Citation Nr: 21031488 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 18-55 155 DATE: May 24, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for an acquired psychiatric disorder other than PTSD, including generalized anxiety disorder and major depressive disorder, is denied. REMANDED Entitlement to service connection for pulmonary disability other than asthma and chronic bronchitis, to include pansinusitis and allergic rhinitis, is remanded. Entitlement to service connection for bilateral otosclerosis status post (s/p) stapedectomy is remanded. Entitlement to service connection for hypertension, to include hypertensive heart disease and grade 1 diastolic dysfunction, to include as due to exposure to herbicide agents, is remanded. Entitlement to service connection for bilateral hearing loss is remanded. FINDING OF FACT The more persuasive evidence does not support a diagnosis of PTSD or any other psychiatric disability at any time during or approximate to the pendency of the Veteran's claim. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disability, to include PTSD, anxiety, and depression, are not met. 38 U.S.C. §§ 1110, 5103, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.655. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service in the U.S. Army from October 1965 to October 1967, including active service in the Republic of Vietnam. His service awards include the Combat Infantry Badge and the Purple Heart Medal. These matters initially came before the Board of Veterans' Appeals (Board) from an October 2018 rating decision. The matters on appeal were initially before the Board in May 2019. The May 2019 Board decision reopened the previously denied claims of service connection for bilateral hearing loss, tinnitus, bronchitis, and hypertension; denied service connection for dyslipidemia; and granted service connection for bronchitis and tinnitus. It also remanded the claims of service connection for otosclerosis, bilateral hearing loss, a pulmonary disability, depression, and hypertension for further evidentiary development. First, the Board instructed the agency of original jurisdiction (AOJ) to obtain the Veteran's outstanding VA medical records. Then, the AOJ was to schedule the Veteran for VA examinations to determine the nature and etiology of his claimed disabilities. Pursuant to the Board's remand, all outstanding VA treatment records were obtained and associated with the claims file and the Veteran had VA examinations in November 2020, December 2020, and January 2021. Specifically, a VA psychiatric examination was conducted in November 2020 and the examination appears to be adequate. Therefore, the AOJ substantially complied with the Board's remand instructions with respect to the claims of service connection for PTSD and psychiatric disability other than PTSD. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). However, as explained in more detail below, the opinions obtained pursuant to the Board's May 2019 remand that pertain to the service connection claims for hypertension, otosclerosis, bilateral hearing loss, and a respiratory condition are not adequate and do not substantially comply with the 2019 remand directives. Therefore, those claims must be again remanded, as explained below. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stegall, 11 Vet. App. at 271. Subsequent to the 2019 Board grant of service connection for tinnitus and bronchitis, in a May 2020 rating decision, tinnitus was granted with a 10 percent evaluation, effective June 2, 2018, and chronic bronchitis and bronchial asthma, claimed as chronic pneumonia, was granted with a noncompensable rating, effective June 2, 2018. Thereafter, in July 2020, the Veteran filed a claim for higher level review for the evaluations of the granted claims, and in a February 2021 rating decision, the AOJ granted service connection for asthma to include the chronic bronchitis, with an evaluation of 30 percent, effective June 2, 2018. Therefore, these claims are no longer before the Board. The Veteran has not raised any issues with the duty to notify or duty to assist in obtaining documentary evidence. 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). Thus, the Board need not discuss any potential issues in this regard. Service Connection for psychiatric disability, to include PTSD The Veteran contends that he has a current psychiatric disorder, to include PTSD, anxiety, and depression, caused by his combat service when serving in Vietnam. However, for service connection to be warranted, a current psychiatric disorder must be diagnosed, and must be found to relate back to such incidents of service. Specifically, 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. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition to the elements of service connection stated above, with respect to PTSD in particular, the regulations provide: "Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with § 4.125(a) of this chapter; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred." See 38 C.F.R. § 3.304(f); Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. Gilbert, at 53. The question for the Board is whether the Veteran has any current psychiatric disabilities that began during service or are at least as likely as not related to an in-service injury, event, or disease. Upon review, the Board finds that the evidence of record does not show that the Veteran experiences any current psychiatric disability, and has not experienced any such disability at any time since his service connection claim was received in June 2018 or prior thereto. Cf. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (Board erred in failing to address pre-claim evidence in assessing whether a current disability existed, for purposes of service connection, at the time the claim was filed or during its pendency); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). A review of the Veteran's VA and private treatment records also reveal no adequate diagnosis of or treatment for a psychiatric disorder that is attributable to service. First, the Veteran's service treatment records (STRs) reveal no complaints, treatment, or diagnosis pertinent to an acquired psychiatric disorder. At service separation in October 1967, the Veteran marked "no" to any conditions or issues and it was noted he did not have any significant abnormalities; he specifically reported that he had no history of, or current depression, excessive worry, or nervous trouble of any sort. When examined at service separation, the Veteran was found to be psychiatrically normal. After service, there are no records of treatment for any mental health issues for several decades. Significantly, there is no confirmed manifestation of a mental illness to a degree of 10 percent or more within one year of service separation. Further, in July 1990, the Veteran filed claims of service connection for, in part, pneumonia and high blood pressure; but he did not report or indicate any mental health conditions. He also submitted private medical records from between 1981 and 2003, which consistently indicated he had no mood disorder and he was consistently noted to be calm, alert, and oriented. The first indication for a psychiatric disorder was in April 2018, with a provisional diagnosis for PTSD; however, this is not a valid diagnosis as it was not done by a mental health specialist. Specifically, in an April 2018 private medical letter, a private doctor stated the Veteran met all the diagnostic criteria for PTSD and that it is "more probable than not secondary to his military service performance" but does not state specifically why; rather, he simply stated 'refer to' medical records with no clear explanation or discussion. Additionally, one of the medical records the examiner pointed to states the Veteran "was found to be alert, cooperative, oriented." Further, as noted above, the Veteran had not previously mentioned any PTSD-related symptoms during his prior visits with his doctors. That notwithstanding, the Veteran has stated that he has nightmares and flashbacks due to his combat service in Vietnam. See April 2018 statement, wherein the Veteran first reports that he was in direct fights while in Vietnam and that he has trouble sleeping due to flashbacks because of this and requested a VA examination. Therefore, the provisions of 38 U.S.C. § 1154(b) are applicable in this case, which state, in pertinent part, that in any case where a veteran is engaged in combat during active service, lay or other evidence of service incurrence of a combat related disease or injury will be considered sufficient proof of service connection if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence during service, and, to that end, VA shall resolve every reasonable doubt in favor of the Veteran. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the presumption found in § 1154(b) applies not only to the potential cause of a disability, but also to whether a disability itself was incurred while in service. Reeves v. Shinseki, 682 F.3d 988, 999 (Fed. Cir. 2012). The combat presumption, however, does not alleviate the requirement that the evidence show a current disability, and if it is attributable to the past in-service disorders, but rather the provisions of § 1154(b) can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See, e.g., Dalton v. Nicholson, 21 Vet. App. 23 (2007) As such, the Board acknowledges the Veteran's combat service and concedes that he may have experienced incidents in service that potentially could have affected his mental health; however, for the reasons discussed herein and below, the evidence indicates that he has not had any psychiatric disability at any time during or approximate to the pendency of his claim. For example, in August 2018, he had an initial PTSD evaluation with a VA examiner. Following a complete examination, the examiner opined the Veteran does not have a mental health disorder. During the evaluation, the Veteran reported that he was referred for psychiatric evaluation during active duty after he was assaulted and pushed by his sergeant onto the floor and he was punished. He also reported that he saw children shooting rifles, that he saw many deaths, and that when he thinks about this, he gets nervous. He stated that he has been unable to sleep and yells and has had nightmares frequently since he returned from Vietnam, and that he gets angry and violent. However, the examiner noted that while the Veteran was exposed to actual or threatened death and has reported recurrent distressing dreams of these reported traumatic events, he did not meet the criterion for any other section. Further, the examiner opined that "it is noteworthy to mention that, although Veteran complains about sleep difficulties, available claims file and VA records are silent for this complaint." As such, the examiner opined that there was no criteria for any mental health diagnosis during the examination, and noted that the Veteran has been able to maintain a stable family and employment after discharge from service. Following the 2019 Board remand, the Veteran was afforded a VA examination in November 2020. The 2020 examiner also determined that the Veteran's reported symptoms do not meet the diagnostic criteria for PTSD, and he does not have any other mental health disorder. The examiner acknowledged and considered the evidence, to include the April 2018 private examiner's opinion and the August 2018 VA examination report and opinion, and stated that "after reviewing the available medical records and conducting a clinical interview with the Veteran, it can be concluded that there is no current evidence of symptoms related to [PTSD]." The examiner noted the Veteran's reports of having experienced stressful events during service in Vietnam, such as "having observed children walking with weapons and having experienced fear of having to act against the lives of those children if his own life were in danger, recognizing that some colleagues found themselves in the situation of having to shoot at other children." But the examiner noted that during the evaluation, the Veteran "did not report recurrent or involuntary "distressing memories" related to stressful events, nor does he report experiencing dreams that cause distress whose content is related to stressful events." The examiner also noted that the Veteran does not have or report any negative cognitive or mood alterations associated with the reported stressful event, "nor is there any significant alteration in alertness or reactivity associated with the stressful events that he observed and experienced during his military service." The examiner also opined and determined that there is no objective evidence that the Veteran has either major depressive disorder or generalized anxiety disorder. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In this case, the 2018 and 2020 examiners examined the Veteran, were aware of his medical history, provided fully articulated opinions, the 2020 examiner considered the conflicting evidence as requested in the 2019 Board remand, and both examiners furnished a reasoned analysis for the conclusions made. The 2018 and 2020 examiners also accepted the circumstances of the reported in-service events, but still found the Veteran does not have a current psychiatric disability. The Board therefore attaches significant probative value to these opinions. There are no other competent medical opinions to the contrary. Specifically, although the Board acknowledges the 2018 private medical opinion as discussed above, VA regulations state that if a veteran's claimed stressor is related to fear of hostile military or terrorist activity and is adequate to support a diagnosis of PTSD, it must be confirmed by a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted. This private medical professional is not a VA examiner or VA contracted examiner and although he has provided a diagnosis of PTSD, the diagnosis is not adequate for rating purposes. See 38 C.F.R. § 3.304(f)(3). As such, the Board finds that there is no confirmed diagnosis of PTSD based on fear of hostile military activity. Further, as noted above, the AOJ ordered two VA examinations to evaluate the claim and determine whether a diagnosis for PTSD or another psychiatric disorder is warranted, and both VA examiners have determined the Veteran does not have a diagnosis for PTSD, nor does he have a diagnosis for any other psychiatric condition. Additionally, there is no medical opinion that purports to relate the claimed current psychiatric disorders to service or whether the Veteran has a diagnosis for a psychiatric disorder. For example, in his VA medical records between 2003 and December 2018, he did not report, or he denied, any depression or anxiety. In a December 2018 assessment, it was noted he was oriented, calm, and had appropriate affect and that he did not show signs of being anxious, flat, or depressed and he scored negative for any depression. He returned in January 2019 reporting having anxiety. In the January 2019 consultation for the reported anxiety disorder, depression, and PTSD, it was noted that the Veteran reported being nervous "all the time...has been like this all of his life." He reported trouble sleeping and that he has flashbacks to war but could not give any information regarding the reported enemy engagement. The doctor provisionally diagnosed him with major depressive disorder and anxiety as his anxiety and depression scales indicated that he has mild to moderate anxiety and depression. However, the examiner also noted that "information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities." As such, in February 2019, the Veteran was referred for an initial psychiatric evaluation for anxiety and sleep disturbance. During the assessment, he reported that he has had depression since being discharged from service and that it has worsened but cannot remember when it became worse. He stated he has trouble sleeping due to nightmares, but also says he has to get up to void 2-3 times a night. He reported having anxiety "but could not state why." His self-reported assessment indicated moderate anxiety and depression. Regardless, the examiner stated the Veteran's symptoms are more consistent with unspecified personality disorder. The examiner noted that the Veteran "complained of suffering "severe depression", though has never had psychiatric treatment, also complained of having nightmares, but when asked to give specific details of his symptoms was vague." The examiner stated that the results of the self-administered depression and anxiety scales were discussed with the Veteran and stated that the results "fall within the moderate range for depressive symptoms and severe for the anxiety ones. However, these do not correlate with the clinical interview." The examiner opined that rather, "it seems his main problems is characterological in nature." As such, the only diagnosis rendered has been from the February 2019 VA doctor for an Unspecified Personality Disorder. Further, more recent records show that the Veteran denied having depression and depression screens were negative; for example, in October 2020, it was noted he did not have any neuropsychiatric conditions. Additionally, as discussed above, private medical records between 1981 and 2003 show he denied any psychiatric conditions and it was consistently marked that he was calm, alert, oriented, and had no mental health disorders. As noted above, the existence of a current disability is the cornerstone of a claim for VA disability compensation. See 38 U.S.C. § 1110, 1131; see Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer, 3 Vet. App. 223, 225. While the Board recognizes the Veteran's assertions that he has an acquired psychiatric disorder that is related to service and is competent to testify as to events that occurred in military service, the Veteran is not competent to diagnosis himself with a psychiatric condition. Although lay persons are competent to provide opinions on some medical issues, the specific disabilities in this case, psychiatric disorders, fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Board finds that the Veteran's statements of record cannot be accepted as competent evidence sufficient to establish a disability or to establish service connection for his claimed psychiatric disabilities. Further, although the Board has considered the Veteran's statements, in weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). Here, the Board finds that his statements are not as probative as the VA examiners' opinions, as they are outweighed by the remainder of the evidence of record and were made under circumstances indicating bias or interest as he consistently denied or did not report any symptoms of depression or anxiety prior to filing a claim for service connection, despite stating he has been depressed since separation from service. Importantly, although the Veteran reported that he had combat service in Vietnam which caused his claimed PTSD, anxiety, and depression; his statements as to his service were inconsistent and vague and at one point he stated it was due to being pushed by a sergeant, and other times he reported having flashbacks due to his time in service seeing children with rifles, but did not elaborate or provide more information. Further, his military personnel records do not indicate he was ever sent for a psychiatric evaluation, as he stated during the 2018 VA examination. These inconsistencies weigh against his claim, as well as his more contemporaneous medical records which are far more credible than the statements he makes now, since it is reasonable to expect he would report an inability to sleep due to consistent nightmares since service to his medical providers. Although he states he has had depression ever since service, the fact is the Veteran himself consistently reported not having any mental health issues for several decades after service. In sum, the Veteran's statements regarding his mental health history are inconsistent and not as credible as the aforementioned medical evidence. Accordingly, while the Veteran's contentions have been considered, his statements are outweighed by the remaining evidence of record. Finally, the Board also acknowledges the 2021 statement from the Veteran's representative, requesting that "it should be accepted this is a Combat Veteran and his Purple Heart and Combat infantry badge should demonstrate he was in actual combat" and that this should be taken into account. As discussed in detail above, this was considered, and the Veteran was provided two VA examinations to consider this. Again, as noted above, the combat presumption does not alleviate the requirement that the evidence show there is a current disability which is attributable to the past in-service event, but rather the provisions of § 1154(b) are used only to provide a factual basis upon which a determination could be made that an event incurred in service, not to link the claimed disorder etiologically to a current disorder. While it is not disputed that the Veteran is a combat Veteran, the Board may not automatically presume a veteran has a current disorder by virtue of being a combat veteran here, the preponderance of the evidence indicates that the Veteran does NOT have a current psychiatric disorder (emphasis added). In sum, the Board finds that the Veteran does not have a diagnosis for PTSD. Moreover, and in the alternative, competent medical evidence does not show that he has any other current acquired psychiatric disorder, including depression or an anxiety disorder. In light of these findings, the Board concludes that service connection for an acquired psychiatric disorder of any description is not warranted. In reaching this conclusion, the Board considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable, and service connection for psychiatric disability, to include PTSD, is not warranted. See 38 U.S.C.§ 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. REASONS FOR REMAND Although the Board sincerely regrets the additional delay, a remand is necessary to afford the Veteran due process of law and to ensure that there is a complete record upon which to decide the Veteran's appeal, so that he is afforded every possible consideration. See 38 U.S.C. § 5103a; 38 C.F.R. § 3.159. 1. Entitlement to service connection for allergic rhinitis. First, the Board notes that the Veteran underwent a VA examination for his sinusitis/rhinitis in January 2021, wherein he was diagnosed with allergic rhinitis and it was noted the onset was about 20 years ago. However, the examiner again failed to provide an opinion as to whether there was any association between the Veteran's period of service and his noted history of allergic rhinitis. Rather, the examiner made a conclusory statement lumping in all of the claimed conditions that it is "less likely than not due to /related to military service as there are no medical records located for review noting these conditions in service, therefore a nexus/chronicity cannot be established." Once VA undertakes a duty to provide a medical examination, due process requires an adequate medical opinion. Barr, 21 Vet. App. 303, 311. Consequently, a remand is necessary for an opinion, and the opinion provider MUST provide adequate rationale for any opinion rendered. Further, the Veteran is now service-connected for asthma with chronic bronchitis; therefore, an opinion is needed to determine if there is similar symptomatology and, if not, whether the Veteran's service-connected asthma with bronchitis caused or aggravated his non-service-connected rhinitis. Also, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the VA Caribbean Healthcare System and are dated to January 2021. Any VA treatment records are within VA's constructive possession, and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). See also Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (confirming the holding in Sullivan). A remand is required to allow VA to obtain them. 2. Entitlement to service connection for bilateral otosclerosis. In the 2019 Board remand, the Board requested an examination to assess whether the Veteran's otosclerosis is a congenital defect or disease for which service connection may still be granted for any superimposed disability or aggravation which occurred as due to military service. The January 2021 VA examination report noted that the otosclerosis is congenital. However, the corresponding medical opinion indicated that the Veteran's otosclerosis "clearly and unmistakably existed prior to service, [but] was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness." The rationale was that there is no medical evidence to support that there was aggravation while in service due to normal hearing tests at induction into service and at separation. However, this is a conclusory and contradictory opinion. The examiner stated that otosclerosis "is a congenital defect as it means that one of the 3 bones of the middle ear does not transmit sound waves well. Hence it would have had to exist pre-service", but then stated the records do not support pre-existing hearing loss and that the Veteran's hearing was normal at entrance and separation. Finally, the examiner did not properly consider that aggravation means an increase in disability beyond the natural progression. Further, despite explicitly being asked to do so, the examiner did not take into account the 1967 medical report in the Veteran's STRs where he reported having difficulty hearing. Finally, the Veteran's private medical records show that he was diagnosed with hearing loss in both ears in 1981, and he reported having hearing issues since his military service. As such, an addendum opinion is required. Also, all outstanding VA treatment records should be secured upon remand. 3. Entitlement to service connection for bilateral hearing loss. As part of the 2019 remand directives, the Board instructed the AOJ to obtain an adequate medical opinion regarding the etiology of the Veteran's bilateral hearing loss. Specifically, the examiner was asked to determine whether the bilateral hearing loss is associated with the claimed otosclerosis, or if the bilateral hearing loss is not deemed an aggravation of the Veteran's otosclerosis, the examiner was asked to opine whether it is at least as likely as not that the bilateral hearing loss was incurred in, or was aggravated by active military service, including the Veteran's accepted history of in-service noise exposure. Unfortunately, the resulting November 2020 examination is inadequate, and the January 2021 opinion failed to include a sufficiently detailed rationale on the etiology of the Veteran's bilateral hearing loss. Instead, the VA examiner simply noted that the Veteran's in-service and separation audiometric tests were normal, stating that "noise exposure from the in-service does not, in medical literature, cause hearing loss years later. Previous hearing tests during and after service were within normal limits." The examiner did not address the Veteran's lay statements, conceded in-service noise exposure, or the possibility of delayed-onset hearing loss. It is well-established in caselaw that a finding of normal hearing acuity at separation does not preclude a finding of entitlement to service connection for hearing loss. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Importantly, while the 2018 VA examiner opined the Veteran had post-service noise exposure, the 2020 examination report indicated he had no post-service noise exposure. As such, the Board finds that the 2020 opinion remains insufficient upon which to decide the claim. If, essentially, the VA examiner is disputing the notion of "delayed-onset" hearing loss, hence, the reason for finding it significant the Veteran did not have indication of hearing loss when separating from service, there must be more explanation for this conclusion. Further, the examiner was asked to opine whether the Veteran's otosclerosis aggravated the Veteran's hearing loss. The examiner stated that "otosclerosis is a genetic condition which can cause hearing loss" but then gave conclusory opinions as to the otosclerosis (see above). Additionally, the 2021 examiner who provided these opinions is not the 2020 examiner who conducted the audiological examination; importantly, the 2021 examiner stated several times that "the hearing loss is best evaluated by the audiologist on the audio exam", but the audiologist did not provide any opinions. Finally, the 2020 examination is not adequate for rating purposes because the examiner was unable to obtain sufficient information due to a language barrier. As such, the Board finds that another VA examination conducted in Spanish and English, if possible, is warranted. Also, all outstanding VA treatment records should be secured upon remand. 4. Entitlement to service connection for hypertension. Finally, although the 2021 examiner gave an opinion that the Veteran's hypertension is less likely than not due to service, there was no adequate opinion regarding his conceded exposure to herbicide agents. Rather, the examiner stated that "the NIH document has been considered and there is no established peer reviewed medical link between development of hypertension, hypertensive heart disease and grade I diastolic dysfunction and exposure to herbicides." However, this is not adequate. The Veteran has a diagnosis of hypertension and it has already been conceded that he had exposure to Agent Orange in Vietnam. Further, the examiner was requested to consider the most recent National Institute of Health Agent Orange update: that hypertension was moved from the "limited or suggestive" category to the category of "sufficient" evidence of an association. Veterans and Agent Orange: Update 11 (2018). As such, an addendum opinion to take into consideration the changes in medical knowledge illustrated by the moving from the "limited or suggestive" category to the category of "sufficient" evidence of an association between hypertension and Agent Orange is required. Also, all outstanding VA treatment records should be secured upon remand. The matters are REMANDED for the following action: 1. Obtain the Veteran's outstanding VA treatment records from the VA Caribbean Healthcare System for the period since January 2021; and all such relevant records from any other sufficiently identified VA facility. 2. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, request an opinion from the January 2021 examiner, or another appropriate clinician if that examiner is not available, for the Veteran's allergic rhinitis. The entire claims file, including a copy of this remand, must be made available to and be reviewed by the clinician. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The clinician is asked to opine: (a.) whether it is at least as likely as not that any allergic rhinitis experienced by the Veteran since approximately June 2018 (1) began during service; OR (2) is related to an in-service injury or disease, including from conceded herbicide agent exposure and the Veteran's chronic pneumonia in service? (b.) whether it is at least as likely as not that any allergic rhinitis experienced by the Veteran since approximately June 2018 (1) was caused by service-connected asthma and chronic bronchitis; OR (2) was aggravated by service-connected asthma and chronic bronchitis. For purposes of the above opinions, the clinician shall presume that any reports by the Veteran of respiratory problems in service are accurate. Rationale must be provided for the opinions proffered. If the examiner determines that a requested opinion is not possible without resort to mere speculation, then the examiner must explain why. 3. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an updated VA examination conducted in Spanish, if at all possible, for an adequate audiological examination with English translation. Then, request an opinion to address the etiology of the Veteran's bilateral hearing loss. The claims file, including a copy of this remand, must be provided to the examiner in conjunction with the requested opinion. After a complete review of the electronic claims file, the examiner must provide an opinion to the following: (a.) is it clear and unmistakable (obvious, manifest, undebatable) that the deemed preexisting otosclerosis disability was not aggravated (did not increase in severity) beyond its natural progression during service? The examiner should specifically cite to any evidence that supports the opinion and note the 2020 examiner's opinion that the otosclerosis is a congenital condition that pre-existed service. An opinion that the condition was not aggravated by service means it did not undergo an increase in severity or, if so, any such increase was due to the natural progression of the condition. If the otosclerosis is found to have been aggravated by service, the examiner is then asked to opine whether: (a.) the Veteran's bilateral hearing loss is at least as likely as not proximately due to the otosclerosis? (b.) the Veteran's bilateral hearing loss is at least as likely as not aggravated by the otosclerosis? The examiner should cite to any evidence to support the opinions. The examiner is advised that for opinions regarding aggravation by service-connected disabilities, a "permanent" worsening or increase in severity of the bilateral hearing loss is NOT required to demonstrate "aggravation." Rather, aggravation is shown if there is any incremental increase in disability, meaning any additional impairment of earning capacity above the degree of disability existing before the increase, in a nonservice-connected disability resulting from a service-connected disability, regardless of its permanence. If bilateral hearing loss is not deemed an aggravation of the Veteran's otosclerosis, the examiner should provide the following opinion: Is it at least as likely as not that the Veteran's bilateral hearing loss (1) began during service; (2) manifested within one year after discharge from service; or (3) is related to an in-service injury or disease, including from conceded noise trauma? For purposes of the above opinions, the examiner shall presume that any reports by the Veteran of ear and hearing problems in service are accurate. The examiner must discuss the possibility of delayed-onset hearing loss and may not rely solely on normal audiometric findings at separation to support the opinion. The examiner should also consider that the Veteran served as an Assistant Gunner/Mortarman and reported exposure to firearms, explosions, bazookas, mortars and M16s; that hearing protection was not provided; reported he was involved in combat activity in Vietnam for 10 months; that in 1967, he reported difficulty hearing; the 2020 examination report that indicated he has not had post-service noise exposure; the July 1981 private audiological examination which noted mild to moderate hearing loss in both ears and that the Veteran reported he has had hearing loss since his military service during that 1981 examination; his reports of continuous hearing loss since service separation and his private records indicating hearing loss; and the fact that the Veteran is now service-connected for tinnitus. Obtain English language translations for any documents that are in Spanish. All English translations must be associated with their respective Spanish originals in the claims file. Rationale must be provided for the opinions proffered. If the examiner determines that a requested opinion is not possible without resort to mere speculation, then the examiner must explain why. 4. After al efforts have been exhausted to obtain and associate with the claims file any additional treatment records, request an addendum medical opinion from the 2021 examiner (or to another appropriate VA clinician if that person is no longer available) for the Veteran's hypertension, hypertensive heart disease and grade I diastolic dysfunction. The clinician must note his or her review of the complete claims file, including this remand. Then, the clinician should opine as to the following, with full supporting rationales: Is it at least as likely as not that any hypertension, hypertensive heart disease, and grade I diastolic dysfunction experienced by the Veteran since approximately June 2018 (1) began during service; (2) manifested within one year after discharge from service; OR (3) is related to an in-service injury or disease, to include presumed exposure to herbicide agents therein? For purposes of the above opinion, the clinician shall presume that any reports by the Veteran of symptoms in service are accurate. The clinician must provide a complete rationale for any opinion set forth and must specifically address appropriate medical literature, to include but not limited to, the findings by VA and the Institute of Medicine that there is "sufficient" evidence of a relationship between Agent Orange and hypertension. The clinician is advised that the fact that hypertension is not listed as a presumptive disease cannot be the sole rationale of an opinion, but rather the circumstances of this Veteran's specific case should be considered. Rationale must be provided for the opinions proffered. If the clinician determines that a requested opinion is not possible without resort to mere speculation, then the clinician must explain why. Brian J. Elwood Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G.Hoy, 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.