Citation Nr: 21031096 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 15-00 196A DATE: May 20, 2021 ORDER Entitlement to a compensable evaluation for pseudofolliculitis barbae (PFB) is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a low back disorder is remanded. FINDINGS OF FACT 1. The Veteran's PFB affects less than 5 percent of the entire body or less than 5 percent of the exposed areas affected and required no more than topical therapy. The Veteran's PFB is also not productive of scars that are painful or unstable, a characteristic of disfigurement, or visible or palpable tissue loss with either gross distortion of assymetry of one feature. 2. The Veteran's bilateral hearing loss did not manifest in service or within one year thereafter and is not otherwise related to his military service. 3. The Veteran's tinnitus did not manifest in service or within one year thereafter and is not otherwise related to his military service. CONCLUSIONS OF LAW 1. The criteria for a compensable evaluation for PFB have not been met 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.118, Diagnostic Code 7813. 2. Bilateral hearing loss was not incurred in active service, nor may sensorineural hearing loss be presumed to have been so incurred. 38 U.S.C. §§ 101, 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385. 3. Tinnitus was not incurred in active service, nor may it be presumed to have been so incurred. 38 U.S.C. §§ 101, 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1972 to July 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2010 and October 2013 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In July 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. The issues of entitlement to service connection for a low back disorder, an acquired psychiatric disorder, and bilateral hearing loss were previously denied by the Board. In an April 2019 decision, the Board reopened the previously denied claims based on receipt of new and material evidence. The issues were also remanded for further development. The appeal has since been returned to the Board for further adjudication. Law and Analysis Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist regarding the issues decided herein. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Increased Evaluation Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.1. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In this case, the Veteran is currently assigned a noncompensable evaluation for his pseudofolliculitis barbae, pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7899-7813 for dermatophytosis. Hyphenated diagnostic codes including a diagnostic code ending in the digits "99" are used when there is no specifically applicable diagnostic code and the disability is rated by analogy. 38 C.F.R. § 4.27. During the pendency of the appeal, the rating criteria for evaluating a skin disorder under 38 C.F.R. § 4.118 was amended effective August 13, 2018. 83 Fed. Reg. 32593 (July 13, 2018). These amendments revised Diagnostic Code 7813 to state that disabilities evaluated under this Diagnostic Code should be evaluated under the General Rating Formula for the Skin. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); VAOPGCPREC 3-2000. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under both the old and new rating criteria, and the criteria that is more favorable to the Veteran will be applied. If the new criteria are more favorable, they will only be applied from August 13, 2018, when the regulations became effective. Under the amended criteria, the General Rating Formula for the Skin provides that a noncompensable rating is warranted where there is no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating will be warranted where there is at least one of the following: Characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating will be warranted where there is at least one of the following: Characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating will be warranted where there is at least one of the following: Characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required over the past 12-month period. The General Rating Formula further provides that, depending on the predominant disability, the disability could be rated instead as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7804, or 7805). Prior to the regulatory change effective August 13, 2018, Diagnostic Code 7813 stated that depending on the predominant disability, the disability could be rated instead as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7804, or 7805), or dermatitis (Diagnostic Code 7806), depending on the predominant disability. Under Diagnostic Code 7806, a noncompensable evaluation is warranted for dermatitis or eczema affecting less than 5 percent of the entire body or exposed areas affected, and; no more than topical therapy required during the past 12-month period. A 10 percent evaluation is warranted for dermatitis or eczema affecting at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas; or, intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent evaluation is warranted for dermatitis or eczema affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas; or, systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent evaluation is warranted for dermatitis or eczema affecting more than 40 percent of the entire body or more than 40 percent of exposed areas; or, constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. Prior to the regulatory change effective August 13, 2018, under Diagnostic Code 7804, a 10 percent rating is warranted for one or two scars that are unstable or painful; a 20 percent rating is warranted for three or four scars that are unstable or painful; and a 30 percent rating is warranted for five or more scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Code 7804. Note (1) to Diagnostic Code 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) states that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) indicates that scars evaluated under diagnostic codes 7800, 7801, 7802, and 7805 may also receive an evaluation under this diagnostic code, when applicable. Under Diagnostic Code 7805, or other scars, a separate rating can also be warranted for any disabling effects not considered under Diagnostic Codes 7800-7804. Diagnostic Code 7800 pertains to burn scar(s) of the head, face, or neck; scar(s) of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck. Under Diagnostic Code 7800, a 10 percent evaluation is warranted for a scar with one characteristic of disfigurement. A 20 percent evaluation is assigned for scars with visible or palpable tissue loss and either gross distortion or asymmetry of two features of paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent evaluation is assigned for scars with visible or palpable tissue loss and either gross distortion or asymmetry of two features of paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. An 80 percent evaluation is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of three features of paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. Note (1) provides that the eight characteristics of disfigurement, for purposes of evaluation under § 4.118, are: (1) scar five or more inches (13 or more cm. in length); (2) scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo- or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); (8) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Under Diagnostic Code 7801, a 10 percent rating is warranted for burn scars or scars due to other causes, not of the head, face, or neck, that are deep and nonlinear, at least 39 sq. cm. in area but less than 77 sq. cm, with higher ratings assigned for increases in area of the scar. Under Diagnostic Code 7802, a maximum 10 percent rating is warranted for burn scars or scars due to other causes, not of the head, face, or neck, that are superficial (not associated with soft tissue damage) and nonlinear, affecting an area or areas of 144 square inches (929 sq. cm.) or greater. A review of the evidence of record for the relevant time period on appeal shows that the Veteran was afforded a VA examination in connection with his claim in June 2010. At that time, he reported that he had PFB that developed in service and prevented him from being able to shave. He indicated that he had tried topical medications, but they caused burning and redness on his face. The examiner noted that the Veteran had facial pitting and scarring from a history of infections and lesions on his face. In December 2010, the Veteran was afforded another VA examination during which he reported symptoms of pruritis and burning, but no systemic symptoms. The examiner found that PFB affected less than 5 percent of the total and/or exposed body area. The Veteran was noted to have a few tiny papules of the anterior neck with no pustules, and there was no crusting, exfoliation, or folliculitis. The examiner also noted that the Veteran had a few scattered, barely visible scars on the face and anterior neck, which covered less than .5 square centimeters in area. The scars were not painful, had no signs of skin breakdown, and were superficial. There was also no edema, keloid formation, or other disabling effects observed. During the July 2018 hearing, the Veteran testified that he had breakouts from shaving that affected the area of his face underneath his chin, around his neck, and along his hair line. He reported that the breakouts resulted in pus being discharged. He also indicated that, although the breakouts did not happen too often, they bother him more during periods of warmer temperatures. The Veteran reported that he experienced pain and received steroids for the pain from a private dermatologist. In April 2019, the agency of original jurisdiction (AOJ) requested that the Veteran provide information regarding any treatment he was receiving in order to obtain those records. However, the Veteran did not respond with any additional information regarding the treatment he was receiving. During a March 2020 VA examination, the Veteran reported that he did not apply any topical medications and that he had not seen a dermatologist for his PFB for several years. The examiner noted that the Veteran's PFB had completely resolved and no longer required treatment. The examiner also noted that the Veteran had not been treated with any medication in the past 12 months for his PFB, nor had he undergone any treatments or procedures other than systemic or topical medications in the past 12 months. The examiner indicated that the Veteran had a skin condition without any characteristic lesions at the time of examination. In addition, there was no scarring or disfigurement of the head, face, or neck. After reviewing the evidence of record, the Board finds that a compensable evaluation is not warranted for the Veteran's PFB. Despite the Veteran's reported use of steroids during the hearing, the medical evidence does not document any treatment for the disorder. He was provided the opportunity to provide additional information regarding such treatment; however, he did not respond. The duty to assist is not a one-way street. A claimant cannot remain passive when he has relevant information. See Wamhoff v. Brown, 8 Vet. App. 517 (1996); Wood v. Derwinski, 1 Vet. App. 190 (1991). Moreover, the March 2020 VA examiner noted that the Veteran had not been taking any medication or undergoing any treatment for his PFB. Additionally, the evidence shows that less than 5 percent of the total and/or exposed body has been affected by the Veteran's PFB. The Board has considered other potentially applicable Diagnostic Codes. As a preliminary matter, Diagnostic Codes 7801 and 7802 are not applicable because they involve scars that are not of the head, face, or neck. Diagnostic Code 7800 is also not applicable, as the Veteran's PFB has not resulted in visible or palpable tissue loss or gross distortion of any features, and the Veteran has not exhibited any characteristics of disfigurement. Although the December 2010 VA examiner did note that the Veteran had a few scars, they were not painful, were superficial, and were not unstable. In addition, they did not exceed an area greater than .5 square centimeters, and no other disabling effects were observed. Moreover, the March 2020 VA examination found no scarring or disfigurement of the head, face, or neck observed. Thus, higher ratings under Diagnostic Codes 7804 and 7805 are also not warranted. Accordingly, the Veteran did not meet the criteria for a compensable evaluation for his PFB under the rating criteria that existed prior to August 13, 2018. The Board has also considered whether the Veteran would be entitled to a compensable evaluation under the new rating criteria effective from August 13, 2018, however, the March 2020 VA examiner clearly indicated that the Veteran had not been treated with any medication in the past 12 months for his PFB, nor had he undergone any treatments or procedures other than systemic or topical medications in the past 12 months. In fact, there is no indication from the examination that the Veteran was taking any systemic or topical treatments for his PFB. The examiner also indicated that the Veteran had a skin condition without any characteristic lesions at the time of examination. Thus, the Veteran would not be entitled to a compensable evaluation under the current rating criteria for skin disabilities. In summary, having considered the relevant criteria in effect prior to August 13, 2018, and the criteria in effect after August 13, 2018, the Board finds that the Veteran is not entitled to a compensable evaluation for his PFB. The Veteran and his representative have not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also 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). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As organic diseases of the nervous system, including sensorineural hearing loss and tinnitus, are considered to be chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including organic diseases of the nervous system, are presumed to have been incurred in service if they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the purpose of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies 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. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for bilateral hearing loss and tinnitus. The Veteran's service treatment records are negative for any complaints, treatment, or diagnosis of hearing loss or tinnitus. During a May 1973 separation examination, his ears were found to be normal. The Veteran also denied having a medical history of hearing loss and ear trouble at that time. In addition, an audiogram associated with the separation examination revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 5 5 10 LEFT 15 20 5 10 15 The Board notes that neither sensorineural hearing loss or tinnitus, nor manifestations sufficient to identify the diseases' entities, are shown during the Veteran's military service. Rather, the hearing examinations performed during his active service were normal, and the Veteran denied having any history of ear trouble and hearing loss during that time period. The pertinent regulations require that manifestations are "noted" in the service records and that is not case in this instance. Therefore, while currently diagnosed sensorineural hearing loss and tinnitus are chronic diseases under 38 C.F.R. § 3.309(a), no notations of the disease or any characteristic manifestations of sensorineural hearing loss or tinnitus were shown in the service records. As such, service connection under 38 C.F.R. § 3.303(b) is not warranted, and sensorineural hearing loss and tinnitus may not be presumed to have been incurred in service. 38 U.S.C. § 1101; 38 C.F.R. §§ 3.307, 3.309. Moreover, the most competent, credible, and probative evidence does not show that the Veteran had hearing loss or tinnitus that manifested within one year of his military service. Indeed, there was no documentation of either disorder for many years thereafter. Rather, during an August 1992 hearing, the Veteran reported that he started noticing his hearing loss about five years prior. In addition, during an April 2013 VA examination, the Veteran reported that he had longstanding tinnitus, but did not report any specific date or circumstance of onset. The Board does acknowledge the Veteran's statements that his hearing loss and tinnitus began in service. See e.g. July 2018 hearing transcript. Although lay persons are generally not competent to offer evidence which requires medical knowledge, they may provide competent testimony as to visible symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). A veteran can attest to factual matters of which he has or had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Federal Circuit has held that lay evidence is one type of evidence that must be considered, if submitted, when a veteran seeks disability benefits, and competent lay evidence can be sufficient in and of itself for proving the existence of a chronic disease. See Buchanan, 451 F.3d at 1335; 38 C.F.R. §§ 3.303(a), 3.307(b). The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. Buchanan, 451 F.3d at 1336. Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). In this case, the Board finds that the Veteran is competent to state that he has had difficulty hearing and tinnitus since his military service. However, his allegations are inconsistent with the contemporaneous record. There is no evidence of any complaints, treatment, or diagnosis in service, and he denied having ear trouble and hearing loss at the time of his separation examination. Moreover, upon objective testing on separation in May 1973, his hearing was documented as being normal for VA purposes. As such, there is affirmative evidence showing that he did not have hearing loss or tinnitus in service or for many years thereafter (as opposed to a mere absence of evidence). Moreover, as noted above, the Veteran previously testified during an August 1992 hearing that he started noticing his hearing loss about five years earlier. Such testimony is inconsistent with his other statements regarding its onset in service. For these reasons, the Board finds that the Veteran's reported history regarding the onset of his hearing loss and tinnitus is not reliable or credible. Nevertheless, the absence of in-service evidence of hearing loss disability is not fatal to the Veteran's claim. 38 C.F.R. § 3.303(d); Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Rather, competent evidence of a current hearing loss disability (i.e., one meeting the requirements of 38 C.F.R. § 3.385) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Likewise, service connection may be granted for tinnitus diagnosed after service upon the showing of a link between the current disorder and in-service noise exposure, including hearing loss related to such noise exposure. The Veteran has claimed that he was exposed to acoustic trauma from gunshot noises and explosions and that this was the injury sustained from which his hearing loss and tinnitus resulted. During the July 2018 Board hearing, the Veteran reported that he was exposed to these noises during combat service in Vietnam. He also reported that his foreign service was removed from his personnel records because he had witnessed senior officials engaging in illegal activities, so they removed his foreign service in retaliation. A review of the evidence of record shows that the Veteran did not have service in Vietnam or any other foreign service. The Veteran's service personnel record of assignments only shows service at Fort Dix, New Jersey. A July 2013 VA Request for Information also confirmed that there was no evidence in the file to substantiate any service in the Republic of Vietnam. Moreover, while the Veteran has asserted that his records were falsified, a February 2015 Record of Proceedings for the Army Board for Correction of Military Records, does not mention the incident described by the Veteran during the hearing, nor does it contain any allegations of retaliation. Rather, the Veteran asserted that he was sent to Nicaragua, but does not mention any service in Vietnam at all. Thus, to the extent the Veteran indicates that he was exposed to acoustic trauma during combat service in Vietnam, the Board finds that these statements are not credible given that the Veteran's statements are inconsistent with the contemporaneous evidence of record. The Board notes that October 1972 service personnel records document that the Veteran was assigned to complete combat support training with the Company D 1st Battalion 5th Advanced Individual Training Brigade. Post-service medical records also show that Veteran has been diagnosed with bilateral hearing loss in accordance with VA standards. See 38 C.F.R. § 3.385. Specifically, a February 2020 VA examination shows that the Veteran meets the criteria for bilateral hearing loss and has a current diagnosis of tinnitus. However, even assuming the Veteran was exposed to acoustic trauma during this training, the evidence of record does not support a finding that his current bilateral hearing loss and tinnitus are related to his exposure to acoustic trauma in service. The Veteran was afforded a VA examination in April 2013; however, the examiner determined that reliable test results could not be obtained for pure tone testing or speech recognition testing. The examiner noted that the Veteran reported having longstanding tinnitus with no specific date or circumstances of onset reported. The examiner also indicated that, although testing could not be performed, a review of the claims file suggested that hearing loss was less likely than not due to acoustic trauma in service because his enlistment and separation examinations did not show significant threshold shifts that would be indicative of hearing loss due to acoustic trauma. The examiner also noted that the Veteran did not identify a specific date or description of the circumstances of onset regarding tinnitus, but he did have medical history significant for high blood pressure, diabetes, and daily aspirin, which are risk factors for tinnitus. During a February 2020 VA examination, the examiner concluded that it was less likely than not that bilateral hearing loss was due to service. The examiner offered a detailed rationale and explained that a comparison of enlistment and separation audiograms revealed no significant in-service threshold changes. The examiner further explained that the thresholds measured while in service for the Veteran were within normal measurement variability and that one critical issue for determining whether hearing loss or tinnitus are related to noise exposure while in service is whether the Veteran had a significant threshold shift beyond normal measurement variability or normal progression while in service. The examiner further explained that behavioral measurements always involve some degree of variability and that such differences do not constitute injuries. The February 2020 VA examiner also explained that the current audiological evaluation revealed a bilateral, gradually sloping/flat sensorineural hearing loss at all frequencies, which is not a typical noise-induced audiometric configuration. In support of her opinion, the examiner referenced medical literature that noise-induced sensorineural hearing loss is typically greatest in the highest frequencies and least evident in the lower frequencies, often with a reasonably sharp transitional region between the affected and unaffected frequency regions. The configuration of hearing loss discovered upon examination was not that of noise-induced etiology. The February 2020 VA examiner also discussed existing medical literature that challenged Institute of Medicine findings that there was not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one's lifetime, long after the cessation of that noise exposure. The examiner explained that medical literature that challenges these findings do not overturn the conclusions of the Institute of Medicine. In addition, the February 2020 VA examiner opined that it was less likely than not that the Veteran's tinnitus was caused by military noise exposure. The examiner explained that his service treatment records were silent for tinnitus complaints and that there was no significant in-service threshold shift present; therefore, there was no evidence of an in-service noise injury. She stated that, in the absence of an objectively verifiable noise injury, the association between tinnitus and noise exposure cannot be assumed to exist. The February 2020 VA examiner further explained that tinnitus may occur following a single exposure to high-intensity impulse noise, long-term exposure to repetitive impulses, long-term exposure to continuous noise, or exposure to a combination of impulses and continuous noise. She then indicated that, to accept the Veteran's assertion that his exposure to noise in service caused his tinnitus, one would have to accept the scientifically unsubstantiated theory that tinnitus occurred as a result of some latent, undiagnosed noise injury. The examiner explained that the Institute of Medicine never stated that tinnitus could result from undiagnosed noise injuries. The examiner also added that, in most cases, tinnitus is accompanied by measurable hearing loss and that, although the audiogram is an imperfect measurement, it is nevertheless accepted as the objective basis for determining noise injuries. Finally, the examiner indicated that tinnitus may also develop in response to factors other than noise exposure. The Board finds that the February 2020 VA opinion is highly probative, as it was based on a review of the claims file and supported by thorough rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Significantly, the February 2020 VA audiologist compared the hearing test results during service to determine if a significant shift had occurred, considered the Veteran's post-service hearing results, and addressed delayed-onset hearing loss. The examiner also explained in detail why the findings from the Veteran's service audiograms did not constitute an objectively verifiable noise injury that could have caused his tinnitus and considered medical literature. The Board has also considered the Veteran's own lay statements that his current bilateral hearing loss and tinnitus are related to his military service. Although lay persons are competent to provide opinions on some medical issues, the specific issues in this case, the etiologies of hearing loss and tinnitus, fall outside the realm of common knowledge of a lay person, particularly in light of the delayed onset. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Moreover, even assuming that the Veteran is competent to provide such an opinion, the Board finds that the February 2020 VA examiner's opinion is more probative, as it was provided by a medical professional with knowledge, training, and expertise and is supported by a complete rationale based on such knowledge. The examiner also reviewed the claims file and considered the Veteran's reported history, as well as medical literature. Based on the foregoing, the weight of the competent, credible, and probative evidence does not show that the Veteran has current bilateral hearing loss and tinnitus that manifested in service or within one year thereafter or that are otherwise causally related thereto. Therefore, the Board finds that the preponderance of the evidence weighs against the claims and that service connection is not warranted for bilateral hearing loss and tinnitus. REASONS FOR REMAND Low Back Disorder The April 2019 remand directed the AOJ to obtain an opinion regarding the nature and etiology of the Veteran's back disorder. In the first opinion obtained in March 2020, the examiner erroneously stated that the Veteran was service-connected for a lumbosacral strain. In a subsequent July 2020 VA opinion, the examiner indicated that the Veteran's back disability was unrelated to service because there were no records to show that there was a diagnosed back condition or injury in service. The examiner also stated that the separation examination was silent for any diagnosed back injury or condition. However, service treatment records dated in June 1973 clearly document that the Veteran sought treatment for back pain after a fall and was diagnosed with lumbar strain. In addition, the Veteran's May 1973 separation examination took place before the Veteran's injury in service. Thus, the July 2020 VA opinion is inadequate, as it is based on an inaccurate factual premise. Accordingly, a remand is necessary to obtain an additional medical opinion addressing the nature and etiology of the Veteran's low back disorder. Acquired Psychiatric Disorder In the April 2019 remand, the AOJ was directed to obtain a medical opinion regarding the nature and etiology of the Veteran's acquired psychiatric disorder. In a February 2020 opinion, the examiner noted that the Veteran had a diagnosis of unspecified schizophrenia and other psychotic disorder with symptoms of auditory and visual hallucinations, recurrent manic-like episodes, and disturbances of mood. The examiner indicated that these symptoms would be consistent with a thought disorder, potentially schizoaffective bipolar type, but issues related to the reliability of self-report preclude providing further specificity beyond the unspecified schizophrenia spectrum and other psychotic disorder diagnosis at present. The examiner concluded that it was less likely than not that this disorder was due to service because service records were silent for mental health treatment in service. However, no other rationale was provided. Given the lack of specificity regarding the Veteran's diagnosis, as well as the incomplete rationale, the Board finds that a remand is necessary to obtain an additional medical opinion. The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for an acquired psychiatric disorder, to include PTSD, and a low back disorder, that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After the above development has been completed, the AOJ should obtain a medical opinion to determine the nature and etiology of any low back disorder that may be present. A physical examination is not needed unless the examiner determines that one is necessary. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examiner should opine as to whether it is at least as likely as not that the Veteran has a current low back disorder that is causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should address all relevant service treatment records, to include the June 1973 service treatment record that documented treatment for a lumbar strain. The examiner is also advised that the Veteran's May 1973 separation examination occurred prior to his June 1973 back injury. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. After completing the foregoing development, the AOJ should obtain a medical opinion that addresses the nature and etiology of any current acquired psychiatric disorder that may be present. An examination is not needed unless the examiner determines that one is necessary. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and the Veteran's own assertions. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all current acquired psychiatric disorders. If any previously diagnosed psychiatric disorder is not found on examination, the examiner should address the prior diagnoses of record and indicate whether they may have resolved or been misdiagnosed. For each diagnosis identified other than PTSD or a personality disorder, the examiner should state whether it is at least as likely as not that any acquired psychiatric disorder manifested in or is otherwise related to the Veteran's military service. In rendering this opinion, he or she should consider the July 2018 hearing testimony in which the Veteran described an in-service personal assault. If the Veteran is diagnosed with a personality disorder, the examiner should state whether there was a superimposed disease or injury that occurred during service. With respect to PTSD, the AOJ should provide the examiner with a summary of any verified in-service stressors, and the examiner should be instructed that only these events and any personal assault he or she determines to have occurred in service, may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. The examiner should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should address whether there is any relationship between the current disorder and any verified in-service stressor. The examiner should also state whether it is at least as likely as not that the Veteran has an acquired psychiatric disorder that was either caused or aggravated by any low back disorder. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. After the above development is completed, the AOJ should review the medical opinions to ensure that they are in compliance with this remand. If the reports are deficient in any manner, the AOJ should implement corrective procedures. 5. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Saikh, 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.