Citation Nr: 21032103 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 14-27 981A DATE: May 25, 2021 REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for a low back disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1984 to August 1987. This case comes before the Board of Veterans' Appeals (Board) from an August 2011 rating decision by the Department of Veterans Affairs (VA). A hearing was held before the undersigned Veterans Law Judge in October 2017. A transcript of the hearing is of record. In an April 2018 decision, the Board reopened the bilateral hearing loss and tinnitus claims and remanded the above claims, as well as a claim for service connection for an acquired psychiatric disorder, for further development. The agency of original jurisdiction (AOJ) granted the acquired psychiatric disorder claim in a January 2021 rating decision while the case was in remand status, and that is a full grant of the benefit sought on appeal. The case has since returned to the Board for appellate review. On review, the Board finds that additional development is necessary prior to final adjudication of the Veteran's claims. The AOJ did obtain various records in response to the Board's prior remand. Nevertheless, it does not appear that a search for any actual audiological testing results corresponding to VA treatment records was conducted, and this information may be useful given the outcome of the November 2019 VA examination. See also November 2020 clarifying medical opinion (examiner determined etiology opinion for hearing loss and tinnitus could not be provided without resort to speculation based on the invalid testing results on examination). Regarding the low back disorder claim, the AOJ has acknowledged the occurrence of the March 1985 in-service helicopter incident and ordered a VA back examination based on that event. See November 2019 VA examination request; January 2021 rating decision (granted service connection for mental health disability based on that event). The November 2019 VA examiner determined that it was less likely than not that the claimed disorder was incurred in or caused by the claimed in-service injury, event, or illness. In so finding, the examiner noted that the in-service condition was acute only without complaints of or care for low back pain from 1985 to 1990. Nevertheless, it is unclear if the examiner considered the complete history of the development of the disorder, inasmuch as she noted that the Veteran reported multiple back surgeries but also noted that the claims file did not contain operative reports or post-surgical visit treatment records. The claims file does contain such records. Based on the foregoing, an additional VA medical opinion is needed. The AOJ will also have an opportunity to review the records it added to the claims file since the January 2021 supplemental statement of the case in connection with the claims while the case is in remand status. The case is REMANDED for the following actions: 1. Obtain any outstanding VA audiological testing results contained in the Computerized Patient Record System (CPRS) Tools/Vista Imaging, Quasar, or other database, including from the September 2007 audiology consultation. It is also noted that the Veteran requested another audiology consultation during a May 2019 psychiatric treatment appointment, indicating a possibility of more recent VA audiological testing results in updated treatment records. All attempts and responses should be documented in the claims file. 2. Refer the Veteran's claims file to a VA examiner for a clarifying opinion as to the nature and etiology of any current low back disorder that may be present. An additional examination of the Veteran should only be performed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment and personnel records, post-service medical records, and statements. The examiner should identify all current low back disorders. For each diagnosis identified, the examiner should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to the Veteran's military service, including any injury therein. The Veteran has contended that his low back problems are the result of a progressive process that began during service when he was injured in March 1985 as the result of the helicopter in which he was a passenger dropping hundreds of feet multiple times while heading to shore. He has indicated that he slipped exiting the helicopter after it landed due to a slippery floor from spilled fluid and the weight of his gear, hitting his back on a rock. See October 2017 Bd. Hrg. Tr.; December 2019 VA examination report. The post-service evidence shows that the Veteran also sustained an injury in 1989 when he fell off a ladder at work. During a November 1996 Social Security Administration (SSA) evaluation, he was noted to have had a microscopic discectomy in the cervical and lumbar spine in 1990 after that injury, and other records document subsequent complaints, back surgeries, and other treatment. See, e.g., private operative reports from August 2008 and August 2011; July 1997 civil service examination report and report of medical history; VA treatment records from March 2001 (MRI reports), March 2003. The referenced treatment records are contained in June 2011, October 2011, June 2013, July 2019, and September 2019 claims file entries. In providing this opinion, the examiner should discuss medically known or theoretical causes of any currently diagnosed disorder and describe how such a disorder generally presents or develops in most cases, in determining the likelihood that the current disorder is related to in-service events as opposed to some other cause. 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. 3. After the above VA records are obtained to the extent possible, consider whether a new VA examination or VA medical opinion is needed for the bilateral hearing loss and tinnitus claims, including to address whether the currently reported tinnitus is caused by or otherwise related to any current hearing loss. See November 2019 VA examination report and November 2020 clarifying medical opinion; September 2007 VA audiological consultation treatment record. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Postek, 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.