Citation Nr: 21032517 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 16-38 499 DATE: May 27, 2021 REMANDED Entitlement to service connection for carpal tunnel syndrome of the left upper extremity is remanded. Entitlement to service connection for carpal tunnel syndrome of the right upper extremity is remanded. Entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1966 to May 1968. This case is before the Board of Veterans' Appeals (Board) on appeal from a January 2015 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that rating decision, the RO denied entitlement to service connection for carpal tunnel syndrome of the right and left upper extremities, and service connection for bilateral hearing loss. The Veteran's notice of disagreement (NOD) was received in May 2015. The RO issued the statement of the case (SOC) in July 2016, and the Veteran's VA Form 9, substantive appeal was received in August 2016. In November 2018, the Board remanded the issues on appeal, as well as the issue of entitlement to service connection for tinnitus for further development and adjudicative action. A rating decision issued in May 2020 awarded service connection for tinnitus. As such constitutes a full grant of the benefit sought on appeal with respect to that issue, it is no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). The remaining issues now return for further appellate review. 1. Entitlement to service connection for carpal tunnel syndrome of the left upper extremity. 2. Entitlement to service connection for carpal tunnel syndrome of the right upper extremity. The Veteran contends that he has current disabilities of carpal tunnel syndrome, in each upper extremity, which are related to service. Specifically, he reports that his duties during service required "a lot of hand/wrist activity [and his] pain was not too bad at the time but has worsened over the years and required surgery of both wrists." See May 2015 NOD. The Veteran was afforded a VA examination in December 2019 in connection with such claim. The examiner noted diagnoses of carpal tunnel syndrome in the bilateral upper extremities, but opined that the disabilities were less likely than not incurred in or caused by service. The examiner's rationale was as follows: After a thorough medical records review...The veteran reports that while in-service, he had other duties to perform, "clerical duties" in addition to his specialty: dental specialists...It is my opinion, there is a lack of evidence to support the veteran's claimed condition incurred in-service without resorting to speculation...Therefore, the veteran's left [and right] hand disabilities, including carpal tunnel syndrome, was less likely than not (less than 50% probability) that it had its onset in service, or within one year of his separation from service, or is otherwise related to service. Here, it appears the VA examiner based the unfavorable opinion solely on the absence of in-service treatment for carpal tunnel. This alone is an insufficient basis upon which to form a negative opinion; moreover, the examiner did not explain why the Veteran's lay statements concerning in-service onset and continuity of symptoms deserved lesser weight than the absence of in-service evidence. For those reasons, the Board finds additional remand is necessary to obtain an opinion which considers the Veteran's lay statements concerning the history of his symptomatology. 3. Entitlement to service connection for bilateral hearing loss. The Veteran contends that he has a bilateral hearing loss disability that is related to service, including as a result of in-service noise exposure. See, e.g. May 2015 NOD (asserting in-service exposure to "sirens, weapons and road noises while [accompanying] infantrymen during field training"). For the purpose of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels (dB) or greater; or when the auditory threshold for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 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. When audiometric test results at separation from service do not meet the regulatory requirements for establishing a "disability" at that time, a veteran may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155, 160 (1993). The threshold for normal hearing is from 0 to 20 decibels. Id. at 157. Historically, when interpreting audiometric data from service treatment records (STRs), it is important to note that service departments changed from using American Standards Association (ASA) standards, to using International Standards Organization American National Standards Institute (ISO-ANSI) standards when providing audiograms beginning at some point between approximately January 1, 1967, and December 31, 1970; however, the conversion date was not consistent between all branches of the Armed Forces. Accordingly, if the standard used is not clearly indicated on the service department audiogram(s), it is presumed that prior to January 1, 1967, the ASA standard was used. For in-service audiograms conducted between January 1, 1967, and December 31, 1970, where the standard used is unclear, the data under both ASA and ISO-ANSI standards will be considered. For in-service audiograms conducted after December 31, 1970, it is presumed that the ISO-ANSI standard was used. Converting from ASA standards to ISO-ANSI requires the following amounts be added to the recorded ASA audiological results: 15 dB at 500 Hz, 10 dB at 1000 Hz, 10 dB at 2000 Hz, 10 dB at 3000 Hz, and 5 dB at 4000 Hz. The Veteran's STRs include audiometric testing results taken at the time of the Veteran's entrance to service and again upon separation from service. In this regard, an entrance audiogram from May 1966 revealed the following pure tone thresholds in decibels (conversion in parentheses): HERTZ 500 1000 2000 3000 4000 RIGHT 15(30) 5(15) 15(25) -(10) 30(35) LEFT 15(30) 5(15) 5(15) -(10) 45(50) As such reflects the presence of left ear hearing loss as defined by VA regulations, the Veteran is not presumed sound upon entry to military service in regard to such disorder. 38 C.F.R. § 3.385. A separation audiogram from March 1968 revealed the following pure tone thresholds in decibels (conversion in parentheses): HERTZ 500 1000 2000 3000 4000 RIGHT 5(20) 5(15) -5(5) - (10) 5 (10) LEFT 0 (15) 5 (15) 10 (20) -(10) 0(5) In this case, it is unclear whether the March 1968 audiological testing results were recorded using American Standards Association (ASA) units or International Standards Organization-American National Standards Institute (ISO-ANSI) units. A March 1968 separation Report of Medical History shows that the Veteran endorsed a history of hearing loss. Pursuant to the Board Remand, the Veteran was afforded a VA hearing loss examination in November 2019. The associated report shows a current bilateral hearing loss disability for VA purposes. The VA examiner determined the Veteran's left ear hearing loss pre-existed service and then provided the opinion that the Veteran's hearing loss was less likely than not the result of military noise exposure as the medical records noted normal bilateral hearing at separation with significantly improved bilateral thresholds at 4000 Hertz; as such, the VA examiner found acoustic trauma was not indicated during service. Upon review, the Board finds it is unclear whether the VA examiner was aware of the results of the in-service examination audiograms when converted, as such demonstrate both improvement and degradation in the Veteran's hearing during service. In addition, the record shows the award of service connection for tinnitus was premised on the Veteran's exposure to "known sources of acoustic trauma" and based upon the VA examiner's rationale, it is unclear whether such exposure was acknowledged when providing the opinion. Consequently, the Board finds a remand is warranted for an addendum opinion addressing such matters. The matters are REMANDED for the following actions: 1. Forward the record to an appropriate clinician for an addendum opinion addressing the etiology of the Veteran's carpal tunnel syndrome of the bilateral upper extremities. The clinician must review the claims file and provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that Veteran's carpal tunnel syndrome of the bilateral upper extremities had its onset in, or is otherwise related to, his military service. In providing the opinion, the clinician must specifically discuss the Veteran's lay statements that his in-service tasks required significant wrist and hand use and he experienced pain during and since service. If the clinician rejects the Veteran's reports of his symptomatology, he or she must provide a reason for doing so. A complete rationale should be provided for all opinions. 2. Return the record to the audiologist who conducted the November 2019 VA examination, or an appropriate substitute audiologist if unavailable, for an addendum opinion to determine the nature and etiology of the Veteran's bilateral hearing loss. The entire claims file, including a copy of this Remand, must be made available to, and reviewed by, the audiologist. In particular, the conversion of the in-service audiograms from ASA to ISO-ANSI units should be provided to the audiologist for review. The audiologist should address the following: (A) Did the Veteran's pre-existing left ear hearing loss undergo an increase in severity during military service? If so, is there clear and unmistakable evidence that such increase in severity is due to the natural progress of the condition? (B) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's current right ear hearing loss had its onset in, or is otherwise related to, his military service, to include his acknowledged in-service noise exposure to ambulance sirens and high speed dental drills? In offering the above opinions, the audiologist must address the Veteran's lay statements regarding his in-service and post-service symptomatology. A complete rationale should be provided for any opinion offered. M. M. Celli Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. KAYS HUKILL 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.