Citation Nr: 22007229 Decision Date: 02/08/22 Archive Date: 02/08/22 DOCKET NO. 16-37 585 DATE: February 8, 2022 ORDER Service connection for a left shoulder disability, to include as due to exposure to herbicide agents, is denied. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. FINDING OF FACT The Veteran has a left shoulder disability; however, none of the probative and credible evidence of record indicates that the disability may be associated with service. CONCLUSION OF LAW The criteria for an award of service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from March 1966 to March 1968, to include service in Vietnam. His decorations include the Vietnam Service Medal, the Vietnam Campaign Medal, the Purple Heart, and the Combat Medical Badge. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision issued by the Department of Veterans Affairs (VA) Evidence Intake Center in Newnan, Georgia. In February 2021, the Veteran testified at a virtual Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. The issues on appeal were previously before the Board in September 2021, when they were remanded to the agency of original jurisdiction (AOJ) for additional development. In its remand, the Board directed the AOJ to obtain updated VA treatment records, to obtain an addendum VA medical opinion with respect to the Veteran's claim for service connection for bilateral hearing loss, and to readjudicate the Veteran's claims based on his request that he wanted the claims remanded to the AOJ for initial review of newly received evidence. In October and December 2021, the AOJ obtained updated VA treatment records. In December 2021, the AOJ readjudicated the Veteran's claims, taking into consideration the new evidence that had been received. The Board finds that the AOJ has substantially complied with the September 2021 remand directives as they pertained to the Veteran's claim for service connection for a left shoulder disability. See Stegall v. West, 11 Vet. App. 268 (1998). While the AOJ also obtained an addendum VA medical opinion as to the Veteran's claim for service connection for bilateral hearing loss in November 2021, the Board finds that the development undertaken in that regard is not in substantial compliance with the September 2021 remand directives. Although the Board sincerely regrets the additional delay, and for the reasons expressed in additional detail below, a further remand is required as to that claim to ensure that the Veteran is afforded a fully adequate medical opinion. Id. Entitlement to service connection for a left shoulder disability, to include as due to exposure to herbicide agents. The Veteran contends that his left shoulder disability was incurred in or caused by service. Specifically, he stated in his October 2014 notice of disagreement that his left shoulder was injured during a march in service when a claymore mine exploded next to him that caused significant damage to his left arm. He explained that he received the Purple Heart for that incident, and that VA had given him a vibrating neck brace and a TENS unit to help relieve severe pain and arthritis. In an August 2016 submission, the Veteran contended that he had repeated problems with skin infections from jungle rot of the feet, multiple leech bites, and left ankle cellulitis, stating that he was diagnosed with septic arthritis in August 1967 and that a June 1967 record identified a fragment wound on the dorsal side of the left wrist. He also referenced a medical article from the Mayo Clinic which per his report stated that septic arthritis could be caused by bacterial infections, with staph aureus as the most common cause. He stated that he felt that joint damage caused by staph aureus was entirely possible, and that infected skin wounds as well as puncture wounds or cuts could lead to staph infections and septic arthritis. In a May 2019 VA treatment record, the Veteran reported arm pain in his neck, shoulder, and hand, and stated that his father had a history of arthritis and that he believed that he had it too, but that he had never officially been diagnosed. Finally, at his February 2021 hearing, the Veteran testified that while he did not have any complaints related to the left shoulder in service, it began to give him problems down the road. He clarified that he believed he had arthritis in his body and shoulder, that perhaps his service gave rise to arthritis, and that this was the problem in his shoulder. He further testified that he did not know if exposure to herbicide agents had anything to do with the infection or with arthritis, which has raised the theory that his left shoulder disability is due to exposure to herbicide agents. Under applicable law, service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). The requirement of a current disability is satisfied when the claimant is shown to have the disability either at the time of filing a claim for service connection, or during the pendency of that claim, even if the disability resolves prior to final adjudication. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). When the record contains a recent diagnosis of disability prior to the filing of a claim for benefits based on that disability, the report of diagnosis is relevant evidence that must be addressed in determining whether a current disability existed at the time the claim was filed or during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). The U.S. Court of Appeals for the Federal Circuit has held that pain alone can serve as a disability for VA compensation purposes if the pain results in functional impairment that affects earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In the absence of proof of a current disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Degmetich v. Brown, 104 F.3d 1328, 1333 (1997). If a Veteran serves 90 days or more of active, continuous service after December 31, 1946, and manifests certain chronic diseasesincluding arthritisto a degree of 10 percent or more during the one-year period following his separation from that service, service connection for the condition may be established on a presumptive basis, notwithstanding that there is no in-service record of the disorder. See 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA regulations provide that certain diseases associated with exposure to herbicide agents may be presumed to have been incurred in service even if there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 C.F.R. § 3.309(e). A Veteran who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a). The last date on which such a Veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975. If a Veteran was exposed to an herbicide agent during active service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; chronic lymphocytic leukemia; B cell leukemia, Parkinson's disease, multiple myeloma; non-Hodgkin's lymphoma; early-onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma); and ischemic heart disease, (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina). Where the evidence does not warrant presumptive service connection, the United States Court of Appeals for the Federal Circuit has determined that an appellant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom., Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998). However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it pertains to the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007). Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C. § 1154(a). See Davidson, supra. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). As an initial matter, the Board notes that the Veteran has been treated for left shoulder problems during the period on appeal. A November 2013 VA treatment record shows that he complained of left shoulder and neck pain that was limiting functional mobility and independence. A May 2019 VA treatment record shows that he sought treatment for left arm pain at that time, but differential diagnoses included only cervical radiculopathy, lumbar radiculopathy, and hand pain. Imaging of the cervical spine showed severe left foraminal stenosis and neural foraminal stenosis, but no specific diagnosis as to the left shoulder was given. A June 2019 VA treatment record again shows that the Veteran was seen for neck pain which radiated into his left shoulder, but examination of the shoulder was normal with full range of motion, and the provider diagnosed only cervicalgia. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran has a current disability of the left shoulder. The November 2013 VA treatment record demonstrates that he has had pain and limited functional mobility and independence during the period on appeal. See Saunders, supra. The first element of service connection has therefore been established. The Board further notes, however, that there is nothing in the claims file to indicate that the Veteran has arthritis in his left shoulder, as he has never been diagnosed with that condition in that particular joint, even though he has been evaluated for left shoulder problems on several occasions. While the Veteran believes he may have arthritis in his left shoulder, the Board further finds that he is not competent to diagnose arthritis, as it is not a diagnosis that is capable of lay observation. See Jandreau, supra. As the evidence is persuasively against a finding that the Veteran has left shoulder arthritis, the provisions of 38 C.F.R. § 3.309(a), pertaining to chronic diseases, are not applicable in this case. Regarding an in-service event or injury, and first considering service connection on the basis of exposure to herbicide agents, the Board notes that the Veteran served in Vietnam during the requisite time period. His exposure to herbicide agents is therefore presumed. Given his contention that his left shoulder disability may be due to exposure to herbicide agents during his service, the second element of service connection regarding an in-service event or injury has also been established. See Davidson, supra. The Board emphasizes, however, that the Veteran does not have a current disability of the left shoulder that is subject to presumptive service connection on the basis of exposure to herbicides under 38 C.F.R. § 3.309(e). Regarding an in-service event on the basis of a direct service connection theory, the Board notes that the Veteran's service treatment records (STRs) are silent for complaints of, treatment for, or a diagnosis related to the left shoulder. A June 1967 STR does show that the Veteran sustained a left wrist injury when he was hit by a fragment of a claymore mine while on a search and destroy mission, and that he received the Purple Heart as a result of that injury. Other STRs from the same month show marked limitation of the left wrist, that the Veteran sustained a fragment wound in the dorsum of the left wrist, and that he subsequently developed staph aureus. An August 1967 STR shows that he developed septic arthritis in his left ankle at that time, and that he was also diagnosed with cellulitis of the left ankle later that same month. While the Veteran's STRs confirm that his left wrist was injured by a claymore mine, that he subsequently developed staph aureus, and that he was diagnosed with septic arthritis of the left ankle during service, there is nothing in the STRs showing an event, injury, or disease related to his left shoulder per se. The Veteran's February 1968 separation examination report is silent for any complaints or diagnosis related to the left shoulder, and the Veteran specifically denied having had swollen or painful joints or a painful or 'trick' shoulder at that time. Regarding the link, or nexus, between the Veteran's left shoulder disability and his service, the Board finds that none of the probative and credible evidence of record indicates that the disability may be associated with service. The claims file does not contain any probative evidence (including medical opinions, medical treatises, or treatment records) that suggests that the Veteran's left shoulder disability may be associated with his service, to include as due to exposure to herbicide agents. In addition, he is not shown to have the specialized knowledge or training necessary to offer competent opinions with respect to the etiology of his left shoulder disability. See Jandreau, supra. The Board has considered the Veteran's contention that the medical article from the Mayo Clinic purportedly states that septic arthritis can be caused by bacterial infections with staph aureus as the most common cause. However, the Veteran has not submitted that article into evidence. In addition, even assuming for purposes of argument that the Veteran's description of the article is accurate, the Board must find that it's not shown to be relevant to the Veteran's claim. Specifically, although the Veteran's STRs show that he had staph aureus in his left wrist and septic arthritis in his left ankle during service, there is no indication that the Veteran currently has, or ever has had, septic arthritis or any other kind of arthritis in his left shoulder. The Board has also considered the Veteran's contention that his current left shoulder disability is in some way related to the in-service injury to his left wrist and subsequent development of staph aureus, or to left ankle septic arthritis with which he was diagnosed in service. However, the Board finds that the Veteran is not competent to offer opinions on medically complex matters such as the etiology of his current left shoulder disability. See Jandreau, supra. The Board acknowledges that the Veteran has not been afforded a VA examination and/or opinion in connection with this matter. However, in the absence of any probative evidence indicating that the disability in question may be associated with service, no examination or medical opinion is necessary. See McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). In assessing the Veteran's claim, the Board has considered the benefit-of-the-doubt doctrine. However, in the absence of any probative evidence linking the Veteran's disability to service, that doctrine does not apply. 38 U.S.C. § 5107(b). The appeal of this issue must be denied. REASONS FOR REMAND Entitlement to service connection for bilateral hearing loss is remanded. In its September 2021 remand, the Board noted that for service department examinations conducted prior to January 1, 1967, unless otherwise indicated, the Board assumed that audiometric testing was conducted using American Standards Association (ASA) measurements and converted the results of such testing to current International Standards Organization-American National Standards Institute (ISO-ANSI) measurements by adding between 5 and 15 decibels to the recorded data as follows: Hertz 250 500 1000 2000 3000 4000 6000 8000 add 15 15 10 10 10 5 10 10 The Board further noted that for service department examinations conducted between January 1, 1967 and December 31, 1970, unless otherwise indicated, the Board considered audiometric data under both ASA and ISO-ANSI standards, whichever was more beneficial to the Veteran. The Board then noted that because the Veteran was examined for entry into service in October 1965, it assumed that ASA measurements were used, and that audiometric testing at that time revealed the following results, in decibels (with the numbers in parentheses representing converted ISO-ANSI measurements): HERTZ 500 1000 2000 3000 4000 6000 Right Ear 0 (15) 0 (10) 0 (10) 10 (20) 0 (5) omitted Left Ear 5 (20) 0 (10) 0 (10) 10 (20) 0 (5) omitted The Board then noted that when the Veteran was examined for separation in February 1968, he did not report any problems with his hearing, and that because the examination was conducted between January 1, 1967 and December 31, 1970, the Board would consider the audiometric data under both ASA and ISO-ANSI standards, whichever was most beneficial to the Veteran. Audiometric testing at that time revealed the following results, in decibels (with the numbers in parentheses again representing converted ISO-ANSI measurements): HERTZ 500 1000 2000 3000 4000 6000 Right Ear 10 (25) 5 (15) 0 (10) omitted 0 (5) omitted Left Ear 5 (20) 5 (15) 0 (10) omitted 0 (5) omitted In reviewing an August 2014 VA examination report regarding the Veteran's claim, the Board noted that the examiner did not convert the Veteran's scores from ASA to ISO-ANSI units, that his converted score in the right ear at 500 Hertz at separation was 25 decibels, and that the United States Court of Appeals for Veterans Claims (Court) had indicated that thresholds above 20 decibels were indicative of at least some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Board further noted that the examiner did not consider the medical significance, if any, of the fact that no audiometric data were recorded at 3,000 Hertz for either ear when the Veteran was examined for service separation. Additionally, the Board noted that the August 2014 VA examiner cited to a 2005 Institute of Medicine (IOM) report in support of her opinion that medical literature did not provide a sufficient scientific basis for the existence of delayed onset hearing loss, and that the Court had directed attention to the fact that the IOM report on which the examiner relied contains qualifying or contradictory aspects which may impact the probative value of medical opinions that rely on it. See McCray v. Wilkie, 31 Vet. App. 243 (2019). For the reasons outlined above, the Board directed the AOJ to obtain an addendum opinion from the August 2014 examiner. It further directed the examiner to consider the Veteran's converted audiometric scores as laid out by the Board in its September 2021 decision, to discuss the medical significance, if any, of that fact that the Veteran had a converted puretone threshold score of 25 decibels in the right ear at 500 Hertz at the time of his separation from service, and the Court's observation that readings in excess of 20 decibels are indicative of at least some degree of hearing loss. The Board also directed the examiner to address the fact that no audiometric data were recorded at 3,000 Hertz for either ear when the Veteran was examined for separation; how that fact impacted her prior opinion as to whether it was at least as likely as not that the Veteran's hearing loss was due to service; to specifically discuss whether, in the absence of audiometric data at 3,000 Hertz, it was possible to determine whether the Veteran's hearing was normal at that frequency at the time of separation; and whether it was possible to determine whether any threshold shifts occurred at that frequency during service. The Board also noted that if the examiner placed any reliance on the 2005 study from the IOM pertaining to the delayed onset of hearing loss, she must acknowledge and discuss any apparent qualifiers or contradictions in that report as they related to the acknowledgment therein that definitive studies had not been performed to determine whether permanent noise-induced hearing loss could develop much later in one's lifetime, long after the cessation of noise exposure. Finally, the Board directed the examiner to consider a February 2021 opinion from R.S., M.D. The AOJ obtained an addendum opinion from the August 2014 VA examiner in November 2021, who offered a negative nexus opinion. Regarding the converted audiometric scores, the examiner stated that for adjudication purposes, hearing impairment was disabling when puretone thresholds at 500, 1,000, 2,000, 3,000, or 4,000 Hertz were 40 decibels or greater, when puretone thresholds for at least 3 of those frequencies were 26 decibels or greater, or when speech recognition scores were less than 94 percent. She stated that the Veteran's hearing was within normal limits at enlistment and separation from service utilizing the documented thresholds or the newly converted sensitivities. Regarding the fact that no audiometric data were recorded at 3,000 Hertz in either ear when the Veteran was examined for separation from service, the examiner indicated that the lack of threshold testing at that level did not impact her prior opinion. She reasoned that the Veteran denied hearing loss at his separation examination, that all of the recorded threshold data supported that finding, and that it would be speculative to contradict evidence based upon an assumption rather than data on record. Regarding her prior reliance on the 2005 IOM report, the examiner stated that based on some recent studies with rodents, some had speculated the possibility of delayed onset hearing loss and used these non-human studies as a basis for claiming that a veteran's hearing loss was service-connected even though hearing thresholds were normal during service with no significant changes in hearing thresholds from enlistment to separation. She cited to studies by Kujawa and Lieberman and noted that they questioned the conclusions of the IOM report, but noted that the IOM report stated that there was insufficient evidence in lab animals or humans to determine whether permanent noise-induced hearing loss could develop much later in one's lifetime, long after the cessation of noise exposure. She stated that Kujawa and Lieberman had misquoted the IOM report, cited to further findings in the report, and opined that animal studies did not overturn the conclusion of the IOM. She stated that disability is the result of permanent impairment, that temporary threshold changes might indicate noise injury, and that in light of Kujawa, they might indicate progressive neuropathy. She further stated that the Kujawa and Lieberman papers did not state that animals suffered delayed-onset hearing loss, and that in fact hearing thresholds returned to normal. The examiner then noted that the McCray v. Wilkie case found the IOM report inadequate as the basis of negative nexus opinions due to qualifying or contradictory aspects of the report, that specifically the report stated that no longitudinal studies had examined patterns of hearing loss over time in noise-exposed humans or lab animals who did not develop hearing loss at the time of noise exposure, and that the committee's understanding of the mechanisms and processes involved in the recovery from noise exposure suggested that a delay of many years in the onset of noise-induced hearing loss following an earlier noise exposure was extremely unlikely. She stated that the Board had cited animal studies by Kujawa and Lieberman, and that while those were elegant studies, they did not constitute sufficient evidence of a causal relationship for delayed hearing loss in humans. The examiner also considered Dr. S.'s February 2021 statement but found that it was from a provider who had offered a statement based solely on the Veteran's statements, with no audiological data or review of the Veteran's service treatment records. She concluded that based on a thorough review of the evidence, her opinion remained the same, reasoning that the Veteran's hearing was completely normal at all frequencies at separation without significant threshold shifts in either ear. The Board finds that the November 2021 VA opinion does not substantially comply with the Board's September 2021 remand directives. First, in considering the converted audiometric scores, the examiner merely repeated the definition of a hearing loss disability for VA purposes, rather than answering the question at issue, which is whether the Veteran's in-service audiometric scores are indicative of at least some level of hearing loss and/or acoustic damage. The Veteran need not show that he had a hearing loss "disability" for VA purposes during service in order to prevail on his claim. In this regard, it does not appear that the examiner considered the Court's observation that readings in excess of 20 decibels are indicative of at least some degree of hearing loss, as required by the Board's September 2021 remand. Second, while the examiner stated that the absence of audiometric data at 3,000 Hertz in either ear at the time of the Veteran's separation from service did not impact her prior opinion, she did not specifically discuss whether it was possible, in the absence of data at that level, to determine whether any threshold shifts occurred at that frequency during service. This matter is REMANDED for the following action: 1. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 2. Arrange to provide the record on appeal to a VA audiologist other than the audiologist who offered opinions regarding the etiology of the Veteran's hearing loss in August 2014 and November 2021. The examiner should review the record. After reviewing the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran's hearing loss had its onset in, or is otherwise attributable to service, to include as due to in-service exposure to noise. In rendering the requested opinion, the examiner should consider that for service department examinations conducted prior to January 1, 1967, the Board ordinarily assumes that audiometric testing was conducted using ASA measurements and converts the results of such testing to current ISO-ANSI measurements by adding between 5 and 15 decibels to the recorded data. The examiner should also consider that for service department examinations conducted between January 1, 1967 and December 31, 1970, unless otherwise indicated, the Board considers audiometric data under both ASA and ISO-ANSI standards, whichever is most beneficial to the Veteran. Applying the conversion to the audiometric data in the reports of the Veteran's October 1965 entrance examination and February 1968 separation examination yields the results set out in parentheses above, at pages 10-11. In providing an opinion, the examiner should discuss the medical significance, if any, of the fact that the Veteran had a (converted) puretone threshold of 25 decibels in the right ear at 500 Hertz at the time of his separation from service. In so doing, the examiner should consider the Court's observation that readings in excess of 20 decibels are indicative of at least some degree of hearing loss. The examiner should also address the fact that no audiometric data were recorded at 3,000 Hertz for either ear when the Veteran was examined for separation, and how that fact impacts his or her opinion as to whether it is at least as likely as not that the Veteran's hearing loss is due to service. The examiner should specifically discuss whether, in the absence of audiometric data at 3,000 Hertz, it is possible to determine whether the Veteran's hearing was normal at that frequency at the time of separation, and whether it is possible to determine whether any threshold shifts occurred at that frequency during service. In arriving at his or her conclusions, if the examiner places any reliance on the 2005 study from the Institute of Medicine, pertaining to the delayed onset of hearing loss, the examiner must acknowledge and discuss any apparent qualifiers or contradictions in that report as they relate to the acknowledgement therein that definitive studies have not been performed to determine whether permanent noise-induced hearing loss can develop much later in one's lifetime, long after the cessation of noise exposure. The examiner should also consider Dr. S.'s February 2021 opinion. The need for another in-person examination, or telephone or video interview of the Veteran is left to the discretion of the examiner selected to offer the requested opinion. A complete medical rationale for all opinions expressed must be provided. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issue remaining on appeal should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Oldroyd, 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.