, please provide an opinion describing functional impairment of the Veteran's back, left hip, bilateral knee, and left thumb disabilities during flare-ups, accounting for pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report such impairment in terms of additional degrees of limitation of motion. If the examiner is unable to provide such an opinion without resort to speculation, the examiner must provide a rationale for this conclusion, with specific consideration of the instructions in the VA Clinician's Guide to estimate, "per [the] veteran," what extent, if any, flare-ups affect functional impairment. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. If an examination is needed for this determination, one should be scheduled. (b). Opine as to whether the Veteran's functional loss in the back is the functional equivalent of ankylosis during a flare-up. See November 2019 VA examination report (the Veteran reported that a lifting injury caused him to be unable to walk or sit due to the low back pain.) A complete rationale shall be given for all opinions and conclusions expressed. 4. Then obtain an addendum opinion regarding the etiology of the Veteran's hypertension. No additional examination is necessary, unless the examiner determines otherwise. After a review of the claims file, the examiner is requested to provide a specific opinion as to: a. Whether hypertension at least as likely as not (50 percent or greater probability) (1) began during active service, (2) manifested within 1 year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) , is otherwise related to an in-service injury, event, or disease. In addressing this question, the examiner must address the Veteran's in-service elevated blood pressure readings, to include in July 1989 (145/95) and May 1989 (144/96). See November 2018 Board remand, page 14. b. Whether hypertension is at least as likely as not (50 percent or greater probability) (1) proximately due to or (2) aggravated (worsened) beyond its natural progression by a service-connected disability. In addressing secondary service connection, please note that the service-connected disability need not be diagnosed or service-connected at the time hypertension is incurred to establish secondary service connection, and reliance on this fact will render any secondary opinion inadequate. A complete rationale should be provided for all opinions and conclusions expressed. 5. Then obtain an addendum opinion from an examiner other than the November 2019 examiner to address the etiology of the Veteran's bilateral hearing loss. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. The claims file, including a copy of this remand, must be provided to the examiner in conjunction with the requested opinion. The examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's bilateral hearing loss had its onset during service or is otherwise related to service. In addressing this question, the examiner must discuss: a. the Veteran's conceded in-service noise injury from duties of his MOS, including loud machines, generators, other power equipment, and driving a 5-ton tractor trailer; b. the August 2014 examiner's reliance on the statement cited from the American College of Occupational Medicine Noise and Hearing Conservation Committee. Does the examiner opine that the Veteran had noise-induced hearing loss while in service? c. whether the Veteran's conceded in-service noise injury resulted in delayed-onset hearing loss; and d. the Veteran's assertions, which you are to assume are true, that his current bilateral hearing loss had its onset during his active duty service and continued from his active duty service to the present. See November 2019 VA examination report (reported onset in 1993). The examiner must assume this statement as true, even despite the absence of "objective documentation." e. Please state whether a nexus between the Veteran's bilateral hearing loss and service is medically consistent with the symptomatology reported by the Veteran in sub-part (d) above. Otherwise, the opinion will be returned as inadequate. A complete rationale should be given for all opinions and conclusions expressed. If unable to provide a medical opinion without speculation, please indicate whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Forde, 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.