Citation Nr: 22015757 Decision Date: 03/18/22 Archive Date: 03/18/22 DOCKET NO. 19-32 693A DATE: March 18, 2022 REMANDED Entitlement to service connection for bilateral hearing loss is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1965 to September 1967. This matter comes before the Board of Veterans Appeals (Board) on appeal from an October 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board finds that it is necessary to remand the matter for additional development. First, the Board notes that, in addition to his active duty service, the Veteran's records indicate service in the Army Reserve both prior and subsequent to his active duty, including particular periods of active duty for training (ACDUTRA). However, the precise dates of all periods of ACDUTRA and inactive duty for training (INACDUTRA) are not available. On remand, the RO should confirm the Veteran's periods of ACDUTRA and INACDUTRA. Because the Veteran served in the Army Reserve after September 1967, the Board notes that there is a question as to whether the Veteran's conditions manifested during or are the result of his ACDUTRA and/or INACDUTRA. Second, the Board finds that the October 2019 VA examination is inadequate. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The medical opinion must support its conclusions with data and reasoning that the Board can follow. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-304 (2008). The October 2019 examiner primarily relied on a lack of evidence of findings of hearing loss in the Veteran's STRs as the basis of their opinion. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992) (finding that a lack of documented hearing loss while in service is not fatal to a claim for service connection). The examiner also presumed that the Veteran's hearing loss did not have its onset until June 2017, because hearing loss was not documented in the claims file prior to that date. Not only was this assumption inappropriate (as absence of evidence is not evidence of absence, and the Veteran's testimony must be taken into account in addition to medical evidence), but a February 2020 letter from one of the Veteran's treating physicians proves that it was false. The February 2020 letter states that the physician began treating the Veteran for "severe hearing loss" in 1996, leaving open the possibility that his hearing loss had an even earlier onset. Because the October 2019 VA examination provided inadequate reasoning for its conclusions, and was based on incorrect factual statements, a new examination must be obtained. The matters are REMANDED for the following action: 1. The RO should determine the specific dates of when the Veteran served on ACDUTRA and/or INACDUTRA. In this regard a report detailing the Veteran's award of reserve retirement points will NOT represent compliance with this instruction. Rather, each and every date of active duty, ACDUTRA, and INACDUTRA must be verified. Then, issue a memorandum for inclusion in the claims file detailing each period of verified active military service, whether on active duty, ACDUTRA, or INACDUTRA. All medical treatment records associated with the Veteran's Reserve service should also be obtained and associated with the claims file. 2. Obtain an opinion from an appropriate clinician, who has not already provided an opinion in this matter, regarding the nature and etiology of the Veteran's bilateral hearing loss. If the clinician believes an in-person or telehealth examination is necessary, one should be scheduled. The examiner shall be provided with the complete claims file, including a copy of this remand. After certifying that they have reviewed the entire claims file, the examiner should answer the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's hearing loss was caused by, or had its onset during, active duty service? (b) Is it at least as likely as not that the Veteran's hearing loss was caused by a disease or injury incurred or aggravated in the line of duty during a period of ACDUTRA? (c) Is it at least as likely as not that the Veteran's hearing loss was caused by an injury incurred or aggravated in the line of duty during a period of INACDUTRA? (d) Is it at least as likely as not that the Veteran's hearing loss was caused or aggravated by his service-connected tinnitus? A complete and fully explanatory rationale must be provided for any opinion offered, citing any record evidence or medical literature relied upon. The examiner must give due weight to the Veteran's lay testimony and to favorable opinions from treating physicians. If an opinion cannot be rendered without resorting to speculation, the examiner must explain why. 3. This case has been Advanced on the Docket. The AOJ must review the examination reports and opinions to ensure they are adequate and comply with the Board's specific remand directives herein. If an opinion is deficient in any manner, the AOJ must undertake immediate corrective action before returning the case to the Board. Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Shermila Sundquist 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.