Citation Nr: 22008064 Decision Date: 02/11/22 Archive Date: 02/11/22 DOCKET NO. 18-27 741 DATE: February 11, 2022 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for a pulmonary disability, to include bronchitis, is denied. Entitlement to service connection for bilateral tinea pedis is denied. Entitlement to service connection for hemorrhoids is denied. REMANDED Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for bilateral tinnitus is remanded. Entitlement to service connection for migraines, to include as secondary to hypothyroidism, is remanded. Entitlement to service connection for chronic fatigue and weakness, to include as secondary to hypothyroidism, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include unspecified anxiety disorder with depression and insomnia, is remanded. FINDINGS OF FACT 1. The evidence persuasively weighs against finding had a left or right ear hearing loss disability for VA compensation purposes at any point during the pendency of the appeal. 2. The evidence persuasively weighs against finding that the Veteran has had a pulmonary disability, to include bronchitis, at any point during the pendency of the appeal. 3. The evidence persuasively weighs against finding that the Veteran's bilateral tinea pedis had its onset during active duty service or is otherwise etiologically related to an in-service injury, event, or illness. 4. The evidence persuasively weighs against finding that the Veteran's hemorrhoids had their onset during active duty service or are otherwise etiologically related to an in-service injury, event, or illness. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 2. The criteria for service connection for a pulmonary disability, to include bronchitis, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for bilateral tinea pedis have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for hemorrhoids have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from October 2000 to November 2003. These matters come before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) in November 2016. The Veteran testified before the undersigned Veterans Law Judge (VLJ) during a February 2021 Board hearing. A copy of the hearing transcript has been reviewed and associated with the claims file. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires evidence satisfying three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Alternatively, service connection may be granted on a secondary basis for a disability that is proximately due to or the result of (caused) or permanently worsened beyond its natural progression (aggravated) by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (en banc); 38 C.F.R. § 3.310. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Thus, a necessary element for establishing any claim for entitlement to service connection is the existence of a current disability. See Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that the statute requires the existence of a present disability for VA compensation purposes); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). There is no bright line rule prohibiting consideration of evidence dated prior to the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (Board erred in failing to address pre-claim evidence in assessing whether a current disability existed, for purposes of service connection, at the time the claim was filed or during its pendency). In adjudicating these claims, the Board must assess the competence and credibility of the claimant. Washington v. Nicholson, 19 Vet. App. 362 (2005). Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (lay person competent to testify to pain and visible flatness of his feet). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 16533, at *10 (Fed. Cir. June 3, 2021). If "the positive and negative evidence is in approximate balance (which includes but is not limited to equipoise) the claimant receives the benefit of the doubt." Id. 1. Entitlement to service connection for bilateral hearing loss There are specific requirements regarding what constitutes a hearing loss disability under VA law. The threshold for normal hearing is from 0 to 20 decibels. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purpose of applying the laws administered by VA, impaired hearing is considered to be a disability when the auditory threshold at any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores utilizing the Maryland CNC Tests are less than 94 percent. 38 C.F.R. § 3.385. Certain organic diseases of the nervous system are presumed to have been incurred in service if manifested to a compensable degree within one year of separation from service. This presumption applies to veterans who have served 90 days or more of active service during a war period or after December 31, 1946. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). VA deems sensorineural hearing loss as among the organic diseases of the nervous system that are covered. See VA Under Secretary for Health Memorandum (October 1995); see also Fountain v. McDonald, 27 Vet. App. 258, 264, 271 (2015). The Veteran asserts that she is entitled to service connection for bilateral hearing loss. She underwent a VA audiological examination in October 2016. The pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 5 10 5 LEFT 5 5 10 10 5 Her speech recognition score was 100 percent in each ear. The examiner stated that the test results are valid for rating purposes. A review of the claims file did not reveal any other audiological examinations conducted during the period on appeal. After considering the relevant evidence, the Board finds that service connection is not warranted for bilateral hearing loss because the Veteran does not have a left or right ear hearing loss disability for VA compensation purposes. 38 C.F.R. § 3.385. A hearing loss disability is diagnosed primarily on objective clinical findings and audiometric testing; thus, while the Veteran is competent under the facts of this case to relate symptoms of hearing loss that she experienced at any time, she is not competent to diagnose a hearing loss disability because such diagnosis requires specific medical knowledge and training in audiology and must be supported by objective clinical findings and audiometric testing. While hearing difficulty is perhaps shown, the available audiometric results do not meet the criteria for a hearing loss disability for VA purposes. The Board therefore recognizes that the Veteran has hearing difficulty, but such does not rise to the level of a hearing loss disability for VA purposes. Because a bilateral hearing loss disability as defined by the VA regulatory criteria at 38 C.F.R. § 3.385 is not demonstrated in this case, disability benefits are not warranted for bilateral hearing loss. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran and her representative argue that presumptive service connection is warranted pursuant to 38 C.F.R. § 3.307(a)(3), as sensorineural hearing loss is an organic disease of the nervous system subject to the chronic disease presumption. However, as no disability has been established by the evidence of record, the presumption does not apply. In denying the claim, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the evidence persuasively weighs against the claim, that doctrine is not applicable. 38 U.S.C. § 5107; see Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 16533, at *10 (Fed. Cir. June 3, 2021); 38 C.F.R. § 3.102. Accordingly, the Board finds that service connection for bilateral hearing loss is not warranted. 2. Entitlement to service connection for a pulmonary disability, to include bronchitis The Veteran asserts that she is entitled to service connection for a pulmonary disability, to include bronchitis. The Veteran's March 2000 entrance examination was clinically normal regarding any pulmonary issues, and she denied a history of pulmonary issues in the accompanying report of medical history. Service treatment records in October 2001and October 2002 indicate in-service diagnoses of a viral upper respiratory tract infection and pharyngitis. A May 2003 radiologic examination report shows a normal chest, with the lungs adequately inflated and clear, pulmonary vasculature and cardiomediastinal silhouette normal, and bones and soft tissues normal. An undated service medical examination is clinically normal with respect to pulmonary problems. In a May 2003 report of medical history, the Veteran stated that she had bronchitis in 1990. The Veteran's VA treatment records are silent for complaints or diagnoses of, or treatment for, bronchitis or any other pulmonary issues. A May 2018 report of general information indicates that he denied receiving any non-VA health care. During an April 2011 thyroid VA examination, the Veteran denied a history of productive and non-productive cough, wheezing, dyspnea, non-anginal chest pain, hemoptysis, fever, anorexia, and night sweats. The examiner found no evidence of pulmonary hypertension or abnormal breath sounds. During her February 2021 Board hearing, the Veteran testified that she was not treated for bronchitis during her active duty service and was not experiencing any bronchitis issues at the time of the hearing. She stated that she could not recall the last time she had any kind of bronchial infection or bronchial disorder but that "it has been a while ago." The Board finds that service connection is not warranted for pulmonary issues, including bronchitis, because the evidence fails to establish that the Veteran has had a current pulmonary disability at any time during the period on appeal, or from June 2016. Her VA treatment records are silent for any pulmonary issues or diagnosis of bronchitis, and she testified during the hearing that she does not remember the last time she had a bronchial infection or disorder. In the absence of evidence of a current disability, service connection may not be granted. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. In denying the claim, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the evidence persuasively weighs against the claim, that doctrine is not applicable. 38 U.S.C. § 5107; see Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307, at *10 (Fed. Cir. Dec. 17, 2021); 38 C.F.R. § 3.102. Accordingly, the Board finds that service connection for a pulmonary disability, to include bronchitis, is not warranted. 3. Entitlement to service connection for bilateral tinea pedis The Veteran has claimed entitlement to service connection for bilateral tinea pedis. A VA treatment record dated in February 2018 lists "tinea" as an active problem. Thus, a current disability has been established by the evidence of record. The Veteran asserts that her tinea pedis is related to her active duty service. The service treatment records, including the in-service examinations of record, are silent for complaints or diagnosis of, or treatment for, tinea pedis. During her February 2021 Board hearing, the Veteran testified that she was not treated during active duty for tinea pedis. She stated that her tinea pedis had its onset after her active service and that a VA provider prescribed her medication for tinea pedis about seven or eight years ago. The Board finds that service connection is not warranted for the Veteran's tinea pedis. In this regard, her service treatment records are silent for any problems related to tinea pedis, and there is insufficient evidence to find that her tinea pedis had its onset during service or is otherwise caused by her service. She has not pointed to any in-service injury, event, or illness as the cause of her current disability in her June 2016 fully developed claim, February 2017 Notice of Disagreement (NOD), May 2018 VA Form 9, or during the February 2021 hearing. Further, she denied in-service treatment and reported a post-service onset of tinea pedis during her hearing. Therefore, the evidence fails to demonstrate a nexus between the Veteran's tinea pedis and any in-service event, injury, or illness. In denying the claim, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the evidence persuasively weighs against the claim, that doctrine is not applicable. 38 U.S.C. § 5107; see Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 16533, at *10 (Fed. Cir. June 3, 2021); 38 C.F.R. § 3.102. Accordingly, the Board finds that service connection for bilateral tinea pedis is not warranted. 4. Entitlement to service connection for hemorrhoids The Veteran has claimed entitlement to service connection for hemorrhoids. A VA treatment note dated in March 2018 shows that she was diagnosed with external hemorrhoids. Thus, a current disability has been established by the evidence of record. She asserts that her hemorrhoids are related to her active duty service. The Veteran's service treatment records are silent for complaints of, diagnosis of, or treatment for, hemorrhoids. No hemorrhoids or history of such is noted on her in-service examinations. A February 2018 VA treatment note indicates that the Veteran complained of profound rectal pain and bleeding lasting for three weeks. She denied constipation, straining, and a past history of hemorrhoids. She was examined the following month and diagnosed with external hemorrhoids. During her February 2021 hearing, the Veteran testified that she was not treated during active duty for hemorrhoids and indicated that they had an onset after her active duty service. After considering the evidence, the Board finds that service connection for hemorrhoids is not warranted. In this regard, there is no record of hemorrhoids occurring during active duty service, and the Veteran testified that her hemorrhoids began after active duty. In February 2018, she denied a history of hemorrhoids to a VA treatment provider. Further, her fully developed claim, NOD, VA Form 9, and hearing testimony do not point to any in-service injury, event, or illness as the cause of her hemorrhoids. Therefore, the evidence fails to demonstrate a nexus between the Veteran's active service and her hemorrhoids. In denying the claim, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the evidence persuasively weighs against the claim, that doctrine is not applicable. 38 U.S.C. § 5107; see Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 16533, at *10 (Fed. Cir. June 3, 2021); 38 C.F.R. § 3.102. Accordingly, the Board finds that service connection for hemorrhoids is not warranted. REASONS FOR REMAND VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement of relevant treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA is obligated to provide an examination or obtain a medical opinion in a claim of service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. McLendon, 20 Vet. App. at 83. The Veteran's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. Id. 1. Entitlement to service connection for a right ankle disability is remanded. 2. Entitlement to service connection for a left knee disability is remanded. 3. Entitlement to service connection for a right knee disability is remanded. The Veteran has claimed entitlement to service connection for disabilities of the right ankle, left knee, and right knee. During her February 2021 hearing, the Veteran testified that she experiences pain, weakness, and instability in her right ankle. She also testified that her ankle problems began during her active duty service, while she was stationed in Germany. She stated that she injured her ankle and was given pain medicine and placed on a physical profile with limited duties. Regarding the knees, she testified that she experiences periodic pain in both knees. She stated that she does not recall a specific injury but attributed her knee problems to general wear and tear while stationed in Germany. She testified that she was also treated and given medication for her knee problems. She also stated that she sought treatment for her knees less than one year after her discharge and that she underwent physical therapy and was given a knee brace. The Veteran's service treatment records include a physical profile dated in May 2003, which indicates that she was placed on a permanent physical profile for chronic upper back pain. While the profile does not mention ankle or knee problems, and her records do not otherwise show in-service treatment for ankle or knee problems, her testimony suggests that her knee and ankle disabilities may be secondary to her service-connected back disabilities. The Board finds that the Veteran's testimony is sufficient to warrant a VA examination because she has presented evidence of current disabilities that may have been incurred during or caused by her active duty service, or may be secondary to her service-connected back disabilities. See McLendon, 20 Vet. App. at 83. Thus, a remand is warranted to obtain examinations of the right ankle, left knee, and right knee. 4. Entitlement to service connection for bilateral tinnitus is remanded. When VA undertakes the effort to provide an examination, the examination must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Inadequate medical examinations include examinations that provide unsupported conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Barr, 21 Vet. App. at 311. It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion. Nieves-Rodriguez, 22 Vet. App. at 304. VA must consider all lay and medical evidence of record. 38 U.S.C. §§ 1154(a), 5107; 38 C.F.R. § 3.303. The Veteran asserts that she is entitled to service connection for tinnitus. She underwent a VA audiological examination in October 2016, wherein she reported recurrent tinnitus. The examiner opined that her tinnitus is less likely than not caused by her conceded military noise exposure. In support of his opinion, the examiner stated that delayed-onset tinnitus is unlikely to occur and that, while noise exposure is conceded, there is no evidence of a noise injury occurring during service. He stated that, in absence of an objectively verifiable noise injury, one cannot presume the existence of an association between tinnitus and noise exposure. During her February 2021 hearing, the Veteran testified that she was exposed to excessive noise during trainings and field exercises and that her tinnitus began a few years after her discharge from active duty. Her representative argued that tinnitus due to high-intensity noise can have a delayed onset, even years after exposure. He also mentioned that "Dr. Sharon Pajel (ph.) and Dr. Charles Lieberman (ph.) have pointed out" such a finding. The Board finds that the October 2016 VA medical opinion is inadequate for the purpose of adjudicating the claim of service connection for tinnitus. See Nieves-Rodriguez, 22 Vet. App. at 304. The examiner stated that delayed-onset tinnitus is "unlikely;" however, the Veteran's representative argued during the February 2021 hearing that tinnitus may develop years after noise exposure and referenced that at least two doctors have noted that tinnitus may develop years after noise exposure. Therefore, this matter must be remanded for an addendum medical opinion. A review of the claims file did not reveal any study or article discussing delayed-onset tinnitus or authored by a Dr. Lieberman or a Dr. Pajel. If the Veteran and her representative have such a study or article to submit, they may do so on remand. 5. Entitlement to service connection for migraines, to include as secondary to hypothyroidism, is remanded. The Veteran has claimed entitlement to service connection for migraine headaches. During her February 2021 hearing, the Veteran testified that she did not receive treatment for migraines or headaches during service but started getting them after her discharge from active duty. She also testified that she believes her headache disability may be related to the synthetic hormone medication prescribed for her service-connected hypothyroidism. The Veteran has presented competent evidence of a migraine disability present during the period on appeal that may be related to her active duty service or secondary to her service-connected hypothyroidism. Therefore, the low threshold has been met for the duty to provide a VA examination to attach. McLendon, 20 Vet. App. at 83. As such, the matter is remanded to schedule the Veteran for a VA examination. 6. Entitlement to service connection for chronic fatigue and weakness, to include as secondary to hypothyroidism, is remanded. The Veteran has also claimed entitlement to service connection for chronic fatigue and weakness. During her February 2021 hearing, she testified that she has been told by a doctor that her fatigue and weakness are related to her service-connected hypothyroidism. She stated that her fatigue varies in severity depending on the thyroid medication and dosage she takes. Her representative argued that removal of the thyroid, which the Veteran underwent during active duty, can cause chronic fatigue. The Veteran has presented competent evidence that she may have a chronic fatigue disability that may be related to her active duty service or secondary to her service-connected hypothyroidism. Therefore, the low threshold has been met for the duty to provide a VA examination to attach. McLendon, 20 Vet. App. at 83. As such, the matter is remanded to schedule the Veteran for a VA examination. 7. Entitlement to service connection for an acquired psychiatric disorder, to include unspecified anxiety disorder with depression and insomnia, is remanded. The RO's November 2016 rating decision, in relevant part, denied service connection for unspecified anxiety disorder with depression and insomnia. The Veteran's February 2017 NOD lists "depression, insomnia" as an issue of disagreement. The Board finds that the Veteran's NOD included a statement of disagreement with the RO's denial of service connection for unspecified anxiety disorder with depression and insomnia. However, the May 2018 statement of the case (SOC) does not include the issue of entitlement to service connection for unspecified anxiety disorder, depression, insomnia, or any other psychiatric disability. Since the RO has not issued a SOC with regard to the issue of service connection for an acquired psychiatric disorder, the Board has no discretion, and a remand is required. Manlincon v. West, 12 Vet. App. 238, 240 (1999). This issue will only be returned to the Board if the Veteran files a timely substantive appeal after the issuance of an SOC. Smallwood v. Brown, 10 Vet. App. 93, 97 (1997). The matters are REMANDED for the following action: 1. Obtain and associate with the claims file the Veteran's updated VA treatment records, from May 2018 to the present. 2. After completing #1, schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed right ankle disabilities. The entire claims folder, including a copy of this remand, must be made available for review by the examiner, and such review should be noted in the examination report. the examiner should respond to the following: (a.) Please note all right ankle diagnoses. If no disability is diagnosed, is it at least as likely as not (a 50 percent or greater probability) that the Veteran's right ankle pain results in a functional impairment in earning capacity? (b.) For each disability noted, or if pain results in a functional impairment, is it at least as likely as not (a 50 percent or greater probability) that such disability or pain was incurred during active duty service or is otherwise related to an in-service injury, event, or illness? (c.) If not, is it at least as likely as not (a 50 percent or greater probability) that such disability or pain was caused or aggravated (any incremental increase in disability) by the Veteran's service-connected rhomboid-myofascial pain syndrome of the cervical spine and/or thoracic and lumbar strain? (d.) If aggravation is found, is there medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the ankle disability prior to aggravation? If so, please identify. The examiner must provide a comprehensive rationale for each proffered opinion. The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 3. After completing #1, schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed right and left knee disabilities. The entire claims folder, including a copy of this remand, must be made available for review by the examiner, and such review should be noted in the examination report. the examiner should respond to the following: (a.) Please note all right and left knee diagnoses. If no disability is diagnosed, is it at least as likely as not (a 50 percent or greater probability) that the Veteran's right and/or left knee pain results in a functional impairment in earning capacity? (b.) For each disability noted, or if pain results in a functional impairment, is it at least as likely as not (a 50 percent or greater probability) that such disability or pain was incurred during active duty service or is otherwise related to an in-service injury, event, or illness? (c.) If not, is it at least as likely as not (a 50 percent or greater probability) that such disability or pain was caused or aggravated (any incremental increase in disability) by the Veteran's service-connected rhomboid-myofascial pain syndrome of the cervical spine and/or thoracic and lumbar strain? (d.) If aggravation is found, is there medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the knee disability prior to aggravation? If so, please identify. Separate opinions are requested for each disability affecting each knee. The examiner must provide a comprehensive rationale for each proffered opinion. The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 4. After completing #1, obtain an addendum medical opinion from the examiner who conducted the October 2016 VA audiological examination or, if he is unavailable then another similarly qualified examiner may respond instead. The entire claims file, including a copy of this remand, must be made available for review by the examiner, and such review should be noted in the examination report. A new examination is only necessary if deemed so by the examiner. After reviewing the evidence, the examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's tinnitus is related to her active duty service, including her conceded noise exposure. The examiner must provide a comprehensive rationale for the proffered opinion. The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 5. After completing #1, schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed migraine or headache disability. The entire claims folder, including a copy of this remand, must be made available for review by the examiner, and such review should be noted in the examination report. the examiner should respond to the following: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran currently has, or has had at any time since June 2016, a migraine or headache disability? (b.) If so, is it at least as likely as not (a 50 percent or greater probability) that such disability was incurred during active duty service or is otherwise related to an in-service injury, event, or illness? (c.) If not, is it at least as likely as not (a 50 percent or greater probability) that such disability was caused or aggravated (any incremental increase in disability) by the Veteran's service-connected hypothyroidism, to include any medication(s) prescribed for the treatment of hypothyroidism? (d.) If aggravation is found, is there medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the migraine or headache disability prior to aggravation? If so, please identify. The examiner must provide a comprehensive rationale for each proffered opinion. The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 6. After completing #1, schedule the Veteran for a VA examination to determine the nature and etiology of any diagnosed chronic fatigue disability. The entire claims folder, including a copy of this remand, must be made available for review by the examiner, and such review should be noted in the examination report. the examiner should respond to the following: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran has a disability manifested by chronic fatigue and weakness? The examiner should indicate whether the Veteran's fatigue and weakness are symptoms of her hypothyroidism or are an independent disability. (b.) If an independent chronic fatigue disability is found, is it at least as likely as not (a 50 percent or greater probability) that such disability was incurred during active duty service or is otherwise related to an in-service injury, event, or illness? (c.) If not, is it at least as likely as not (a 50 percent or greater probability) that such disability was caused or aggravated (any incremental increase in disability) by the Veteran's service-connected hypothyroidism, to include any medication(s) prescribed for the treatment of hypothyroidism? (d.) If aggravation is found, is there medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the chronic fatigue disability prior to aggravation? If so, please identify. The examiner must provide a comprehensive rationale for each proffered opinion. The examiner is advised that the Veteran is competent to report her symptoms and history, and such reports are to be considered in formulating any opinion. (Continued on the next page) If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 7. Take appropriate action, including issuance of a statement of the case, on the issue of entitlement to service connection for an acquired psychiatric disorder, to include unspecified anxiety disorder with depression and anxiety. The Veteran and her representative should be clearly advised of the need to file a timely substantive appeal if the Veteran wishes to complete an appeal from the determination. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Pratt 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.