Citation Nr: 21042802 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-24 830 DATE: July 13, 2021 ORDER Entitlement to service connection for a right foot condition is denied. Entitlement to service connection for migraine headaches is granted. Entitlement to service connection for a neck condition is denied. Entitlement to service connection for a back condition is denied. Entitlement to a compensable rating for hearing loss is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include depressive disorder, is remanded. Entitlement to service connection for a head laceration or injury is remanded. Entitlement to a total disability based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran had a right foot condition that began during active service or is otherwise related to an in-service injury or disease. 2. The Veteran's migraine headaches are proximately due to his service-connected tinnitus. 3. The Veteran's cervical osteoarthritis was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 4. The Veteran's lumbar osteoarthritis was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established or is attributable to intercurrent causes; and the disability is not otherwise etiologically related to an in-service injury or disease. 5. The Veteran's bilateral hearing has been manifested by hearing acuity of no worse than Level II in the right ear and no worse than Level II in the left ear. CONCLUSIONS OF LAW 1. The criteria for service connection for a right foot condition are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for migraine headaches as secondary to service-connected tinnitus are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for a neck condition are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for a back condition are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1968 to July 1970, and in the United States Marine Corps from August 1972 to July 1974. The Veteran died in April 2020; the Appellant, his surviving spouse, was properly substituted in June 2020. These matters come before the Board of Veterans' Appeals (Board) on appeal from March 2012 and November 2014 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The issues were remanded in October 2018 for additional development. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may also be granted on a secondary basis for a disability that is proximately due to or the result of an established service-connected disorder. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability either (a) was caused by or (b) is aggravated by a service-connected disability. See 38 C.F.R. § 3.310 (a); Allen v. Brown, 7 Vet. App. 439 (1995). 1. Entitlement to service connection for a right foot condition The Appellant seeks service connection for the Veteran's claimed right foot condition. The question for the Board is whether the Veteran had a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Service treatment records are silent for any complaint, diagnosis, or treatment of the right foot. April 1974 treatment reveals the Veteran sought treatment for left foot pain after he struck the left lateral aspect of the foot on a rock. No injury of the right foot was noted. At separation in July 1974, the clinical evaluation showed no related abnormality. Post-service treatment records reflect intermittent right foot and leg complaints. VA treatment records are silent for specific right foot complaints. A July 2009 Social Security Administration (SSA) examination showed pain with spasms that radiated to the right leg and the foot. He reported that he cannot walk because of the pain and weakness. The SSA clinician assessed right leg radiculitis. The Board concludes that, while the Veteran has a diagnosis of right leg radiculitis, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. The Veteran reported having experienced symptoms, the Veteran is competent to report what he is able to discern with his senses. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran is not competent to provide a diagnosis or an etiologically link to service. The issue is medically complex, as it requires knowledge of interaction between multiple body systems. In this case, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Additionally, the Board notes that the Veteran was not afforded a VA examination to assist him in substantiating the claim. While the Board has found that there is an indication of a current disability, there is no competent evidence indicating that a nexus between that disability and active military service may exist which is required to trigger VA's duty to assist. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). In sum, the evidence indicates that the Veteran had right leg and foot radiculitis and pain which caused functional limitation, but there is no nexus between this disability and his active military service. Accordingly, service connection is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine and finds it is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Entitlement to service connection for migraine headaches The Veteran contended that his headaches were related to his service-connected tinnitus. An August 2017 brief noted that the Veteran reported getting more headaches and ringing in his ears getting louder. He reported his tinnitus flares up when he gets a headache. During the pendency of this claim, conflicting opinions have been proffered regarding whether the Veteran's headaches are related to service or his service-connected tinnitus disability. The Veteran was afforded an examination in March 2016 by a private clinician, who completed a disability benefits questionnaire (DBQ) report. The clinician opined that it is at least as likely as not that the Veteran's headaches are caused by his service-connected tinnitus. The Veteran reported that his headaches started in service and have gotten more severe and frequent over the years. The clinician noted April 2011 treatment included the Veteran's report of flare-ups of his tinnitus can cause flare-ups of his headaches. The examiner indicated that it is known that damage to the auditory system resulting in tinnitus can also cause headaches. Thus, the examiner concluded it is as likely as not the Veteran's headaches are caused by his tinnitus. Pursuant to the October 2018 Board remand, the Veteran was afforded a VA examination in October 2019. The VA examiner offered conflicting statements regarding the nature and etiology of the Veteran's headaches. The examiner opined the Veteran's headaches are less likely than not proximately due to or the result of his service-connected tinnitus. The examiner indicated that while damage to the auditory system can result in headaches, there was no noted auditory report to indicate that the Veteran's headaches are due to tinnitus. Thus, the examiner concluded the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner also indicated that there was no noted baseline or aggravation of a condition of migraine headaches due to tinnitus. However, in reviewing the March 2016 favorable DBQ, the examiner stated that he concurred with the private DBQ that the Veteran's as likely as not due to his service-connected tinnitus. The Board initially notes that this statement is inconsistent with the negative secondary opinion offered earlier in the report. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current migraine headaches are proximately due to his service-connected tinnitus. Both nexus opinions are flawed. The VA examiner's nexus opinion does not fully explain the rationale in support of a lack of aggravation of headaches by the service-connected tinnitus and offers an internally inconsistent statement when it addresses the favorable March 2016 DBQ opinion. The favorable medical opinion from the March 2016 private DBQ is speculative in nature and did not discuss whether the increase in headache frequency was the result of running out of pain medication for the non-service-connected neck disability. The Board has considered that this clinician is familiar with the Veteran's relevant history as he has, at least, reviewed the medical history and performed a clinical examination with the Veteran. As both nexus opinions are flawed in some respect, neither outweighs the other in terms of probative value. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for migraine headaches is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for a neck condition The Appellant seeks service connection for the Veteran's claimed neck condition. The question for the Board is whether the Veteran had a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Service treatment records are silent for any complaint, diagnosis, or treatment of the neck. At separation in July 1974, the clinical evaluation showed no related abnormality. Post-service treatment records reflect chronic neck pain complaints. A July 2009 SSA examination showed right shoulder rotator cuff and low back injuries, but is silent with respect to any neck pain or injury. Physical examination normal, full range of motion of the cervical spine. However, an August 2012 radiological report revealed moderately severe multilevel cervical disease. November 2015 VA treatment records show the Veteran reported chronic neck pain, which was managed by his civilian primary care provider. The Board concludes that, while the Veteran has a diagnosis of cervical osteoarthritis and neck pain, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. The Veteran has reported having experienced symptoms, the Veteran is competent to report what he is able to discern with his senses. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran is not competent to provide a diagnosis or an etiologically link to service. The issue is medically complex, as it requires knowledge of interaction between multiple body systems. In this case, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Additionally, the Board notes that the Veteran was not been afforded a VA examination to assist him in substantiating the claim. While the Board has found that there is an indication of a current disability, there is no competent evidence indicating that a nexus between that disability and active military service existed which is required to trigger VA's duty to assist. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). In sum, the evidence indicates that the Veteran had cervical spine osteoarthritis and pain which causes functional limitation, but there is no nexus between this disability and his active military service. Accordingly, service connection is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine and finds it is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 4. Entitlement to service connection for a back condition The Appellant seeks service connection the Veteran's claimed back condition. The question for the Board is whether the Veteran had a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Service treatment records are silent for any complaint, diagnosis, or treatment of the low back. At separation in July 1974, the clinical evaluation showed no related abnormality. Post-service, the Veteran reported issues with the low back in July 2009 at a SSA disability examination. At that time, the Veteran indicated back pain after a lifting incident in 2008 while he was at work for Toyota. He reported pain in the back that radiated to the right leg. The Veteran was given a clinical diagnosis of lumbar strain with radiculitis to the right leg. September 2010 VA treatment records similarly reflect complaints of low back pain radiating to the neck and both shoulders. Treatment providers assessed osteoarthritis of the lumbar, thoracic, and cervical spine. The Board concludes that, while the Veteran had a diagnosis of osteoarthritis of the spine, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. The Veteran has reported having experienced symptoms, the Veteran is competent to report what he is able to discern with his senses. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran is not competent to provide a diagnosis or an etiologically link to service. The issue is medically complex, as it requires knowledge of interaction between multiple body systems. In this case, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Additionally, the Board notes that the Veteran has not been afforded a VA examination to assist him in substantiating the claim. While the Board has found that there is an indication of a current disability, there is no competent evidence indicating that a nexus between that disability and active military service may exist required to trigger VA's duty to assist. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). As noted above, the July 2009 SSA examination report suggests that the Veteran's back pain is related to a work injury sustained in 2008, decades after his discharge from service. In sum, the evidence indicates that the Veteran had lumbar osteoarthritis and pain which causes functional limitation, but there is no nexus between this disability and his active military service. Accordingly, service connection is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine and finds it is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. Hart v. Mansfield, 21 Vet. App. 505 (2007). 5. Entitlement to a compensable rating for hearing loss The Appellant seeks a compensable rating for the Veteran's bilateral hearing loss. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, Diagnostic Code 6100. To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). The Veteran was afforded a VA examination in June 2009. The Veteran reported decreased hearing and constant ringing in both ears. Pure tone thresholds, in decibels, were as follows: June 2009 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 45 45 50 55 49 96% LEFT 30 40 50 55 50 96% Applying the results to Table VI, the findings yield a numeric designation of Level I in the right ear and Level I in the left ear. Entering the resulting bilateral numeric designation of Level I for the right ear and Level I for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a noncompensable disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. The Veteran was afforded a VA examination in November 2010. The Veteran reported hearing loss and constant ringing in both ears. Pure tone thresholds, in decibels, were as follows: November 2010 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 105 105 105 105 105 0 LEFT 105 105 105 105 105 0 The Veteran was afforded a VA examination in January 2012. The Veteran's Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: January 2012 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT CNT CNT CNT CNT VOID CNT LEFT CNT CNT CNT CNT VOID CNT However, the VA examiner indicated that inter-test reliability for the June 2009, November 2010, and January 2012 VA examinations was poor. Word recognition was presented below veteran's response level for speech and pure tones. Thus, the examiner concluded that valid hearing thresholds could not be obtained in either the right or left ear because veteran would not or could not respond consistently to speech or pure tone stimuli. Based upon the 2012 VA examiner's assessment, the Board finds the November 2010 and January 2012 VA audiological examinations are not valid for VA adjudication purposes. The Veteran submitted a private audiogram dated May 2013. However, it is not clear from the report whether the test was conducted by a state-licensed audiologist. Maryland CNC speech discrimination score was not reported. Puretone thresholds were indicated as follows: May 2013 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 85 95 105 110 98.75 N/A LEFT 95 105 110 110 105 N/A As Maryland CNC testing was not conducted, the Board finds that as the private May 2013 audiogram report is not valid for adjudication purposes. In October 2018, the Board found that a contemporaneous VA examination was needed to assess the current severity of the Veteran's hearing loss. The Veteran was afforded a VA examination in October 2019. The Veteran reported that he must use hearing aids, otherwise he indicated that he could not hear. Pure tone thresholds, in decibels, were as follows: October 2019 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 40 65 70 75 65 98% LEFT 60 55 60 70 61.25 98% Applying the results to Table VI, the findings yield a numeric designation of Level II in the right ear and Level II in the left ear. Entering the resulting bilateral numeric designation of Level II for the right ear and Level II for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a noncompensable disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. Based on the evidence above, a compensable rating for the Veteran's bilateral hearing loss is not warranted. The Board expressly acknowledges its consideration of the lay evidence of record when adjudicating this claim, including difficulty hearing and constant ringing in his ears. The Veteran is competent to report difficulty with his hearing; however, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes, is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran's main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a compensable rating for hearing loss. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder, to include depressive disorder As noted in the October 2018 remand, the evidence included an April 2016 private opinion from Dr. HHG who opined the Veteran suffered from unspecified depressive disorder which more likely than not began in service and continued to the time of the examination. However, the Board determined that this opinion was not supported by adequate rationale nor did it address the multiple negative depression screenings in the Veteran's medical treatment records. The Board remanded for a VA psychiatric examination and opinion. The Veteran underwent a VA examination in September 2019. The VA examiner determined the Veteran did not meet the criteria for a diagnosis of a psychiatric disorder. In January 2021, the Veteran's representative submitted a private opinion which indicated the Veteran had alcohol use disorder and anxiety disorder. Thus, the Board finds a remand is necessary in order to obtain an addendum opinion reconciling the VA examiner's determination that the Veteran did not have a diagnosis of an acquired psychiatric disorder with the other evidence of record, and if there is such a diagnosis, whether such was related to the Veteran's military service. 2. Entitlement to service connection for a head laceration or injury is remanded. The Appellant seeks service connection for residuals of a head laceration or injury. He reports physical and cognitive residuals that he attributes to his head laceration injury in service. The September 2018 competency evaluation diagnoses a general neurocognitive disorder. The September 2019 VA examination provides a current diagnosis of dementia. While the September 2019 VA examination provides a negative medical opinion, it is limited to evaluation of the nature and etiology of any acquired psychiatric disorder. As there is evidence of a current disability and an in-service occurrence, the Board finds that a medical opinion should be obtained the determine the nature and etiology of the Veteran's current neurocognitive disorder. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2). 3. Entitlement to a total disability based upon individual unemployability (TDIU) is remanded. The Board has granted service connection for headaches. The AOJ will assign an evaluation for this disability in the first instance. The AOJ has not had an opportunity to consider the Veteran's TDIU claim in light of the Board's grant of service connection. A remand of the claim for TDIU is required. The matters are REMANDED for the following action: 1. Return the claims file to a qualified VA examiner other than she who conducted the September 2019 VA mental disorder examination. The claims folder must be reviewed in its entirety, and the reviewer should address the following: Reconcile the findings of the September 2019 VA examination which determined the Veteran did not meet the criteria for a DSM diagnosis of an acquired psychiatric disorder with remainder of the evidence of record, to include VA treatment records, the April 2016 opinion of Dr. HHG and the January 2021 opinion of Dr. KHB (April 2016) and Dr. KFB (January 2021) that reflect diagnoses of depression, alcohol abuse disorder and anxiety. If the examiner finds that the aforementioned diagnoses are invalid, a basis for these opinions must be provided. If a diagnosis of depression or anxiety is found to be valid at any time since October 2014, even if asymptomatic or resolved, the examiner should offer an opinion as to whether such is at least as likely as not (50 probability or greater) that such has its onset in service, or is in any way related to the Veteran's time in service, to include as related to service-connected tinnitus and/or bilateral hearing loss; or if any diagnosed depression or anxiety was worsened beyond its natural progression (aggravated) by service-connected bilateral hearing loss and/or tinnitus. A full and complete rationale for all opinions offered should be provided. 2. Obtain an opinion for his neurocognitive and/or residuals of head laceration. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is the neurocognitive disorder at least as likely as not related to service, including the head laceration during active service? Provide a rationale to support the opinion(s). 3. Following the implementation of the award in this Board decision, readjudicate the claim for entitlement to TDIU. 4. Then, readjudicate the claims on appeal. If any benefit sought remains denied, issue a supplemental statement of the case and, following appropriate time for response, return the matter to the Board for further consideration. MARGARET M. LUNGER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Lauritzen, 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.