Citation Nr: 21041707 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 14-35 224A DATE: July 10, 2021 ORDER Entitlement to service connection for vertigo/dizziness/Meniere's Disease is granted. FINDING OF FACT It is as likely as not the Veteran's vertigo/dizziness/Meniere's Disease is attributable to his service. CONCLUSION OF LAW Resolving all reasonable doubt in his favor, the criteria are met for entitlement to service connection for vertigo/dizziness/Meniere's Disease. 38 U.S.C. § 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1992 to August 1996. This appeal to the Board of Veterans' Appeals (Board) is from an October 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified in support of this claim during a hearing before the undersigned Veterans Law Judge (VLJ) in January 2019. A transcript of the hearing is of record. In September 2019 and February 2021, the Board remanded this claim back to the RO for further development and consideration including for needed medical nexus opinions concerning the etiology of this claimed condition (irrespective of whether it is vertigo/dizziness, Meniere's disease, etc.), especially in terms of whether it is directly related to the Veteran's service or secondary to his already determined to be service-connected right ear hearing loss. Those remand instructions since have been completed, as directed. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions); but see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only "substantial" rather than strict or exact compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Entitlement to service connection for dizziness, claimed as Meniere's disease. The Veteran contends that his vertigo or dizziness is due to his military service, including especially owing to acoustic trauma he sustained in service that, in turn, was reason for determining the hearing loss in his right ear is attributable to his service (i.e., a service-connected disability). Alternatively, he asserts that his dizziness/vertigo is secondary to his service-connected right hearing loss, meaning caused or aggravated by it. Service connection may be granted on a direct basis for disability directly resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or an injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. See Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection also may be established on a secondary basis for disability that is caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310. See also Allen v. Brown, 7 Vet. App. 439 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran need only prevail under one theory of entitlement for a successful appeal, and, as will be discussed, the Board finds that service connection is warranted on a direct-incurrence basis. The Veteran has received several diagnoses involving the symptom of dizziness throughout the pendency of this appeal, including Meniere's Disease and Benign Paroxysmal Positional Vertigo (BPPV). See January 2019 Disability Benefits Questionnaire (DBQ); see also August 2020 VA examination. So, there is no disputing he experiences dizziness, i.e., this claimed condition despite these several different diagnoses said to be the underlying reason for it. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (discussing how to determine the scope of a claim and characterization of the alleged disability, focusing on the symptoms rather than a particular diagnosis). In addition, VA concedes acoustic trauma in service as service connection for his right ear hearing loss already has been established predicated on that injury. Therefore, the remaining question is whether the Veteran's dizziness is related or attributable to the conceded noise exposure and consequent injury (acoustic trauma) in service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). With the benefit of the doubt in his favor, the Board concludes there is indeed this correlation. A November 2016 VA treatment note indicates the Veteran had been feeling dizzy intermittently (on and off) for the past six to eight months, however, the Epley maneuver improved his condition. The VA examiner indicated it was most likely BPPV. The Veteran continued to report and seek treatment for dizziness in an October 2018 VA treatment note. After reviewing the Veteran's claims file, a private examiner opined in April 2019 that it is at least as likely as not the Veteran's service-connected hearing loss was the initial manifestation of his Meniere's disease. This private examiner reasoned that that Veteran entered military service with normal hearing and then developed right ear sensorineural hearing loss followed by tinnitus. This private physician added that the Veteran subsequently developed recurrent episodes of vertigo and a feeling of fullness in his right ear. This private examiner explained that Meniere's Disease is a multifactorial clinical disorder that manifests as recurrent, spontaneous, episodic vertigo accompanied by sensorineural hearing loss and either aural fullness or tinnitus in the affected side. This private physician thus concluded that the Veteran meets the criteria for Meniere's disease. This private physician also pointed out the Veteran's young age at diagnosis and the unilateral nature of his measured hearing loss are unusual and his medical history is consistent with the natural history of Meniere's Disease as, according to medical studies, hearing loss precedes the onset of vertigo by months to years in approximately 50 percent of cases. An April 2021 VA examiner conversely concluded that it is less likely than not that the Veteran's vertigo, BPPV, was caused by his exposure to loud noise during his military service. This April 2021 VA examiner reasoned that the Veteran developed symptoms of dizziness more than 15 years after his release from active duty. This VA examiner explained that medication induced dizziness would be more closely associated with the timing of the Veteran taking the drug and inconsistent only sporadic occurrence (3-4 times a month) and, similarly, the symptoms would resolve with discontinuation of the medication. This VA examiner added that it is extremely unusual, but that loud noise may cause acute symptoms of vertigo in some patients; on the other hand, remote exposure to loud noise is not a known cause of vertigo in any patient decades after the fact. This April 2021 VA examiner then goes on to surmise that the April 2019 private physician's opinion that the Veteran's Meniere's Disease began with the unilateral hearing loss in the Navy is inconsistent with the natural history of Meniere's Disease. The VA examiner reasoned that it typically begins, instead, in patients in their 40's (consistent with this case) and with low frequency hearing loss (see Meniere's Disease: Diagnosis, Natural History, and Current Management). This VA examiner pointed out the Veteran conversely had high-frequency, right-sided hearing loss in service with no symptoms of dizziness or tinnitus for many years after his release from active duty. According to this VA examiner, the Veteran's symptoms being relieved by the Epley maneuver is more consistent with BPPV. After considering these medical opinions that are both for and against the claim, the Board is unable to conclude that one necessarily is more probative than the other. Both opinions were provided by licensed medical professionals that are qualified to diagnose and provide probative opinion on the cause of dizziness, irrespective of whether in the guise of BPPV or Meniere's Disease. And, in this circumstance of relative balance of evidence for versus against a claim (equipoise), this reasonable doubt is resolved in the Veteran's favor and the claim granted rather than denied. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (indicating "absolute" etiology is not a condition precedent to granting service connection, nor is "definite" or "obvious" etiology). Rather, this need only be an "as likely as not" proposition, which in this instance it is for the reasons and bases discussed. KEITH W. ALLEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Hamm, 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.