Citation Nr: 22018482 Decision Date: 03/29/22 Archive Date: 03/29/22 DOCKET NO. 17-26 188 DATE: March 29, 2022 ORDER Entitlement to a rating in excess of 10 percent for diverticulosis is denied. Entitlement to a compensable rating for bilateral hearing loss is denied. Entitlement to a compensable rating for recurrent prostatitis is denied. Entitlement to service connection for muscle joint pain is denied. Entitlement to compensation under 38 U.S.C. § 1151 for status-post cerebrospinal fluid (CSF) leak and repair (claimed as ear pain) is denied. REMANDED Entitlement to compensation under 38 U.S.C. § 1151 for chronic headaches is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's service-connected diverticulosis has been manifested by no more than mild peritoneal adhesions. 2. Audiometric testing establishes that the Veteran's bilateral hearing loss disability was no worse than level "I" in his right ear and level "II" in his left ear. 3. There is no probative evidence showing that the Veteran's service-connected prostatitis manifested in urinary tract infection or voiding dysfunction. 4. The Veteran's muscle joint pain condition did not occur during active service, or is otherwise unrelated to an in-service injury, event, or disease. 5. The Veteran does not have an additional disability, to include CSF leak and repair, resulting from the August 2014 tympanectomy conducted by VA that is either the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA or an event that was not reasonably foreseeable. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent for diverticulosis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.114, Diagnostic Codes 7301, 7327. 2. The criteria for entitlement to a compensable rating for service-connected bilateral hearing loss have not been met. 8 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.85, Diagnostic Code (DC) 6100, 4.86. 3. The criteria for entitlement to a compensable rating for recurrent prostatitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.21, 4.115a, 4.115b, Diagnostic Code 7527. 4. The criteria for entitlement to service connection for muscle joint pain have not been met. 38 U.S.C. §§ 101, 1101, 1110, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 5. The criteria for compensation under 38 U.S.C. § 1151 for s/p CSF leak and repair (claimed as ear pain) have not been met. 38 U.S.C. §§ 1151, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.358, 3.361. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 1995 to May 1998 and from February 2003 to January 2004. These matters come before the Board of Veterans' Appeals (Board) on appeal from December 2014 and February 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran was scheduled for a hearing before a member of the Board, but he subsequently submitted a written request to withdraw the Board hearing. To the extent that the Veteran's private representative included boilerplate language about preserving for appeal any due process deficiencies (see May 2017 Form 9), the Board does not find these statements actually allege any particular procedural due process issues in this Veteran's case. The Board also affirmatively finds that VA satisfied all relevant due process requirements as to the claims being decided herein. Thus, the Board need not discuss any potential issues in this regard. Neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the Veteran fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Thus, the Board need not discuss any potential issues in this regard. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is a balance of positive and negative evidence regarding any material issue, the benefit of the doubt shall be given to the claimant. See 38 U.S.C. § 5107 (b). The Board has reviewed all the evidence of record. Although the Board has an obligation to provide adequate reasons and bases supporting its decisions, there is no requirement that the Board discuss every piece of evidence in the record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence, as deemed appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claim on appeal. INCREASED RATING Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 1. Entitlement to a rating in excess of 10 percent for diverticulosis. The Veteran seeks a higher rating for his service-connected diverticulosis condition. He has not provided any specific contentions in support of this claim. The Veteran is currently in receipt of a 10 percent under DC 7301-7327, effective September 25, 2014. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the rating assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. DC 7327 instructs to rate diverticulitis as for irritable colon syndrome, peritoneal adhesions, or ulcerative colitis, depending on the predominant disability picture. In this case, a 10 percent rating has been assigned for moderate peritoneal adhesion. 38 C.F.R. § 4.114, Diagnostic Code 7301. A next higher rating of 30 percent rating is assigned for moderately severe peritoneal adhesion, in which partial obstruction manifested by delayed motility of barium meal (test for detecting esophagus/stomach/small bowel abnormalities using x-ray imaging) and less frequent and less prolonged episodes of pain is present. The maximum schedular rating of 50 percent is warranted for severe peritoneal adhesion, involving definite partial obstruction shown by X-ray, with frequent and prolonged episodes of severe colic distension (abdominal pain), nausea or vomiting, following severe peritonitis, ruptured appendix, perforated (pierced with holes) ulcer, or operation with drainage. Disabilities of the digestive system are evaluated under 38 C.F.R. § 4.114, which provides that ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. Rather, a single rating will be assigned under the diagnostic code which reflects the predominant disability picture, with evaluation of the next higher rating where the severity of the overall disability warrants such rating. 38 C.F.R. § 4.114. During a September 2015 VA examination, the Veteran was diagnosed with diverticulosis. He denied gastrointestinal symptoms and reported using his core muscles of the abdomen when experiencing a pain to the left lower quadrant of his abdomen. His intestinal condition was not found to require continuous medication for control nor was he found to have undergone surgical treatment. There was no evidence of signs/symptoms attributable to any non-surgical noninfectious intestinal conditions. His weight loss was noted to be attributable to an intestinal condition, but there was neither evidence of episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition, nor of malnutrition, serious complications, or other general health effects attributable to the intestinal condition. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms. No functional impact was noted, although the examiner indicated that the Veteran's complaints noted in medical history would be less likely than not a result of diverticulosis, but instead, consistent with abdominal muscle involvement. His treatment records throughout the appeal period merely lists diagnosis of diverticulitis (see December 2018, July 2016, February 2014 VA treatment records) and/or physical examination showing soft and nontender abdomen (see September 2017 VA treatment records), good appetites, normal bowel movements, no constipation/NVD/blood in the stool, and the Veteran's denial of abdominal pain. See January 2019 and August 2019 VA treatment records. There is no indication that the Veteran manifests partial obstruction (it does not appear that the Veteran had undergone any barium meal showing delayed motility during the appeal period), not to mention evidence suggestive of definite partial obstruction with frequent and prolonged episodes of severe colic distension (abdominal pain), nausea or vomiting, following sever peritonitis, ruptured appendix, perforated (pierced with holes) ulcer, or operation with drainage. Upon review of record, the Board finds that a rating in excess of 10 percent for diverticulitis is not warranted throughout the appeal period. There is no evidence suggestive of any form of partial obstruction associated with peritoneal adhesions required for a rating in excess of 10 percent. At most, it appears that the Veteran manifested pain in the lower left abdomen throughout the appeal period (which, as noted by the examiner, was not a result of diverticulosis, but instead, consistent with abdominal muscle involvement See September 2015 VA examination). Furthermore, the Board notes that there is no evidence showing the presence of either irritable colon syndrome or ulcerative colitis (and thus, there is no finding suggestive of either being the predominant disability of the Veteran) that might warrant a higher rating under either DC 7319 or DC 7323. The evidence persuasively weighs against the Veteran's claim. The benefit of the doubt doctrine is therefore not for application, and the Veteran's claim is denied. Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37312 (Fed. Cir. Dec. 17, 2021) (only when the evidence persuasively favors one side, or another is the benefit of the doubt doctrine not for application). 2. Entitlement to a compensable rating for bilateral hearing loss, previously evaluated as hearing loss, right ear The Veteran seeks a higher rating for his service-connected bilateral hearing loss. He has not provided any specific contentions in support of this claim. The Veteran is currently in receipt of a noncompensable rating under DC 6100. Ratings for service-connected bilateral hearing loss range from noncompensable (0 percent) to 100 percent. These ratings are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000 and 4000 cycles per second. In evaluating service-connected bilateral hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992); 38 C.F.R. § 4.85. Diagnostic Code (DC) 6100 provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment. The hearing impairment is established by a state licensed audiologist using a controlled speech discrimination test and the pure tone threshold average (which is the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four). See 38 C.F.R. § 4.85. Table VII is used to determine the percentage rating by combining the Roman numeral designations for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. Id. Under 38 C.F.R. § 4.86(a), when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear is to be evaluated separately. See 38 C.F.R. § 4.86(a). The provisions of 38 C.F.R. § 4.86 (b) provide that when the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be evaluated to the next higher Roman numeral. See 38 C.F.R. § 4.86(b). Table VIA is also utilized when the audiologist certifies that the use of the speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc. See 38 C.F.R. § 4.85(c). The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran described in his November 2016 hearing testimony is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran's main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). The Veteran first underwent a VA audiological examination in October 2014, summarized in the chart below, with puretone threshold recorded in decibels. HERTZ 1000 2000 3000 4000 Average RIGHT 95 65 60 60 70 LEFT 10 0 20 45 18.75 The audiologist also administered the Maryland CNC word list pursuant to VA regulations. See 38 C.F.R. § 4.85. The Veteran attained a 96 percent score in his right ear and a 98 percent score in his left ear. Applying the results of the October 2014 VA examination to Table VI shows that the Veteran had a level II hearing acuity in the right ear, and a level I hearing acuity in the left ear. Under Table VII, such hearing acuity warrants a 0 percent rating. The findings do not reflect an exceptional pattern of hearing loss, nor did the examiner indicate that speech recognition scores were unreliable; therefore, Table VIA is not for application. The Veteran underwent another VA audiological examination in September 2015, summarized in the chart below, with puretone threshold recorded in decibels. HERTZ 1000 2000 3000 4000 Average RIGHT 40 15 25 35 28.75 LEFT 20 10 25 50 26.25 The audiologist also administered the Maryland CNC word list pursuant to VA regulations. See 38 C.F.R. § 4.85. The Veteran attained a 96 percent score in his right ear and a 98 percent score in his left ear. Applying the results of the September 2015 VA examination to Table VI shows that the Veteran had a level I hearing acuity in the right ear, and a level I hearing acuity in the left ear. Under Table VII, such hearing acuity warrants a 0 percent rating. The findings do not reflect an exceptional pattern of hearing loss, nor did the examiner indicate that speech recognition scores were unreliable; therefore, Table VIA is not for application. The record does not include any further pertinent audiometry during the period under consideration. Although there are audiology notes, such do not provide clear numerical values for pure tone testing (other than stating "within normal limits," "moderate to severe," or "severe," i.e., see May 2014 VA audiology notes; November 2016 VA audiology note; June 2017 VA audiology notes). As the assignment of a disability rating for hearing impairment is derived by mechanical application of the rating schedule to the numeric designations assigned after audiometry evaluations are rendered, there is no doubt as to the proper evaluation to be assigned. Lendenmann, 3 Vet. App. 345; 38 C.F.R. § 4.85, Tables VI-VII, Code 6100. The findings on official audiometry fall squarely within the parameters of the criteria for a noncompensable rating, and that rating reflects the reported functional impairment (unable to locate the location of the sound; cannot communicate very well when someone is on his right side). Factors warranting referral for extraschedular consideration are not shown or alleged. The Board notes that a noncompensable rating does not mean that the Veteran's hearing is normal. The initial grant of service connection acknowledged that he has hearing loss, while the assigned rating reflects that the degree of disability of his hearing loss does not meet VA's criteria for a compensable rating. The evidence persuasively weighs against the Veteran's claim. The benefit of the doubt doctrine is therefore not for application, and the Veteran's claim is denied. Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37312 (Fed. Cir. Dec. 17, 2021) (only when the evidence persuasively favors one side, or another is the benefit of the doubt doctrine not for application). 3. Entitlement to a compensable rating for recurrent prostatitis The Veteran seeks a higher rating for his service-connected recurrent prostatitis. He has not provided any specific contentions in support of this claim. The Veteran's prostatitis is currently in receipt of a noncompensable rating under DC 7527. DC 7527 rates prostate gland injuries, infections, hypertrophy and postoperative residuals as urinary tract infection or voiding dysfunction, whichever is predominant. Voiding dysfunction is rated under the three subcategories of urine leakage, urinary frequency, and obstructed voiding. 38 C.F.R. § 4.115a. For urine leakage a 20 percent rating is warranted when there is continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence, such that the Veteran is required to wear absorbent materials which must be changed less than two times per day. A 40 percent rating is warranted when the Veteran is required to wear absorbent materials that must be changed two to four times per day. A 60 percent disability rating is warranted with the use of an appliance or the wearing of absorbent materials that must be changed more than four times per day. 38 C.F.R. § 4.115a. With regard to urinary frequency, a daytime voiding interval between two and three hours or awakening to void two time per night warrants a 10 percent rating, a daytime voiding interval between one and two hours or awakening to void three to four times per night warrants a 20 percent rating, and daytime voiding interval less than one hour, or awakening to void five or more times per night warrants a 40 percent rating. 38 C.F.R. § 4.115a. For obstructed voiding, a 30 percent rating requires urinary retention requiring intermittent or continuous catheterization. 38 C.F.R. § 4.115a. With respect to urinary tract infections, a 30 percent rating is warranted for recurrent symptomatic infection requiring drainage/frequent hospitalization (greater, than two times a year), and/or requiring continuous intensive management. 38 C.F.R. § 4.115a. During a November 2014 VA examination, the Veteran was diagnosed with chronic prostatitis. He was not found to have voiding dysfunction, and there was neither evidence of erectile dysfunction nor a history of recurrent symptomatic urinary tract/kidney infections. He reported thickening semen and odorous discharge with no improvement despite treatment with various antibiotics and prednisone. There were no other pertinent physical findings/symptoms, and no functional impairment was found. In a subsequent VA examination conducted in September 2015, the Veteran was again diagnosed with prostatitis. He denied any obstructive urinary complaints but reported only odorous discharge. There was no evidence of renal dysfunction, male reproductive organ infections, erectile dysfunction, retrograde ejaculation, or retrograde ejaculation. No functional impact was noted. The Veteran's treatment records merely document the Veteran's diagnosis of prostatitis, without providing any relevant information relating to his symptoms/severity of this condition. After reviewing all pertinent records, the Board finds that a compensable rating is not warranted throughout the appeal period for his service-connected prostatitis condition. As noted above, while DC 7527 directs prostate gland injuries, infections, postoperative residuals be rated as either voiding dysfunction or urinary tract infectionwhichever is predominanthe was consistently not found to have either condition. Moreover, the Veteran himself denied having any related symptoms to such, but only consistently reported symptoms of odorous discharges/thickening semen. Even taking into consideration his complaint of these symptoms not having improved despite his use of antibiotics and prednisone, the Board notes that the extent of his symptoms were limited to odorous discharges/thickening semen, with no other symptoms suggestive of voiding/urinary tract infection. There was also no evidence suggestive of any recurrent symptomatic infection requiring drainage/frequent hospitalization and/or requiring continuous intensive management. In light of these findings, the Board regrettably finds that a compensable rating is not warranted for this disability. The evidence persuasively weighs against the Veteran's claim. The benefit of the doubt doctrine is therefore not for application, and the Veteran's claim is denied. Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37312 (Fed. Cir. Dec. 17, 2021) (only when the evidence persuasively favors one side, or another is the benefit of the doubt doctrine not for application). SERVICE CONNECTION Generally, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38U.S.C. §§1110, 1131, 5107; 38C.F.R. §3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 4. Entitlement to service connection for muscle joint pain The Veteran filed a claim for service connection for his muscle joint pain, to include as Gulf War Syndrome. He has not provided any specific contentions in support of this claim. It is not in question that the Veteran has a current disability, as he has been diagnosed with joint pain during the appeal period. His service treatment records are silent as to joint pain (other than back/shoulder/abdominal pain, for which he is already in receipt of separate ratings). Considering that the Veteran denied having any joint/musculoskeletal issues but reported other non-joint pain related symptoms during a January 2004 separation examination, it is reasonable to assume that he would have reported his muscle joint pain during that time had he actually experienced it. Although a VA examination was scheduled, the Veteran did not show up and failed to provide good cause. Thus, a decision will be made based on the evidence of record. There is no medical nexus opinion of record addressing his claimed joint pain condition (as will be addressed further below, he only underwent a Gulf War examinationwhich does not include any medical nexus opinion). Review of his treatment records suggests that it was not until many years after separating from service that the Veteran first complained of "joint pain" and sought treatment for "joint pain," and during that time, he did not report any onset in service or in-service injuries related to the alleged condition. In fact, it seems that he first complained of joint pain almost simultaneous to the time he first filed a claim for service connection for joint pain in 2014, almost 10 years after separating from service (and the Board also points out that he filed claims for other unrelated conditions years prior to 2014). If he had, in fact, been experiencing joint pain since he left service, it is reasonable to expect that he would have reported such when seeking treatment and have filed a service connection claim years prior to 2014. The Board also recognizes the Veteran has raised an entitlement to service connection based on Gulf War presumption. The law provides for compensation for Persian Gulf Veterans who have a chronic disability resulting from an undiagnosed illness or medically unexplained chronic multi-symptom illness that became manifest during active duty in the Southwest Asia theater of operations or became manifest to a compensable degree within the prescribed presumptive period and by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. If an undiagnosed chronic symptom or illness is not manifest in service, the claimed chronic disability must have been manifest to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317 (a)(1). See 82 Fed. Reg. 49121 (October 24, 2017). A "Persian Gulf Veteran" is one who served in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317 (e). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (e)(2). The term "qualifying chronic disability" means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; or (B) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia (widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues); (3) functional gastrointestinal disorders (excluding structural gastrointestinal disorders). 38 C.F.R. § 3.317 (a)(2)(i). Irritable bowel syndrome is a "functional gastrointestinal disorder" under the regulations. The Veteran's DD-214 form confirms his Gulf War service, as it shows his service in Southwest Asia from April 2003 to December 2003. However, the Board finds that this presumption does not apply. Although the Veteran underwent a Gulf War examination in 2013, he was not found to have any diagnosed illness for which no etiology was established, nor additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness." Upon physical exam, he was found to have normal musculoskeletal condition, with no evidence of fibromyalgia or muscle injuries. Also, the Board reiterates that the Veteran has been diagnosed with muscle joint pain for his alleged condition. The medical evidence does not indicate that his disorder is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Thus, the Veteran's muscle joint pain cannot be considered an undiagnosed illness or a qualifying chronic disability for entitlement to service connection based on the Veteran's service in the Persian Gulf. To the extent there is no evidence of a qualifying chronic disability, the Board finds that he is not warranted service connection under this presumption. The Board is cognizant of the Veteran's belief that his current condition is related to his military service. Although the Veteran is competent to report the symptoms he perceived directly through the senses, he has not been shown to have the appropriate medical training and expertise to offer a competent opinion on the etiology of muscle joint pain. As such, his lay statement is not sufficient to establish a medical nexus between his muscle joint pain and his active military service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The evidence persuasively weighs against the Veteran's claim. The benefit of the doubt doctrine is therefore not for application, and the Veteran's claim is denied. Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37312 (Fed. Cir. Dec. 17, 2021) (only when the evidence persuasively favors one side, or another is the benefit of the doubt doctrine not for application). 5. Entitlement to compensation under 38 U.S.C. § 1151 for s/p CSF leak and repair (claimed as ear pain) The Veteran contends that during his tympanectomy (surgical excision of the tympanic membrane of the ear) conducted for hearing loss on August 1, 2014, at a VA medical center, a cyst on the ear drum/attached to his brain was found and that in scrapping the cyst off his brain, the surgeons slipped and punctured his brain, resulting in his brain fluid leaking out. The Veteran further claims that they later cauterized the hole to try to stop the leak, and that he has had shooting pains to bilateral ear regions daily and an unknown fluid dripping out of his right ear for approximately 2 months since then. He also submitted a statement from his wife, stating that Dr. S. told her that the surgery did not go as planned and that he attempted to remove the cyst entirely, which was located on or near the Veteran's brain, to avoid follow-up surgeries, and that while removing the cyst, the brain was nicked, releasing fluid which required cauterization. For the reasons discussed below, the Board finds that compensation under the provisions of 38 U.S.C. § 1151 for the s/p CSF leak and repair is not warranted. When a claimant incurs additional disability or death as the result of training, hospital care, medical or surgical treatment, or an examination by VA, disability compensation shall be awarded in the same manner as if such additional disability or death were service connected. 38 U.S.C. § 1151; 38 C.F.R. § 3.358 (a). To be awarded compensation under 38 U.S.C. § 1151, a claimant must show that (1) VA treatment (or other qualifying event) resulted in additional disability, and that (2) the proximate cause of the additional disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or that the proximate cause of the disability was an event which was not reasonably foreseeable. 38 U.S.C. § 1151; 38 C.F.R. § 3.361. See also VAOPGCPREC 40-97, 63 Fed. Reg. 31,262 (1998). To determine whether additional disability exists, the claimant's condition immediately prior to the beginning of the hospital care, medical or surgical treatment, or other relevant incident in which the claimed disease or injury was sustained, upon which the claim is based, is compared to the claimant's condition after such treatment, examination, or program has stopped. 38 C.F.R. § 3.361 (b). Provided that additional disability exists, the next consideration is whether the causation requirements for a valid claim for benefits have been met, to consist of both actual and proximate causation. In order to establish actual causation, the evidence must show that the medical or surgical treatment rendered resulted in the additional disability. If it is shown merely that a claimant received medical care or treatment, and has an additional disability, that in and of itself would not demonstrate actual causation. 38 C.F.R. § 3.361 (c)(1). The proximate cause of the disability claimed must be the event that directly caused it, as distinguished from a remote contributing cause. To establish that carelessness, negligence, lack of proper skill, error in judgment or other instance of fault proximately caused the additional disability, it must be shown that VA failed to exercise the degree of care expected by a reasonable treatment provider or furnished the treatment at issue without informed consent. 38 C.F.R. § 3.361 (d)(1). Proximate cause may also be established where the additional disability was an event not reasonably foreseeable, based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable medical provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider the type of risk that a reasonable health care provider would have disclosed as part of the procedures for informed consent (in accordance with 38 C.F.R. § 17.32). 38 C.F.R. § 3.361 (d)(2). In order for additional disability to be compensable, it must have been actually caused by, and not merely coincidental to, hospital care, medical or surgical treatment, or medical examination furnished by a VA employee or in a VA facility. Loving v. Nicholson, 19 Vet. App. 96, 99-100 (2005). The additional disability must have been the result of injury flowing directly from the actual provision of care, treatment, or examination furnished by VA. Id. at 101. The mere fact that a claimant is harmed by an event that occurs coincidentally with VA care, treatment, or an examination is not sufficient to establish causation. Mangham v. Shinseki, 23 Vet. App. 284, 287 (2009). The relevant issue is whether VA's direct actions caused harm. Id. at 289. Here, a pre-operative note from August 1, 2014, shows preoperative diagnosis of cholesteatoma, and lists planned procedure of "right revision tympanomastoidectomy with possible OCR, left myringotomy with possible PE tube placement" and includes his signed consent form for tympanoplasty with possible ossicular reconstruction, which provides that the reason for treatment is "infection/tear in the middle ear. Infection, injury, cholesteatoma, or other lesion of the mastoid bone" "to relieve buildup of fluid in the middle ear" among others. The operation note dated August 1, 2014, provides that the Veteran underwent "left tympanostomy tube placement, right revision tympanomastoidectomy, and secondary repair of CSF leak." It shows that the Veteran presented with chronic eustachian tube dysfunction and history of right middle ear cholesteatoma, and that he was found to have cholesteatoma in the anterior epitympanum at that time and possible recurrent cholesteatoma in the right middle ear. The procedure report dated August 1, 2014, shows that there was a cystic structure at the anterior superior quadrant of the mastoid cavity, which upon further evaluation, was consistent with a cholesteatoma retraction pocket and that care was taken not to enter the cyst. The physician further noted that cholesteatoma sac was teased from the dura and any remaining squamous elements were bipolared from the dura, that they revised the mastoid cavity using various sized drill bits; and that upon elevating the tympanic membrane, there were many adhesions within the middle ear space. The facial ridge was smoothed using diamond burs, epitympanum was fully exposed and the remaining cholesteatoma elements were removed from the anterior epitympanum. The tensor tympani was cut, the mastoid bowl was smoothed using a diamond bur, an inferiorly based muscle flap was created and sized to fill the mastoid defect. CSF oozing from the site of cholesteatoma adherence was noted during that time, and that this defect was immediately fixed with a free muscle graft and fascia overlying. The mastoid and middle ear were thoroughly irrigated, there were no remaining cholesteatoma/squamous elements, the postauricular incision was closed and a mastoid dressing was applied. ENT postoperative note dated August 1, 2014, shows "procedure: left tympanostomy tube, right revision tympanomastoidectomy-canal wall down, right secondary repair of CSF leak" with findings "left-serous middle ear effusion, myringoincudopexy. Right-superior retraction pocket with cholesteatoma extending into the mastoid cavity and adherent to dural; small CSF leak repaired with muscle graft" "drains: no." The August 1, 2014, post-procedure nursing assessment shows "right ear with bulky head dressing "earphone" muff, no visible bleeding/drainage. Left ear tube not visible." The January 2016 VA examiner opined that the Veteran's additional disability (CSF leak and repair) less likely as not resulted from carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel. In doing so, the examiner pointed out that one of the known risks is CSF leak, as stated on the informed consent, and pointed to the operative report, which documents the CSF leak occurred due to adherence of the cholesteatoma to the dura. The examiner further indicated that "it is at least as likely as not the additional disability [CSF leak and repair] resulted from an event that could not have reasonably been foreseen by a reasonable healthcare provider. Although CSF leak is a possible risk, it is not an event that could have been predicted. It is less likely as not that the additional disability resulted from failure on the part of VA to timely diagnose and/or properly treat the claimed disease or disability allowed the disease or disability to continue to progress. Based on the available medical records, the VA staff diagnosed and treated the conditions in timely manner. The CSF leak was repaired once it was visualized during the procedure." The Board provides a high probative value to this opinion, as it was provided after thorough review of all pertinent records. In this case, the persuasive evidence of record indicates that the attending physicians exercised the degree of care expected by a reasonable treatment provider by obtaining an informed consent prior to the August 1, 2014, surgery, and by timely diagnosing and treating CSF leaking after noting it during the surgery. Notably, after noting CSF leaking at the site of cholesteatoma adherence during the surgery, the attending physicians immediately fixed this with a free muscle graft and fascia overlying. Moreover, the persuasive evidence of record shows that while CSF leak is a possible risk, it is not an event that could have been reasonably predicted. The evidence persuasively weighs against the Veteran's claim. The benefit of the doubt doctrine is therefore not for application, and the Veteran's claim is denied. Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37312 (Fed. Cir. Dec. 17, 2021) (only when the evidence persuasively favors one side, or another is the benefit of the doubt doctrine not for application). REMANDED 1. Entitlement to compensation under 38 U.S.C. § 1151 for chronic headaches The Veteran seeks compensation for chronic headaches under 38 U.S.C. § 1151. Specifically, he claims residual headaches resulted from a tympanectomy surgery conducted on August 1, 2014, for his service-connected hearing loss. During a January 2016 VA examination conducted for an ear condition, the Veteran reported having occasional headaches. However, the examiner found that the only potential additional disability that resulted from the August 1, 2014, procedure was the CSF leak that was repaired during the procedure. However, the Veteran has continued to complain of ongoing headaches as documented by the medical evidence of record (ie., January 2018 and June 2017 VA treatment records). To date, the Veteran has not been afforded a VA examination and no medical opinion specifically addressing the alleged headaches condition has been obtained. In determining whether a VA examination or opinion is warranted in a section 1151 claim, the Board must analyze the evidence of record to determine whether it "indicates" that the disability or symptoms "may be associated with" VA treatment, a question with a similarly low threshold as that applicable to service connection claims. Trafter v. Shinseki, 26 Vet. App. 267, 279-80 (2013). Although the January 2016 medical opinion indicated that CSF leak is the only additional disability that resulted from the August 1, 2014 surgery, considering that this was the examination conducted solely for the ear condition, and as this opinion consequently does not address any headaches condition (other than containing the Veteran's report of headaches), or whether the claimed condition was the result of VA treatment due to carelessness, negligence, lack of proper skill, error in judgment, or some other instance of fault on the part of VA, or a result of an event that was not reasonably foreseeable, the Board finds that the Veteran has met the low threshold of Trafter and is entitled to a VA examination. This matter is REMANDED for the following action: Afford the Veteran a VA examination for his claimed entitlement to compensation under 38 U.S.C. § 1151 for chronic headaches. The examiner must review the complete claims file, including this Remand, and then address: a. Is at least likely as not that the Veteran sustained an additional disability of residual headaches due to his tympanectomy surgery conducted on August 1, 2014? b. If additional disability or disabilities exist, is it at least as likely as not that the proximate cause of such disability was carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA? In determining whether the proximate cause of a disability was the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA, please discuss if VA failed to exercise the degree of care that would be expected of a reasonable health care provider. c. Is it at least likely as not that the proximate cause of such disability was from an event that was not reasonably foreseeable? The entire claims file, including a copy of this REMAND, must be reviewed. A thorough rationale should be provided for all opinions expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. L. ANDERSEN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lee, Catherine 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.