Citation Nr: 22017785 Decision Date: 03/26/22 Archive Date: 03/26/22 DOCKET NO. 18-53 407 DATE: March 26, 2022 ORDER The petition to reopen the claim for entitlement to service connection for headaches is granted. The petition to reopen the claim for entitlement to service connection for a lower back condition is granted. Entitlement to service connection an acquired psychiatric disability to include major depressive disorder, and/or for post-traumatic stress disorder (PTSD) to include insomnia is granted. Entitlement to service connection for left hip condition is denied. Entitlement to service connection for skin rash on buttocks and chest is denied. REMANDED Entitlement to an initial compensable rating for bilateral hearing loss is remanded. Entitlement to service connection for left shoulder condition is remanded. Entitlement to service connection for a neck condition (cervical strain) is remanded. Entitlement to service connection for lower back condition, injury is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for a neurological disability to include traumatic brain injury (TBI) and/or non-combat related concussion is remanded. FINDINGS OF FACT 1. The claim for entitlement to service connection for headaches was initially denied in the January 2005 rating decision. The Veteran was notified of the decision, but did not appeal, thus it became a final decision. 2. Evidence received since the January 2005 rating decision relates to a previously unestablished fact necessary to substantiate the claim for entitlement to service connection for headaches. 3. The claim for entitlement to service connection for lower back condition was initially denied in the April 2003 rating decision. The Veteran was notified of the decision, but did not appeal, thus it became a final decision. The Veteran's claim was also denied in January 2005, and February 2010. 4. Evidence received since the April 2003, January 2005, and February 2010. rating decisions relate to a previously unestablished fact necessary to substantiate the claim for entitlement to service connection for lower back conditions. 5. The Veteran's acquired psychiatric disability diagnosed to include major depressive disorder, and PTSD has been linked to his active service by a medical professional. 6. The evidence of record is against finding that the Veteran has had a left hip condition at any time during, or approximate to, the pendency of the claim. 7. The evidence of record is against finding that the Veteran has had a skin condition at any time during, or approximate to, the pendency of the claim. CONCLUSIONS OF LAW 1. New and material evidence to reopen the claim for service connection headaches has been received. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a)(2021). 2. New and material evidence to reopen the claim for service connection lower back condition has been received. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156(a)(2021). 3. The criteria for service connection for acquired psychiatric disability to include major depressive disorder and PTSD has been met. 38 U.S.C. § 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2021). 4. The criteria for entitlement to service connection for a left hip condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303(a)(2021). 5. The criteria for entitlement to service connection for a skin condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303(a)(2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1991 to October 1994. In September 2020, the Veteran testified at a video conference hearing (hearing) before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. The Board of Veterans' Appeals (Board) notes the Veteran's claim for a lower back condition was initially denied in April 2003. In December 2018, the Veteran attended a VA examination, which suggests that the claim was reopened. Despite the determination by the Regional Office (RO) concerning new and material evidence, the Board must find new and material evidence in order to establish its jurisdiction to review the merits of the previously denied claim. See Barnett v. Brown, 83 F. 3d 1380, 1383 (Fed. Cir. 2001) (the Board is under the statutory obligation to conduct a de novo review of the new and material issue). Thus, the title page includes the issue of whether new and material evidence has been presented to reopen the claim for service connection for lower back condition. The Board also observes that the Veteran initially filed a claim for TBI. However, the Veteran's VA treatment records confirm a diagnosis of loss of consciousness and concussion. In this regard, a claim for service connection may be expanded beyond a veteran's lay description of a disability to include any disability "that may reasonably be encompassed by several factors including: the claimant's description of the claim; the symptoms the claimant describes; and the information the claimant submits or that the Secretary obtains in support of the claim." See Clemmons, 23 Vet. App. 1, 5 (2009). "[T]he claimant's intent in filing a claim is paramount to construing its breadth." Id. To effectuate that intent, "VA shall afford lenity to a veteran's filings that fail to enumerate precisely the disabilities included within the bounds of a claim," which "is best accomplished by looking to the veteran's reasonable expectations in filing the claim and the evidence developed in processing that claim." Murphy v. Wilkie, 983 F.3d 1313, 1318 (Fed. Cir. 2020); see also Grimes v. McDonough, 34 Vet. App. 84 (2021) (citing and discussing Clemons and the scope of a Veteran's claim/appeal). Thus, the Veteran's TBI claim has been recharacterized more broadly as neurological disability to reflect the different diagnoses. Petition to Reopen Generally, a claim that has been denied in a final unappealed decision may not thereafter be reopened and allowed. An exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. New and material evidence is defined as evidence not previously submitted to agency decision makers that bears directly and substantially upon the specific matter under consideration; such new and material evidence can neither be cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 U.S.C. § 3.156(a); Hickson v. Shinseki, 23 Vet. App. 394, 398 (2010). The Board will generally presume the credibility of the newly submitted evidence for determining whether new and material evidence has been presented. Duran v. Brown, 7 Vet. App. 216, 220 (1994). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). In deciding whether new and material evidence has been submitted, the Board looks at the evidence submitted since the last final denial of the claim on any basis. Hickson v. West, 12 Vet. App. 247, 251 (1999). 1. Headaches The petition to reopen the claim for entitlement to service connection for headaches is granted. Here, the claim for entitlement to service connection for headaches was denied in the January 2005 rating decision due to lack of a current disability. The Veteran was notified but did not appeal the decision, thus it became a final decision. See 38 U.S.C. §§ 7105, 38 C.F.R. § 20.1103. At the time of the last final decision, the January 2005 rating decision, the evidence of record included: the Veteran's service treatment records (STRs) from January 1991 to October 1994; VA treatment records from October 2003 to October 2004; and a November 2004 VA Form 21-4138, Statement in Support of Claim. The evidence received since the January 2005, includes the Veteran's testimony at the September 2020 Board hearing, a December 2017 VA examination for headaches, VA treatment records dated through December 2018, which confirmed a current diagnosis. The Board finds that the evidence is new as it was not previously before the agency and it is relevant because it relates to the issues of a current disability and etiology which is related to nexus. Accordingly, the Veteran's claim for headaches is reopened based on new and material evidence. 2. Lower Back Condition The petition to reopen the claim for entitlement to service connection for lower back condition, is granted. Here, the claim for entitlement to service connection for lower back condition was denied in the April 2003 rating decision due to lack of a current disability and negative nexus. The Veteran was notified but did not appeal the decision, thus it became a final decision. See 38 U.S.C. §§ 7105, 38 C.F.R. § 20.1103. Similarly, the claim was denied in a January 2005 and February 2010 rating decisions because the evidence did not show a link between the Veteran's back disability and active service. At the time of the last final decision, the January 2005 rating decision, the evidence of record included: the Veteran's service treatment records (STRs) from January 1991 to October 1994; VA treatment records from October 2003 to October 2004; and a November 2004 VA Form 21-4138, Statement in Support of Claim. The evidence received since the January 2005 rating decision, includes the Veteran's testimony at the September 2020 Board hearing, a February 2010 VA examination, VA treatment records from January 2004 to February 2010, and November 2017 Letter from Dr. B.S., which confirmed a current diagnosis and provided a nexus opinion. The Board finds that the evidence is new as it was not previously before the agency and it is relevant because it relates to the issues of a current disability and nexus. Accordingly, the Veteran's claim for lower back condition is reopened based on new and material evidence. Service Connection 3. An Acquired Psychiatric Disability The Veteran seeks service connection for an acquired psychiatric disability and PTSD. See August 2017 VA Form 21-526 EZ, Fully Developed Claim. Legal Criteria Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained in the line of duty during active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for a disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303 (d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Relevant Facts and Analysis In November 2017, a VA psychologist assessed the Veteran with PTSD. See November 2017 VA Psychology Note in CAPRI received November 2017. The Veteran was also diagnosed with PTSD and major depressive disorder during the December 2018 VA examination. See December 2018 VA Initial Post Traumatic Stress Disorder Disability Benefits Questionnaire (DBQ). Thus, the first element of service connection has been established. Regarding, the second element of service connection, an in-service event or illness, the Veteran provided competent and credible lay statements. During the December 2018 VA examination, the Veteran reports that while stationed in Korea, he was "subjected to small arms fire from North Koreans. December 2018 VA Initial Post Traumatic Stress Disorder PTSD. He also states he witnessed a fellow soldier was shot in the head. Id. The examiner finds that the Veteran's stressor contributed to his PTSD. Id. The Board finds the Veteran competent to assert the events and symptoms he observed and experienced firsthand. See Layno v. Brown, 6 Vet. App. 465 (1994). Therefore, these statements have been accorded probative weight. Based on the Veteran's statements of an inservice stressor, the second element of service connection has been met. The question before the Board is whether the Veteran's current disability is related to active service. The Board notes that the December 2018 VA examiner did not provide a nexus opinion. However, in November 2021, Dr. K.S.P., a VA Psychologist provided a nexus opinion. See Dr. K.S.P. Letter dated November 2021. She notes that the Veteran has received treatment from the PTSD clinic since November 2017. Furthermore, she states that the Veteran's "chronic PTSD was caused by a traumatic event that occurred while serving in Korea...." Id. The Board finds the opinion from Dr. K.S.P. is based on treatment of the Veteran for four (4) years and includes consideration of the Veteran's statements of traumatic events he experienced during active service. Additionally, this opinion is based on knowledge of Veteran's treatment history and is consistent with the evidence of record. Therefore, the Board accords great probative value to Dr. K.S.P.'s medical opinion. Based on the above and resolving all reasonable doubt in favor of the Veteran, the Board finds that the weight of the evidence supports a grant of service connection. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Accordingly, service connection for an acquired psychiatric disability including PTSD and major depressive disorder is granted. 4. Left Hip The Veteran seeks service connection for a left hip injury. See August 2017 VA Form 21-526 EZ, Fully Developed Claim. However, the Board finds that the Veteran does not have a current left hip disability for VA compensation purposes, as such there is no present-day left hip disability which can be related or attributed to his military service. In this regard, the Board notes that the Veteran's STRs are silent for any left hip injury or complaints. Additionally, his post service VA treatment records document do not contain any diagnosis or complaints related to left hip. For the purposes of service connection, pain alone, without any underlying pathology or disease process, can constitute a current disability if there is objective evidence that the pain causes functional impairment resulting in a decrease of earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1363 (Fed. Cir. 2018). Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the evidence of record weighs against finding that the Veteran has a current left hip disability or pain resulting in functional impairment. Specifically, the July 2015 VA examiner notes that the Veteran has normal range of motion (4 out of 5) for the left hip. Thus, without a diagnosis or qualifying pain resulting in functional impairment during the period on appeal, the Board finds that the first element of service connection has not been established. See Saunders, 886 F.3d at 1363; Brammer, 3 Vet. App. at 225; 38 C.F.R. § 3.303(a). There is no other competent and credible evidence demonstrating a current left hip disability. To the extent the Veteran has reported he has a left hip disability, the Board notes that he is not competent to diagnose such a disability. To diagnose a specific disability and opine as to the etiology of such symptoms requires medical expertise when the question is a complex one, such as this case. See Jandreau v. Shinseki, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The record does not show that the Veteran has the required expertise. The Board acknowledges that the Veteran was not afforded an opportunity to attend a VA examination for his left hip claim. The Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). Given the absence of competent evidence of a current disability, the Board finds that the Veteran has not substantiated his claim for service connection for a left hip disability. Therefore, the Board concludes that a VA examination or opinion is not warranted. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). Based on the forgoing, the Board finds that service connection for a left hip disability is not warranted. As there is not an approximate balance of evidence, that benefit-of-the-doubt rule is not applicable in this case. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 5. Skin The Veteran seeks service connection for a skin disability. See August 2017 VA Form 21-526 EZ, Fully Developed Claim. Upon review of the evidence, the Board finds that the Veteran does not have a currently diagnosed skin disability. The Board notes that the December 2017 VA examiner noted normal skin in the diagnosis section. See December 2017 VA Skin Diseases DBQ. However, the examiner also notes in the medical history that the Veteran's skin symptoms are located in his ankles, scrotum, and groin and occur two to three times a year. Id. In her remarks, the examiner notes that there was no objective evidence of a chronic skin condition and that his complaints were subjective only. The examiner did not find any occupational impairment as a result of the Veteran's claimed skin disability. Additionally, the Veteran's VA treatment records also fail to confirm a diagnosis of a skin disability. See i.e., April 2017 VA Ambulatory Outpatient Note in CAPRI received November 2017 (noting skin was negative for rash, dry skin, itching, hives, or lesions). Accordingly, the Board concludes that the evidence does not establish that he has a diagnosis of any skin condition. In the absence of proof of an underlying condition, there can be no valid claim as to that issue. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. In the absence of any competent evidence of any skin condition, the Board must conclude the Veteran does not currently suffer from any such disability and must thus deny the Veteran's claim as to that particular issue. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). The Board considered whether pain could constitute a disability if it causes impairment in earning capacity. See Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). Here, however there is no evidence, nor does the Veteran allege, that there are any current skin symptoms, such as pain, that limit his functional ability. Id. As there is no approximate balance of the evidence, the benefit of the doubt is not applicable and the claim is denied, where the evidence weighs against the claim. REASONS FOR REMAND 1. Bilateral Hearing Loss The Board finds that a remand is warranted for a new VA examination to assess the current severity of the Veteran's service-connected bilateral hearing loss disability based on evidence of worsening since the last VA examination. During the September 2020 Board hearing, the Veteran reported that his hearing loss has worsened since his last VA audiological examination in December 2017. Specifically, the Veteran reported that his hearing has gotten worse and is currently using hearing aids. See Hearing Transcript. The Board notes that during the December 2017 VA examination, the Veteran states that hearing aids were recommended but he was not using them. See December 2017 VA Hearing Loss and Tinnitus DBQ. Thus, based on his competent and credible testimony, the Veteran should be provided with a new VA examination to specifically address the current level of severity of his bilateral hearing loss as there is an indication the disability has increased in severity since the last examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007) (holding that a VA audiologist conducting a VA audiological evaluation must fully describe the functional effects caused by a hearing disability in his or her final report). Therefore, the Board finds that a remand is warranted. 2. Left Shoulder Condition Upon review, the Board finds that a remand is warranted to determine the etiology of the Veteran's left shoulder because additional clarification is necessary. The Board notes that the Veteran's July 1990 entrance examination denotes the Veteran's had a left shoulder gunshot wound from 1986 and that he was qualified for active duty. See July 1990 Report of Medical Examination, in STR-Medical. Thus, the Veteran's left shoulder gunshot wound has been noted as a pre-existing disability, and the presumption of soundness does not attach as to the gunshot wound. However, if a pre-existing disorder is noted upon entry into service, service connection may be granted based on aggravation of that disorder. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b); Wagner v. Principi, 370 F. 3d 1089, 1096 (Fed. Cir 2004). Independent medical evidence is needed to support a finding that the pre-existing disorder increased in severity in service. See Paulson v. Brown, 7 Vet. App. 466, 470-471 (1995); Crow v. Brown, 7 Vet. App. 238, 246 (1994). A pre-existing disability or disease will be considered to have been aggravated by active service when there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306 (a), (b). The Veteran was diagnosed with a left shoulder strain during the December 2017 VA examination. See December 2017 VA Shoulder Conditions DBQ. The VA examiner opined that the Veteran's left shoulder disability clearly and unmistakably pre-existed service and was not aggravated during service. See December 2017 VA Medical Opinion DBQ. The examiner reasoned that there was no evidence of medical treatment for the Veteran noted in his STRs. Id. The Board finds that the December 2017 VA medical opinion is insufficient because the examiner did not address the Veteran's left shoulder gunshot wound. Additionally, the examiner did not provide an adequate rationale for her conclusion that the Veteran's current left shoulder strain pre-existed service when his entrance examination only notes a gunshot wound. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007)(A medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.) Thus, based on the foregoing, the Veteran should be afforded a VA examination with medical opinion from a physician concerning whether the Veteran's currently diagnosed left shoulder disability is due to the pre-existing gunshot wound and, if so, was it clearly and unmistakably aggravated by his active service beyond the natural progress of the disease. See McLendon v Nicholson, 20 Vet. App. 79 (2006). If it is determined that the Veteran's left shoulder strain or any other disorder diagnosed on remand, is not due to the pre-existing gunshot wound, a medical opinion is also needed as to the etiology of that disorder. 3. Cervical Strain The Board finds a remand is necessary for the Veteran's cervical spine disability because the VA medical opinions did not address the Veteran's lay statements. Specifically, during the September 2020 Board hearing the Veteran testifies he injured his neck during a training exercise at Fort Sill, Oklahoma when the Bradley tank he was in hit a whole and he was thrown out of tank. See Hearing Transcript. The Board also notes that the Veteran's STRs also confirm that the Veteran complained of neck pain/injury as a result of a car accident in June 1994. See June 1994 STR. The December 2017 and March 2018 VA examiners opined that the Veteran's cervical strain was less likely than not related to active service because the Veteran's injury was acute and that there was no evidence of chronicity of care. See December 2017 VA Medical Opinion DBQ; March 2018 VA Medical Opinion DBQ. However, the examiners did not address the Veteran's contention that the injury he sustained from being thrown from a Bradley tank is related to his current cervical strain. See Miller v. Wilkie, 32 Vet. App. 249 (2020) (stating that a VA medical opinion lacks probative value when the examiner fails to address a veteran's lay reports of his medical history and symptoms). Additionally, it is unclear from the medical opinions which incident the examiners considered when rendering their opinions. The Board also notes that a December 2018 VA examiner recorded the Veteran's lay statements regarding his in-service injuries, but the examiner did not provide a medical opinion on the etiology of his current cervical strain. See December 2018 VA Neck (Cervical Spine) Conditions DBQ. As such, the Board finds a remand is warranted for an addendum medical opinion to determine the etiology of the Veteran's current cervical spine disability. 4. Lower Back Disability The Board finds a remand is warranted for an addendum medical opinion for the Veteran's lower back condition in order to obtain an adequate medical opinion. Notably, the February 2010 VA examiner provided a negative nexus opinion for the Veteran's low back disability. See February 2010 VA Compensation and Pension Examination for Spine. The examiner reasoned that the Veteran entered service after a car accident with no residuals and was cleared for active duty and that he left active service with no history of reinjury. Id. While the examiner documents the Veteran's report of being injured from falling off a tank during active service, which included treatment and change in physical profile, the examiner did not address this important information which appears to contradict his rationale of no reinjury during service. Thus, it appears that the examiner relied on inaccurate facts to support his rationale. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (A medical opinion based on an inaccurate factual premise has no probative value.) The Board also notes that a December 2018 VA examiner confirmed the Veteran's diagnosis of degenerative arthritis of lumbar spine with bilateral lower extremity radiculopathy. See December 2018 VA General Medical Pension DBQ. However, the examiner did not provide a nexus opinion. See Barr v. Nicholson, 21 Vet. App. 303 (2007)(When VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate.) The Board notes that the Veteran submitted medical opinions from Dr. B.S.-R. dated January 2018, December 2018, and October 2020. See i.e., October 2020 Letter from Dr. B.S.-R. In her letter, Dr. B.S.-R. states that the Veteran's current back condition is related to military service. Id. In the January and December 2018 letters, Dr. B.S.-R stated that she reviewed the Veteran's service records and that the Veteran's lower back condition was related to service. Unfortunately, the Board finds that the VA medical opinion from Dr. B.S.-R. is inadequate because it is not supported by an adequate rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (A medical examination and opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). Thus, based on the foregoing, an addendum medical opinion is necessary to determine the etiology of the Veteran's low back disability, which is supported by adequate rationale. 5. Erectile Dysfunction The evidence of record indicates that the Veteran's claimed erectile dysfunction disability, is potentially related to his lower back condition. Because the issue of entitlement to service connection for a lower back disability is being remanded, the issues of entitlement to service connection for an erectile dysfunction disability, and a bilateral lower extremity neuropathy disability are inextricably intertwined and must be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). The Veteran has also asserted that his erectile dysfunction is due to medications for his other medical conditions. See August 2017 VA Form 210526EZ, Fully Developed Claim. As such, the claim is remanded as intertwined with the pending claims. The RO should obtain a medical opinion if the Veteran's service connection for a lower back condition is granted. 6. Headaches The Board finds a remand is necessary to obtain an addendum medical opinion for the Veteran's headaches. Notably, the Veteran was diagnosed with acute intermittent tension (tension type headaches) during the December 2017 VA examination. See December 2017 VA Headache Conditions DBQ. However, the examiner provided a negative nexus opinion for the Veteran's claimed headaches. See December 2017 VA Medical Opinion DBQ. The examiner reasoned that the Veteran had subjective symptoms only, and that there was no objective evidence of a chronic condition. Id. However, the Veteran's VA treatment records confirm that he was assessed with generalized headaches in October 2018. See October 2018 VA Nurse Practitioner Note, in CAPRI received November 2018. Generalized headaches are also listed on the Veteran's medical problem lists. See December 2018 VA Problem List, in CAPRI received December 2018. Thus, in light of the Veteran's VA treatment records which confirm he was diagnosed with headaches, the December 2017 VA medical opinion is inadequate as it is based on inaccurate facts. Accordingly, a new medical opinion is required to determine the etiology of the Veteran's current headache disability. 7. Neurological Disorder The Board finds a remand is necessary to obtain a VA examination and opinion for clarification of the Veteran's neurological disorder because the Board lacks sufficient information to decide the claim. The Board notes that a March 2018 VA examiner found that the Veteran did not have a diagnosis of TBI or residuals of TBI. See March 2018 VA Initial Evaluation of Residuals of TBI DBQ. The examiner also noted that the Veteran had headaches and insomnia in addition to cervical and lumbar spine disc disease. The examiner also stated that the Veteran's multiple medical conditions accounted for his symptoms. Id. However, the Board notes that the Veteran's VA treatment records reflect he has a diagnosis of concussion with one (1)-24 hours loss of consciousness. See October 2018 VA Nurse Practitioner Note, in CAPRI received November 2018. He was also assessed with non-combat concussion in July 2018. See July 2018 VA TBI Examination Non-Combat Related Note, in CAPRI received November 2018. As the March 2018 VA examiner did not have an opportunity to review the July and October 2018 diagnosis of concussion, the March 2018 is incomplete. Accordingly, a new VA examination and opinion should be obtained to determine whether the Veteran's neurological disability is related to service. The matters are REMANDED for the following action: Hearing Loss 1. Schedule the Veteran for a VA audiological examination to determine the current severity of his service-connected bilateral hearing loss. Pursuant to § 4.85 an examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. The claims file and a copy of this remand must be made available to the examiner and reviewed in conjunction with the examination. 2. The examiner is asked to provide the following information: 3. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. Specifically report the numerical findings of pure tone decibel loss at 500, 1000, 2000, 3000 and 4000 Hertz and speech recognition derived using the Maryland CNC Test. The examiner must fully describe the functional effects caused by the Veteran's hearing disability. Left Shoulder 4. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any current left shoulder disorder. All indicated tests and studies should be performed and all findings should be reported in detail. The entire record should be made available to the examiner. 5. The examiner is requested to render the following opinions: 6. Identify the Veteran's currently diagnosed left shoulder disability(ies). 7. The examiner should take into account the fact that the Veteran has been diagnosed with left shoulder gunshot wound, which has been found to pre-exist service. 8. IF there is an increase in severity for the Veteran's left shoulder gunshot wound, the examiner should indicate whether there is clear and unmistakable evidence that any increase in severity was due to the natural progression of the condition(s). The examiner should note that "clear and unmistakable" means that the evidence is undebatable. 9. If left shoulder strain, or any other currently diagnosed shoulder condition(s) is not related to the pre-existing gunshot wound, then an opinion must be provided as to whether it is at least as likely as not that the currently diagnosed disorders are due to the Veteran's active service and an injury, he sustained from falling from a tank in 1991. Cervical and Lumbar Spine Disabilities 10. Obtain an addendum opinion from a medical professional with appropriate experience to render an etiology opinion for the Veteran's cervical and lumber spine disabilities. If the examiner determines that an opinion may not be offered without first examining the Veteran, then schedule the Veteran for an appropriate examination(s). Any clinically indicated testing and/or consultations should be performed. 11. The examiner must review the claims folder including this remand and acknowledge such review in the report. Based on review of the, February 2010, December 2017, March 2018, and December 2018 VA examination reports and medical opinions, the examiner is requested to address the following: 12. Identify the Veteran's current cervical and lumbar spine disability(ies). 13. If arthritis is found, the examiner should opine whether it at least as likely as not any arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 14. Assuming that the standard is at least as likely as not, is it possible that the Veteran's current cervical and/or lumbar spine disabilities could be related to or caused by any in-service event, injury, or disease including an injury he sustained from falling from a tank in 1991 or the car accident in June 1994. 15. The examiner must discuss the veteran's lay statements regarding the history, chronicity, and continuity of symptomatology, to include the veteran's report of his in-service injury. S/he should outline that history in the report. 16. Are the Veteran's assertions that his current cervical and/or lumbar spine disability was incurred as a result of falling from a tank in 1991 or the car accident in June 1994, consistent with medical knowledge or implausible? 17. Do the Veteran's reports about his symptoms or his in-service injury from falling from a tank in 1991 or the car accident in June 1994 align with how the Veteran's current cervical and/or lumbar spine disabilities are known to develop? 18. Whether it is medically feasible that his current cervical and/or lumbar spine disability was caused by his in-service injury from falling from a tank in 1991 or the car accident in June 1994? 19. If the answer to any of the above questions is negative, state why not and on what basis this conclusion was made. 20. If any answer to any of the above questions is positive, state why and on what basis this conclusion was made. 21. The examiner should address the medical opinions from Dr. B.S.R. dated January 2018 December 2018, and October 2020 and state the basis for agreement or disagreement with these medical opinions. Erectile Dysfunction 22. Is it at least as likely as not that the Veteran's erectile dysfunction has been caused by his medication prescribed for any of his service-connected disabilities? 23. Is it at least as likely as not that the Veteran's erectile dysfunction underwent an incremental increase (aggravated), regardless of permanence, by medication prescribed for any of his service-connected disabilities? The term incremental increase in disability means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any incremental increase in disability need not be permanent. Neurological Disabilities 24. Schedule the Veteran for a neurological examination to determine the nature and etiology of the claimed TBI or neurological condition 25. The examiner is asked to address the following questions: 26. Identify any currently diagnosed neurological disabilities to include TBI and or concussion. 27. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. 28. Opine whether any diagnosed TBI residuals or neurological condition is at least as likely as not related to an in-service injury, event, or disease, including the service injury from falling from a tank in 1991 and hitting his head or from being knocked out from a car accident in June 1993? 29. Do the Veteran's reports about his symptoms or his in-service injury from falling from a tank in 1991 or hitting his head or from being knocked out from a car accident in June 1993 align with how the Veteran's current TBI residuals or neurological condition are known to develop? 30. Whether it is medically feasible that his current TBI residuals or neurological condition were caused by his in-service injury from falling from a tank in 1991 or hitting his head or from being knocked out from a car accident in June 1993? 31. If the answer to any of the above questions is negative, state why not and on what basis this conclusion was made. 32. If any answer to any of the above questions is positive, state why and on what basis this conclusion was made. Headaches 33. Schedule the Veteran for a VA examination to determine the onset and etiology of his migraine headaches. The examiner is required to review the claims file. The examiner should provide an opinion to the following: 34. Whether it is at least as likely as not (50 percent or greater probability) that any migraine headache disability began in active service; or is due to an injury or disease during such service to include the March 1994 complaint of headache pain and June 1994 diagnosis of tension headaches. 35. Are the Veteran's assertions that his headaches were incurred as a result of falling from a tank in 1991 or the car accident in June 1994, consistent with medical knowledge or implausible? 36. Do the Veteran's reports about his symptoms or his in-service injury from falling from a tank in 1991 or the car accident in June 1994 align with how the Veteran's current headaches are known to develop? 37. Whether it is medically feasible that his current headaches were caused by his in-service injury from falling from a tank in 1991 or the car accident in June 1994? 38. If the answer to any of the above questions is negative, state why not and on what basis this conclusion was made. 39. If any answer to any of the above questions is positive, state why and on what basis this conclusion was made. The VA examiners should outline that history in the report. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, a reason for doing so must be provided. Any opinion expressed by the VA examiner should be accompanied by a complete rationale. If medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 40. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. (continued on the next page) YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Lilly, 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.