Citation Nr: 21031313 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 19-26 340 DATE: May 21, 2021 REMANDED Entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from October 1965 to August 1969. This September 2019 appeal comes before the Board of Veterans' Appeals (Board) from a September 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), in Montgomery, Alabama. The Veteran was afforded a March 2021 Board hearing. This appeal has been advanced on the Board's docket. 38 U.S.C. § 7107(a)(2) (2012); 38 C.F.R. § 20.800(c) (2020). 1. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran contends that his bilateral hearing loss is due to excessive noise exposure during service as he worked on a flight deck with minimal hearing protection. During a September 2017 VA examination, the examiner diagnosed the Veteran with right ear sensorineural hearing loss and left ear mixed hearing loss. He stated that he could not provide an opinion regarding the etiology of the Veteran's right ear hearing loss without resorting to speculation because there was no audiogram at separation and he opined the Veteran's left ear hearing loss preexisted service and was aggravated beyond normal progression by his military service. Id. The Board finds the September 2017 VA examination to be inadequate as the VA examiner failed to consider all the relevant evidence of record prior to rendering his opinion, specifically the Veteran's report of trauma to his left ear and medical treatment for bilateral hearing loss immediately after service. The mere absence of treatment records should not be the sole basis for a negative opinion. See Dalton v. Nicholson, 21 Vet. App. 23, 40 (2007). In addition, although the Veteran's September 1965 enlistment audiogram indicated sensorineural hearing loss at a frequency range of 6000 Hz, this is not considered a hearing loss disability for VA purposes. 38 C.F.R. § 3.385. The Board finds the Veteran did not have a left ear hearing loss disability noted at entry to service. McKinney v. McDonald, 28 Vet. App. 15, 29 (2016). Therefore, the Board finds that the Veteran was sound as to the left ear at entrance to active duty in October 1965 and the presumption of soundness has not been rebutted. The issue is, therefore, one of in-service incurrence, not aggravation of a preexisting disability. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Therefore, the Board finds an additional medical examination is warranted before the claim can be adjudicated on its merits. Finally, the Veteran stated that he had been treating with a private ear, nose, and throat (ENT) physician, that he had multiple hearing tests and that the physician told him that his ear drums had a lot of scarring. See May 2017 VA Medical Treatment Records. Id. The Veteran testified in a March 2021 hearing that he began treating with his private ENT immediately after separation from service. However, to date, the Veteran has not provided the name of the physician, a release for medical records, or copies of the medical records. While on remand, the Veteran should submitted any additional evidence in support of his claim including private medical treatment records, or in the alternative, provide a signed medical release form identifying the treating physician so that VA may attempt to acquire the outstanding medical records. The matter is REMANDED for the following action: 1. Schedule the Veteran for an examination with an appropriate medical professional to determine the nature and etiology of the Veteran's bilateral hearing loss. The claims file must be made available for review, and the examination report should reflect that such review occurred. After reviewing the claims file and completing a physical examination of the Veteran, the examiner must: a. Discuss the Veteran's statements regarding his in-service symptoms and trauma including his left ear perforation during service and document the Veteran's contentions in the examination report. b. Provide an opinion for any hearing loss disability found on examination, as to whether it is at least as likely as not (50 percent or greater probability) that the disorder 1) began during active duty service; or, 2) is related to any incident/event of the Veteran's active duty service. c. Provide an opinion regarding the nature and etiology of the Veteran's left ear mixed hearing loss and which elements, if any, may be attributed to his military service. It should be noted that the Veteran is competent to attest to observable symptomatology. The examiner's attention is directed to the Veteran's statements concerning the in-service injuries and the onset of the claimed condition and the continuity of symptomatology he has experienced since service. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran's reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed should be provided as the Board is precluded from making medical findings. A discussion of the facts and the medical principles involved will be of considerable assistance to the Board, including citation to any supporting medical treatises. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Aubee, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.