Citation Nr: 22015398 Decision Date: 03/17/22 Archive Date: 03/17/22 DOCKET NO. 16-60 095 DATE: March 17, 2022 ORDER 1. Entitlement to service connection for gout is denied. 2. Entitlement to service connection for hypertension is denied. 3. Entitlement to service connection for a left shoulder disability is denied. 4. Entitlement to service connection for a right shoulder disability is denied. 5. Entitlement to service connection for bilateral hearing loss is denied. FINDINGS OF FACT 1. Gout was not manifested during service; gout was not manifested within a year following the Veteran's separation from active service; and any current gout is not shown to be etiologically related to his service. 2. Hypertension was not manifested during service; hypertension was not manifested within a year following the Veteran's separation from active service; and any current hypertension is not shown to be etiologically related to his service. 3. A chronic left disability was not manifested during service; left shoulder arthritis was not manifested within a year following the Veteran's separation from active service; and his current left shoulder disability is not shown to be etiologically related to his service/injury therein. 4. A chronic right shoulder disability was not manifested during service; right shoulder arthritis was not manifested within a year following the Veteran's separation from active service; and his current right shoulder disability is not shown to be etiologically related to his service/injury therein. 5. A hearing loss disability in either ear was not manifested in service; sensorineural hearing loss (SNHL) was not manifested to a compensable degree within a year following the Veteran's discharge from active duty; continuity of hearing loss disability postservice is not shown; and his current hearing loss disability is not otherwise shown to be etiologically related to his service, to include as due to exposure to noise therein. CONCLUSIONS OF LAW 1. Service connection for gout is not warranted. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). 2. Service connection for hypertension is not warranted. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). 3. Service connection for a left shoulder disability is not warranted. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). 4. Service connection for a right shoulder disability is not warranted. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). 5. Service connection for bilateral hearing loss is not warranted. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from July 1980 to November 1983. These matters are before the Board on appeal from a February 2015 Department of Veterans Affairs (VA) rating decision. In December 2018, the matters were remanded for additional development. A Supplemental Statement of the Case (SSOC) was issued in October 2021. In the December 2018 remand, the Board also addressed claims for service connection for disabilities of the low back, left hip, left foot, right foot, left knee, and right knee, and sleep apnea. A November 2020 rating decision granted the Veteran service connection for degenerative arthritis of the thoracolumbar spine; a March 2021 rating decision granted service connection for left hip limitation of abduction, extension, and flexion, and left and right foot degenerative arthritis with calcaneal spurs; a May 2021 rating decision granted service connection for left and right knee osteoarthritis; and a September 2021 rating decision granted service connection for obstructive sleep apnea, thereby resolving each of those claims. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disability first diagnosed after discharge may be service connected if all the evidence establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Certain chronic diseases listed in 38 C.F.R. § 3.309(a) (to include hypertension, arthritis, and SNHL as an organic disease of the nervous system) may be presumed to be service connected if manifested to a compensable degree within a specified period of time postservice (one year for hypertension, arthritis, and organic disease of the nervous system). 38 U.S.C. § 1137; 38 C.F.R. §§ 3.307, 3.309(a). Nexus of a chronic disease listed in § 3.309(a) to service may be established by showing continuity of symptomatology following service. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). Gout is a form of arthritis. Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 1. Service connection for gout. The Veteran contends that he currently has gout that was first manifested during service. His STRs (service treatment records) are negative for complaint, finding, treatment, or diagnosis of gout. There is no indication, nor is it contended, that gout, a form of arthritis, was noted as chronic in service or manifest to a compensable degree within one year of separation. Thus, service connection on a presumptive basis is not for application. 38 C.F.R. §§ 3.307, 3.309. A November 1983 DA Form 1811, Physical Data and Aptitude Test Scores Upon Release from Active Duty, states that the Veteran's PULHES score was 1-1-1-1-1-1A. In a physical profile block on an examination report, there are six categories (P,U,L,H,E,S), including "P" for physical capacity or stamina, "U" for upper extremities, "L" for lower extremities, "H" for hearing and ears, "E" for eyes, and "S" for psychiatric. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992), quoting Para. 9-3(c)(1) AR 40-501, Change 35 (Feb. 9, 1987) ("An individual having a numerical designation of '1' under all factors is considered to possess a high level of medical fitness and, consequently is medically fit for any military assignment."). The post-service medical evidence is negative for complaint, finding, treatment, or diagnosis regarding gout until a December 2007 VA treatment record, when the Veteran feared he might have gout, noting hard bony prominences around his finger joints without pain for many years that he thought might be tophi; the provider told him that these were not tophi but early osteoarthritis. On May 2008 VA treatment, the Veteran sought emergency treatment for ankle pain with radiation toward the foot. He reported that his left wrist had hurt similarly two weeks earlier but went away after one day. The assessment was foot pain "pretty suspicious for gout". On follow-up treatment, he reported that he was given indomethacin which he took once with good results, and the gout was resolving. The provider opined that if in fact the pain disappeared in the length of time stated, it is unlikely that the pain was secondary to gout; the provider suggested that the Veteran be seen during an acute episode of his "gout" so that an aspiration of the joint for uric acid crystals could be done. On January 2009 VA treatment, the Veteran presented with severe left inguinal pain and difficulty with moving the left leg, most concerning for septic joint/synovitis vs. gout. He was not aware whether he had had gout in the past, but he did not remember ever having big toe pain. The impressions included left hip septic arthritis vs. synovitis vs. gout. The provider opined that although the Veteran was never diagnosed with gout and his history and exam did not really support the diagnosis, gout should still be on the differential. On follow-up treatment three days later, the provider noted that the concern of gout was now low given no crystal growth and the Veteran improved after rapid wash-out surgery the previous day; the provider opined that a septic arthritis was the most likely etiology for the acute left hip arthritis. On February 2015 VA treatment, the Veteran was noted to have a history of polyarthralgia for the previous 5 years or more; his primary care doctor had recently suspected rheumatoid arthritis. Subsequent VA treatment records reflect treatment for rheumatoid arthritis. In September 2016, the Veteran was afforded VA examinations for disabilities of the back, feet, knees and lower legs, and shoulders and arms; there was no diagnosis of gout. Similarly, in July 2017 he submitted Disability Benefits Questionnaires (DBQs) for disabilities of the ankles, feet, hips and thighs, knees and lower legs, shoulders and arms, back, and wrists; there was again no diagnosis of gout. On March 2020 VA treatment, the Veteran reported that his feet and ankles had been swollen with streaks of pain from his hip to his toes, and at times his feet were numb and hot. He reported having an attack that was so bad he was thinking it could possibly be gout. A provider opined in response that it is possible he has gout since his uric acid levels were elevated and he had already been started on tofacitinib. In May 2020, the Veteran reported having swollen feet and ankles "due to the last gout attack". The Board notes that the Veteran is already service-connected for favorable ankylosis of five digits of both hands, thoracolumbar spine degenerative arthritis with intervertebral disc syndrome, bilateral foot degenerative arthritis with calcaneal spurs, left hip limitation of abduction/extension/flexion, left and right knee osteoarthritis, and left wrist osteoarthritis. Gout was not manifested in service and was not clinically noted for many years postservice. Accordingly, service connection for gout on the basis that it became manifest in service and persisted is not warranted. While the Veteran may substantiate the claim by competent medical evidence that he currently has gout that is etiologically related to his service, he has presented no such evidence. There is no credible evidence of a related disease or injury in service, and therefore no possibility of a probative positive nexus opinion based on the current record in this matter. The Board concludes that, as the evidence persuasively favors against service connection for gout, it is not in approximate balance, and the benefit-of-the-doubt rule does not apply. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Therefore, the appeal in the matter must be denied. 2. Service connection for hypertension. The Veteran contends that hypertension was first manifested during his service. His STRs are negative for complaint, finding, treatment, or diagnosis regarding high blood pressure/hypertension. A November 1983 DA Form 1811, Physical Data and Aptitude Test Scores Upon Release from Active Duty, states that the Veteran's PULHES score was 1-1-1-1-1-1A. In a physical profile block on an examination report, there are six categories (P,U,L,H,E,S), including "P" for physical capacity or stamina, "U" for upper extremities, "L" for lower extremities, "H" for hearing and ears, "E" for eyes, and "S" for psychiatric. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992), quoting Para. 9-3(c)(1) AR 40-501, Change 35 (Feb. 9, 1987) ("An individual having a numerical designation of '1' under all factors is considered to possess a high level of medical fitness and, consequently is medically fit for any military assignment."). The post-service medical evidence is negative for complaints, findings, treatment, or diagnosis of high blood pressure or hypertension until an August 2004 VA treatment visit record, when hypertension was first diagnosed and HCTZ was prescribed. Subsequent VA treatment records reflect ongoing treatment for hypertension. Hypertension was not manifested in service and was not clinically noted for many years postservice. See 38 C.F.R. § 4.104, Code 7101, Note (1) (Hypertension must be confirmed by readings taken two or more times on at least 3 days. The term hypertension means that the diastolic blood pressure is predominantly 90 mm. or greater, or isolated systolic blood pressure means that systolic blood pressure is predominantly 160 mm. or greater and diastolic pressure is less than 90 mm.) Accordingly, service connection for hypertension on the basis that it became manifest in service and persisted, or on a presumptive basis (as a chronic disease under 38 U.S.C. § 1137) is not warranted. While the Veteran may substantiate the claim by competent medical evidence that his current hypertension is etiologically related to his service, he has presented no such (medical opinion or textual) evidence. Although VA has a duty to assist the appellant in the development of his claim, such duty is not "a one-way street." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991), aff'd on reconsideration, 1 Vet. App. 406 (1991). Rather, the appellant also has an obligation to assist in the adjudication of his claim. "If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood, 1 Vet. App. at 195. A mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, the Board finds that VA medical opinions regarding service connection are not necessary to decide the claim. Rather, there is sufficient medical evidence upon which to base a decision. See Locklear v. Nicholson, 20 Vet. App. 410 (2006). The Board concludes that, as the evidence persuasively favors against service connection for hypertension, it is not in approximate balance, and the benefit-of-the-doubt rule does not apply. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Therefore, the appeal in the matter must be denied. 3. Service connection for a left shoulder disability. 4. Service connection for a right shoulder disability. The Veteran's STRs show that, in August 1981, he was seen twice for a left shoulder injury incurred in a fall; the assessment was a 1st degree AC strain. The STRs are otherwise negative for complaints, findings, treatment, or diagnosis of a left or right shoulder disability. A November 1983 DA Form 1811, Physical Data and Aptitude Test Scores Upon Release from Active Duty, states that the Veteran's PULHES score was 1-1-1-1-1-1A. In a physical profile block on an examination report, there are six categories (P,U,L,H,E,S), including "P" for physical capacity or stamina, "U" for upper extremities, "L" for lower extremities, "H" for hearing and ears, "E" for eyes, and "S" for psychiatric. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992), quoting Para. 9-3(c)(1) AR 40-501, Change 35 (Feb. 9, 1987) ("An individual having a numerical designation of '1' under all factors is considered to possess a high level of medical fitness and, consequently is medically fit for any military assignment."). The post-service medical evidence is negative for complaint, finding, treatment, or diagnosis regarding a disability of either shoulder until a February 2015 VA treatment record, when the Veteran reported pain in the anterior shoulders. He was noted to have a history of polyarthralgia for the previous 5 years or more; his primary care doctor had recently suspected rheumatoid arthritis. Subsequent VA treatment records include treatment for joint pain in widespread joints including the shoulders, with assessments of seropositive rheumatoid arthritis. On September 2016 VA examination, the Veteran reported that during military service his shoulder would hurt when carrying heavy equipment and gear that he estimated to weigh 150 pounds. He reported that his shoulders were hurting all the time and had become worse over time. He reported that, currently, when he has back pain he experiences shooting pain that goes up the back into the shoulders, and carrying weight of 20 pounds or more increases the shoulder pain. Bilateral shoulder X-rays were negative, and the examiner noted that there was no ongoing treatment of a shoulder condition found in the medical records. Following a physical examination, the diagnosis was bilateral shoulder strain. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, noting that during service the left shoulder condition was acute only, and there is no evidence of chronicity of care, and therefore a nexus has not been established. On July 2017 shoulder and arm conditions disability benefits questionnaire (DBQ), the Veteran reported that he hurt his shoulder on active duty in August 1981 during field maneuvers. On physical examination, the diagnoses included left shoulder glenohumeral joint osteoarthritis and glenohumeral joint instability. The provider opined that this disability is service connected. It is not in dispute that the Veteran has current left and right shoulder disabilities (bilateral shoulder strain was diagnosed on VA examination). However, a chronic left or right shoulder injury or disease in service is not shown, and arthritis of the left or right shoulder is not shown to have been manifested within a year following his separation from service. His STRs reflect that he sought treatment for left shoulder pain in August 1981 with no further or follow-up treatment. Indeed, as noted above, in November 1983, it was determined that the Veteran's upper extremities merited a numerical designation of "1," which, as delineated above, indicates a high level of medical fitness. Odiorne, supra. As such, the Veteran's symptoms evidently were acute and resolved without residual. The earliest (documented in the Veteran's claims file) postservice notation of a left or right shoulder complaint is in February 2015. Consequently, service connection for a left or right shoulder disability on the basis that either became manifest in service, or on a chronic disease presumptive basis (for arthritis) is not warranted. Considering the earliest postservice documentation of left or right shoulder complaints in 2015, continuity of a left or right shoulder disability is not shown, and service connection based on continuity of symptomatology is also not warranted. The September 2016 VA examiner opined that the Veteran's current diagnosed bilateral shoulder strain is less likely than not related to an injury, disease, or event in service. The examiner is a medical professional and the opinion is probative evidence in these matters; it reflects familiarity with the Veteran's medical history and includes rationale that cites to supporting factual data. It is the most probative competent (medical) evidence in these matters, and the Board finds it persuasive. The Board finds the July 2017 private provider's opinion in support of these claims to be inadequate because no rationale was provided in support of the opinion given. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Whether the Veteran's left or right shoulder disability is related to an injury or activities in service is a medical question beyond the scope of common knowledge and incapable of resolution by lay observation; it requires medical expertise. The Veteran is a layperson; consequently, his own opinion is not competent evidence in these matters. See Jandreau, supra. Significantly, he has not submitted a medical opinion with adequately explained rationale in support of these claims (or identified any medical provider who has offered such opinion). Although VA has a duty to assist the appellant in the development of his claim, such duty is not "a one-way street." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991), aff'd on reconsideration, 1 Vet. App. 406 (1991). Rather, the Veteran also has an obligation to assist in the adjudication of his claim. "If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood, 1 Vet. App. at 195. The Board concludes that, as the evidence persuasively favors against service connection for left or right shoulder disability, it is not in approximate balance, and the benefit-of-the-doubt rule does not apply. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Therefore, the appeal in the matters must be denied. 5. Service connection for bilateral hearing loss. The Veteran contends that his bilateral hearing loss resulted from his exposure to noise trauma during service. His DD 214 confirms that his MOS was heavy anti-armor weapons crewman, and he was a rifle M-16 expert, and hand grenade sharpshooter, with an Expert Infantryman Badge. The Veteran's STRs are negative regarding complaint, finding, treatment, or diagnosis of hearing loss. On May 1980 service enlistment examination and May 1983 service separation examination audiometry, all puretone thresholds in the pertinent frequencies (between 500 and 4000 Hertz) were in the normal range. On October 2006 VA audiology consult, the Veteran's hearing was within normal limits with excellent speech discrimination bilaterally. On January 2015 VA examination, the examiner noted the Veteran's MOS of heavy anti-armor weapons crewman and that he was a rifle M-16 expert, hand grenade sharpshooter, and earned the expert infantryman badge. His hearing was noted to be normal in both ears upon enlistment, at periodic hearing conservation screenings during service, and at separation from service. The Veteran reported that he did not participate in combat activity. He reported that he fired weapons with both hands and used hearing protection, and he did not require a hearing conservation program. Audiometry revealed that puretone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 35 35 25 20 25 LEFT 25 25 25 25 25 Speech audiometry revealed speech recognition ability of 96 percent in each ear. The assessment was normal hearing bilaterally. The examiner opined that there is no diagnosis because there is no pathology to render a diagnosis of hearing loss: there was no hearing loss present at the current time per VA disability criteria. On August 2015 VA audiology consult, the Veteran reported having a hard time hearing in background noise. Test results indicated a moderate to mild SNHL in the right ear and a mild hearing loss in the left ear. Speech discrimination was excellent bilaterally. Hearing aids were discussed and ordered. On May 2019 VA treatment, audiogram results showed moderate to severe hearing loss in both ears. On November 2020 VA examination, the Veteran reported that he did not wear hearing protection during service. He reported that he intermittently wore hearing aids 4 years ago. Audiometry revealed that puretone thresholds, in decibels were: HERTZ 500 1000 2000 3000 4000 RIGHT 95 80 80 85 90 LEFT 100 85 90 90 105+ Speech audiometry revealed speech recognition ability of 0 percent in each ear. The diagnosis was bilateral SNHL. The examiner opined that there was no permanent positive threshold shift (worse than reference threshold) greater than normal measurement variability at any frequency between 500 and 6000 Hertz for either ear. The examiner opined that the Veteran's hearing loss is not at least as likely as not (50% probability or greater) caused by or a result of an event in military service. The examiner noted that his MOS was infantryman and he reported noise exposure from artillery and cannons. The examiner noted that review of the medical records reveal that during service, the Veteran did not complain of nor was he treated for hearing loss; his service audiograms reveal that there were no recorded threshold shifts, and his enlistment and separation audiograms were normal. The examiner opined that, at the time of the examination and review of all available records, there is a lack of evidence to support military service as a cause of the Veteran's current hearing impairment. The examiner opined that the current literature does not support delayed manifestation of noise induced hearing loss, and the Veteran's hearing loss therefore is a result of age-related cochlear degeneration. The examiner opined that the Veteran's hearing loss did not begin during service, was not caused by service, and is unrelated to service; it is less likely than not due to military noise exposure. Postservice treatment records do not include any further opinions regarding the etiology of the Veteran's hearing loss. For purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies at 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; when the auditory thresholds for at least three of the frequencies at 500, 1000, 2000, 3000, and 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Hearing loss as defined in 38 C.F.R. § 3.385 need not be shown by the results of audiometric testing during a claimant's period of active military service in order for service connection for such disability to be granted. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992); see also Hensley v. Brown, 5 Vet. App. 155, 159 (1993). Thus, a claimant who seeks to establish service connection for hearing loss must show, as is required in any claim of service connection, a current hearing loss disability that is the result of an injury or disease in service, the determination of which depends on a review of all the evidence of record including that pertinent to service. It is not in dispute that the Veteran now has a bilateral hearing loss disability. Hearing loss disability (as defined in 3.385) was found on November 2020 VA examination. It may also reasonably be conceded (based on his MOS as a heavy anti-armor weapons crewman) that he was exposed to excessive levels of noise in service. What remains necessary to substantiate the claim is evidence that the current hearing loss is etiologically related to his service/acknowledged exposure to noise therein. A hearing loss disability was not manifested in service, and SNHL is not shown to have been manifested to a compensable degree within a year following the Veteran's discharge from service. Accordingly, service connection for his current hearing loss on the basis that it became manifest in service, and persisted, or on a chronic disease presumptive basis (under 38 U.S.C. § 1137; 38 C.F.R. §§ 3.307, 3.309), is not warranted. As SNHL is a chronic disease listed in 38 C.F.R. § 3.309(a) the Board has considered whether service connection may be granted based on continuity of symptomatology (under 38 C.F.R. § 3.303(b)). However, continuity of hearing loss symptomatology is not shown. It was not noted in service, to include on service separation examination (when audiometry was normal), or for many years thereafter. The evidence in the record establishes that a hearing loss disability developed after a January 2015 VA examination, and before a November 2020 VA examination. Under 38 C.F.R. § 4.85, hearing loss disability must be established by audiometry specified in governing regulation. The allegations of onset in, and continuity from, service are self-serving, and are contradicted by clinical records in the claims file; they are not competent evidence in the matter, and have no probative value. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Therefore, service connection for bilateral SNHL based on continuity of symptomatology is not warranted. The evidence is also persuasively against a finding that the Veteran's current hearing loss is otherwise shown to be etiologically related to his service. On the dispositive question of a nexus between the current hearing loss disability and service/exposure to noise therein, the only competent (medical) and probative evidence in the claims file is in the reports of the VA examinations and the opinions therein. The Board finds the opinion offered on November 2020 VA examination to be entitled to great probative weight, as the examiner reviewed the Veteran's medical history and included adequate rationale for the conclusions reached, citing to accurate factual data, medical principles, and relevant medical literature. While the Veteran is competent to report his perceptions of reduced hearing acuity, he is a layperson, and is not competent to provide a nexus opinion relating such disability to exposure to noise or acoustic trauma during remote service (absent a showing of onset in service/continuity since). The etiology of hearing loss in such cases is a medical question that requires medical expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board concludes that, as the evidence persuasively favors against service connection for bilateral hearing loss, it is not in approximate balance, and the benefit-of-the-doubt rule does not apply. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Therefore, the appeal in the matter must be denied. R. Behlen Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Schechner, 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.