Citation Nr: 22028430 Decision Date: 05/13/22 Archive Date: 05/13/22 DOCKET NO. 17-47 039 DATE: May 13, 2022 ORDER Entitlement to service connection for fatigue, to include as secondary to service-connected posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus, is denied. Entitlement to an initial compensable rating for service-connected right ear hearing loss is denied. Entitlement to an initial rating in excess of 10 percent disabling for service-connected chronic laryngitis is denied. Entitlement to an initial rating in excess of 10 percent disabling for service-connected PTSD prior to October 7, 2020, is granted. Entitlement to an initial rating in excess of 70 percent disabling for service-connected PTSD beginning October 7, 2020, is denied. REMANDED Entitlement to service connection for left ear hearing loss is remanded. FINDINGS OF FACT 1. Resolving all doubt in the Veteran's favor, his currently diagnosed fatigue was caused by or is related to his service-connected PTSD. 2. Erectile dysfunction was not manifested during service or within one year of service discharge and is not shown to be causally related to or aggravated by the Veteran's service or any service-connected disabilities. 3. The Veteran's hearing acuity was not shown to be greater than Level I in the right ear. 4. The Veteran's chronic laryngitis manifested by hoarseness and inflammation of the vocal cords without more severe manifestations to include thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. 5. For the period prior to October 7, 2020, the Veteran's service-connected PTSD manifest in occupational and social impairment with deficiencies in most areas as a result of psychiatric symptomatology to include suicidal ideation, difficulty falling or staying asleep, nightmares, hypervigilance, irritability, and an exaggerated startle response, without more severe manifestations that more nearly approximate total occupational and social impairment. 6. For the appeal period beginning October 7, 2020, the Veteran's PTSD is manifested by occupational and social impairment, with deficiencies in most areas as a result of psychiatric symptomatology to include irritability, hypervigilance, exaggerated startle response, problems with concentration, nightmares, depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impairment of short and long term memory, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, and impaired impulse control, such as unprovoked irritability with periods of violence, without more severe manifestations that more nearly approximate total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for fatigue as secondary to service-connected PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for erectile dysfunction, to include as secondary to diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 3. The criteria for a compensable rating for service-connected right ear hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 3.385, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.85, 4.86, Diagnostic Code 6100. 4. The criteria for an initial rating in excess of 10 percent for service-connected chronic laryngitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.3, 4.7, 4.97, Diagnostic Codes 6819-6516. 5. For the period prior to October 7, 2020, the criteria for an initial 70 percent rating, but no higher, for service-connected PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411. 6. For the period beginning October 7, 2020, the criteria for an initial rating in excess of 70 percent disabling for service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1968 to July 1970, to include service in the Republic of Vietnam. The Board must discuss all theories of entitlement raised by the Veteran or by the evidence of record. Robinson v. Mansfield, 21 Vet. App. 545 (2008). Accordingly, the Board has recharacterized the claims on appeal, as indicated above to afford the Veteran the broadest possible scope of review. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). In November 2019 the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In April 2020, the Board remanded the claims on appeal for further development and adjudication. The Board finds that there was substantial compliance with its prior remand directives as they pertain to the issues decided herein. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Nonetheless, it is only substantial compliance, rather than strict compliance, with the terms of a remand that is required. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to an internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). The Board notes that in the April 2020 remand, it requested that the AOJ determine if service connection had been awarded for diabetes mellitus, as there was some confusion in the record (Veteran alleged that a September 2011 rating decision had granted him service connection). In the AOJ's February 2021 supplemental statement of the case, they clarified that the Veteran was not service connected for diabetes mellitus and that he was notified in an October 2013 rating decision that he was not, nor had he ever been service connected for diabetes mellitus. The AOJ further noted that the Veteran first filed a claim for diabetes in January 2013, which was denied after an April 2013 examination confirmed that the Veteran did not have a diagnosis of diabetes. While the AOJ noted that the April 2013 rating decision erroneously stated that a prior denial was confirmed and continued and should have reflected that it was an original denial of service connection, the Veteran was notified of the denial in August 2014. However, a notice of disagreement was never submitted in relation to the denial. Therefore, the Board notes that as there is no valid NOD of record, the Board does not have jurisdiction and the claim for service connection for diabetes mellitus is not on appeal at this time. Finally, in a February 2021 rating decision, the AOJ granted service connection for sinusitis, loss of smell, loss of taste, and rhinitis. The AOJ assigned a 50 percent rating prior to October 16, 2020, and a 30 percent rating thereafter for sinusitis; a noncompensable rating prior to October 16, 2020, and a 10 percent rating thereafter for loss of smell; a noncompensable rating prior to October 16, 2020, and a 10 percent rating thereafter for loss of taste; and a noncompensable rating effective September 5, 2012, for rhinitis. As the grants reflect full grants of the benefits sought, such claims are no longer on appeal. The RO also granted an increased rating for the Veteran's service-connected PTSD, assigning a 70 percent disability rating effective October 7, 2020. As such is not a full grant of the benefit sought, the Veteran's increased rating claim remains on appeal. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309 (a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303 (b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309 (a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Entitlement to service connection for fatigue, to include as secondary to service-connected PTSD is granted. The Veteran contends that he suffers from fatigue as a result of his service. Specifically, he contends that such was caused or permanently aggravated by his service-connected PTSD. The Veteran's service treatment records are silent for any complaints, treatment, or diagnosis of fatigue. Post-service the Veteran's treatment records reflect complaints of fatigue. However, they are silent for such within one year of the Veteran's service discharge. The first notation of any fatigue complaints was in 2011, approximately 41 years after the Veteran's discharge from service. Furthermore, the records do not include any opinions linking the Veteran's current fatigue with the Veteran's service. In April 2013 the Veteran underwent a VA Thyroid and Parathyroid Conditions examination with an accompanying disability benefits questionnaire (DBQ). The examiner noted that the Veteran suffered from hypothyroidism. The examiner noted that the Veteran suffered from fatigability, noting "increased fatigue with mild instability or s/s of PTSD." In September 2013 the Veteran underwent a VA PTSD examination with an accompanying DBQ. The examiner noted that the Veteran suffered from hypervigilance and exaggerated startle response but made no mention of any fatigability as a symptom of PTSD. In October 2020 the Veteran underwent an additional VA PTSD examination. The examiner noted that the Veteran suffered from irritability, hypervigilance, exaggerated startle response, problems with concentration, sleep disturbance, depressed mood, anxiety, suspiciousness, sleep impairment, memory loss and impairment, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, and impaired impulse control. However, the examiner made no mention of any fatigue as a symptom of PTSD. In February 2021 the Veteran was provided with VA Medical Opinions. The examiner opined that the Veteran's fatigue was less likely than not incurred in or caused by any claimed in-service injury, event, or illness. The examiner noted that the Veteran's service records were silent for any fatigue and that the first complaints of fatigue were not for decades after his discharge. Therefore, the examiner found that it was less likely than not that the Veteran's fatigue was directly caused by his service. Furthermore, the examiner found that the Veteran's fatigue was less likely than not aggravated beyond its natural progression by his service-connected PTSD. However, the examiner opined that it was at least as likely as not that the Veteran's fatigue was proximately due to or the result of his service-connected PTSD. The examiner noted that the Veteran's fatigue was an ongoing problem for which he had been seen multiple times. Furthermore, the examiner noted that there was a strong link between chronic fatigue, PTSD, and traumatic symptoms; he stated that medical research shows that the same part of the brain is involved in PTSD and chronic fatigue issues which often results in fatigue being a primary symptom of PTSD. He noted that there was also ample evidence in medical literature of an association between PTSD and the development of fatigue. Therefore, the examiner opined that the Veteran's fatigue was at least as likely as not proximately due to his service-connected PTSD. Throughout the appeal, the Veteran has submitted statements in support of his claim. Furthermore, the Veteran testified at a Board hearing in November 2019 indicating his belief that his fatigue was caused or aggravated by his service-connected PTSD. The Board notes that the medical evidence is not in dispute as to whether the Veteran had fatigue in-service or whether such began in service. Furthermore, the Veteran has not alleged that his fatigue is directly related to service. Rather, he has alleged that such is secondary to his service-connected PTSD. The Board notes that the Veteran is service connected for PTSD, therefore, while direct service connection is not warranted, secondary service connection is available to the Veteran. The questions which remain are whether the Veteran has a current fatigue diagnosis and if so whether such is causally related to his service-connected disability. The Board notes that whether the Veteran has current fatigue is also not in dispute. Here, the Veteran's post-service treatment records reflect his complaints of symptoms related to fatigue as well as a diagnosis of fatigue. See VA examinations in April and September 2013 and February 2021. Furthermore, the February 2021 VA examiner provided the opinion that it is at least as likely as not that the Veteran's service-connected PTSD aided in the development of or proximately caused the Veteran's fatigue. The Board notes that there are no contrary opinions of record. Under the circumstances, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran's fatigue was caused or permanently aggravated by his service-connected disability. Resolving all remaining reasonable doubt in the Veteran's favor, the Board finds that service connection for fatigue, as secondary to his service-connected PTSD is warranted, and the appeal in this matter must be granted. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus, is denied. The Veteran contends that he suffers from erectile dysfunction as a result of his service. Specifically, he contends that such was caused or permanently aggravated by diabetes mellitus. The Veteran's service treatment records are silent for any complaints, treatment, or diagnosis of erectile dysfunction. Post-service the Veteran's treatment records reflect complaints of and a definitive diagnosis of erectile dysfunction. However, they are silent for such within one year of the Veteran's service discharge. The first notation of any erectile dysfunction complaints was in 2008/2009, approximately 38 to 39 years after the Veteran's discharge from service. Furthermore, the records do not include any opinions linking the Veteran's current erectile dysfunction with the Veteran's service or diabetes mellitus. In April 2013 the Veteran underwent a VA Endocrine Diseases examination with an accompanying DBQ. The examiner did not note a diagnosis of diabetes mellitus or erectile dysfunction, but did note that the Veteran "must watch blood sugar." In addition, the Veteran underwent a VA Diabetic Sensory Motor Peripheral Neuropathy examination with an accompanying DBQ. The examiner noted that the Veteran was not diagnosed with diabetic peripheral neuropathy, but did suffer from neuropathy and hyperglycemia. He also noted that the Veteran had a history of increased blood sugars. Ultimately, the April 2013 examiner did not find diagnoses of diabetes mellitus or erectile dysfunction and therefore provided no etiological opinions. In February 2021 the Veteran underwent a VA Male Reproductive Organ Conditions examination with an accompanying DBQ. The examiner noted that the Veteran suffered from erectile dysfunction since January 2020 as a result of damage to nerves and blood vessels. He stated that the condition began not long after the Veteran underwent treatment for cancer. In February 2021 the Veteran was provided with VA Medical Opinions in relation to his claimed erectile dysfunction. The examiner opined that the Veteran's erectile dysfunction was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran developed diabetes mellitus as a result of his herbicide exposure in service and that it is well documented that diabetes mellitus leads to other conditions, to include erectile dysfunction. The examiner noted that the Veteran did not develop erectile dysfunction for many years following his discharge and therefore based on a review of the Veterans records, it was less likely than not that the Veteran's erectile dysfunction was incurred in, directly caused by, or aggravated beyond its natural progression by his service. However, the examiner found that it was at least as likely as not that the Veteran's erectile dysfunction was proximately due to or the result of his diabetes mellitus. Throughout the appeal, the Veteran has submitted statements in support of his claim. Furthermore, the Veteran testified at a Board hearing in November 2019 indicating his belief that his erectile dysfunction was the result of his service or in the alternative due to diabetes mellitus. It is not in dispute that the Veteran currently suffers from erectile dysfunction. See post service records in June and December 2010 and February 2021 VA examination. Therefore, the first element of service connection either presumptive, direct, or secondary has been met. In regard to presumptive service connection, there is no evidence of complaints, treatment, or diagnosis of erectile dysfunction during service. Therefore, service connection for erectile dysfunction on the basis that such began during service and persisted is not warranted. Furthermore, erectile dysfunction is not listed as a chronic disease under 38 C.F.R. § 3.309 (a), and the presumptive provisions in 38 U.S.C. § 1112 for such diseases do not apply. Therefore, service connection for erectile dysfunction, on a presumptive basis as a chronic disease under 38 U.S.C. § 1112 is not warranted. In regard to direct service connection, what remains for consideration is whether the Veteran's erectile dysfunction is directly related to his active-duty service. The Veteran has made no specific allegation in support of his claim for direct service connection and has not submitted any medical evidence of a nexus between his erectile dysfunction and service. Notably, this is a medical question and his unsupported opinion has no probative value. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, the February 2021 VA examiner specifically found that his erectile dysfunction was not incurred in or directly caused by his active-duty service. Accordingly, service connection for erectile dysfunction as directly related to service is not warranted. In regard to secondary service connection, while the Veteran has specifically alleged that his erectile dysfunction was caused or aggravated by diabetes mellitus, and while the VA February 2021 examiner found a positive connection between the Veteran's erectile dysfunction and diabetes mellitus, the Veteran is not service connected for diabetes mellitus. Accordingly, service connection for erectile dysfunction as secondary to a service-connected disability is also not warranted. The Board has also considered the Veteran's statements that his erectile dysfunction is related to his active service or a service-connected disability. In this regard, a layperson is competent to report on that of which he or she has personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as a fall leading to a broken leg. Jandreau, 492 F.3d at 1376-77. However, as previously noted, the question of causation of erectile dysfunction, involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. In this regard, such an opinion requires specialized knowledge of several different bodily systems, to include the endocrine, nervous, and muscular systems. There is no indication that the Veteran possesses such specialized knowledge. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's opinion regarding the etiology of his erectile dysfunction is non-probative evidence. See Jandreau, supra; Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Moreover, the Veteran has offered only conclusory statements regarding the relationship between his erectile dysfunction and his service. In contrast, the VA examiner took into consideration all the relevant facts in providing opinions. Therefore, the Board accords great probative weight to the VA examiner's opinions. Furthermore, while the examiner and the Veteran are in agreement as to the connection between erectile dysfunction and diabetes, the Veteran is not service connected for diabetes mellitus at this time. Consequently, the Board finds that the Veteran's erectile dysfunction is not shown to be causally or etiologically related to a disease or injury incurred in or aggravated during active service or proximately due to or aggravated by a service-connected disability. Therefore, service connection for such claimed disability is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the evidence is against the Veteran's claim of entitlement to service connection for erectile dysfunction. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). While the Veteran's entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that, in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, are expected in all instances. 38 C.F.R. § 4.21. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Entitlement to an initial compensable rating for service-connected right ear hearing loss is denied. The Veteran contends that the severity of his right ear hearing loss warrants a compensable rating. The Veteran's right ear hearing loss has been evaluated as noncompensable effective September 17, 2012. The Rating Schedule provides a table for ratings purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, established by a state-licensed audiologist including a controlled speech discrimination test (Maryland CNC), and based upon a combination of the percent of speech discrimination 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 evaluation 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. Table VIA is used when the examiner certifies that the use of speech discrimination test is not appropriate because of language difficulties, inconsistent speech discrimination scores, etc., or when indicated under the provisions of 38 C.F.R. § 4.86. 38 C.F.R. § 4.85(c). 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 will be evaluated separately. 38 C.F.R. § 4.86 (a). 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 elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86 (b). To evaluate the degree of disability from defective hearing, the rating schedule establishes eleven auditory acuity levels designated from I for essentially normal acuity, through XI for profound deafness. 38 C.F.R. § 4.85, Tables VI, VII. Pertinent case law provides that the assignment of disability ratings for hearing impairment are to be derived by the mechanical application of the Ratings Schedule to the numeric designations assigned after audiometry evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Post-service treatment records reflect the Veteran's reports of impaired hearing. He was afforded a VA examination in October 2020 and audiometric testing revealed the following: 500 1000 2000 3000 4000 6000 8000 Avg. Right 30 25 30 40 55 45 60 37.50 Left 30 30 35 35 30 35 40 32.50 The pure tone threshold average was 37.5 in the right ear and 32.5 in the left ear. Speech recognition was 94 percent in the right ear and 96 percent in the left ear. The examiner reviewed the claims file and diagnosed bilateral sensorineural hearing loss. Throughout the appeal, the Veteran has submitted statements in which he has indicated his belief that his right ear hearing loss warrants a compensable rating. In addition, he testified in November 2019 that a compensable rating should be assigned. At the time of the October 2020 VA audiological examination, the Veteran was shown to have an average pure tone hearing loss of 37.5 decibels in the right ear, with 94 percent speech discrimination in the right ear, which translates to a Roman numeral designation of I for the right ear. Thus, when applying Table VII, Diagnostic Code 6100, level I for the right ear, equates to a noncompensable disability evaluation. Based on the average pure tone threshold findings from the VA examination, when applying Table VII, Diagnostic Code 6100, the findings equate to a noncompensable disability evaluation. While documenting hearing loss, VA clinical records during this period do not address the severity of the Veteran's right ear hearing loss for rating purposes. There is simply no evidence to show that the Veteran met the rating criteria for a compensable rating. Therefore, the evidence shows that the Veteran is not entitled to a compensable rating for his service-connected right ear hearing loss. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Entitlement to an initial rating in excess of 10 percent disabling for service-connected chronic laryngitis is denied. The Veteran contends that his service-connected chronic laryngitis is worse than is reflected by the current 10 percent rating. The Veteran's chronic laryngitis is rated under Diagnostic Codes 6819-6516. Hyphenated codes are used when a rating for a particular disability under one diagnostic code is based upon rating of the residuals of that disability under another diagnostic code. 38 C.F.R. § 4.27. The hyphenated diagnostic codes in this case indicate that malignant neoplasms of any specified part of the respiratory system exclusive of skin growths under Diagnostic Code 6819 is the service-connected disorder and that chronic laryngitis under Diagnostic Code 6516 is the residual condition. Under Diagnostic Code 6516, a 10 percent disability rating is assigned when there is evidence of hoarseness with inflammation of the cords or mucous membrane. A 30 percent disability rating, the highest disability rating available, is assigned when there is evidence of hoarseness with thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. 38 C.F.R. § 4.97; Diagnostic Code 6516. Post-service treatment records reflect the Veteran's reports of hoarseness and occasional trouble breathing. In July 2009 the Veteran was diagnosed with squamous cell carcinoma. The Veteran received treatment for his cancer and his condition improved. In September 2011 the Veteran underwent a VA Nose, Sinus, Larynx and Pharynx examination. The examiner noted that the Veteran had been diagnosed with vocal cord (laryngeal) cancer in 2009. The Veteran experienced hoarseness and underwent radiation therapy. The Veteran reported some breathing trouble and hoarseness. The examiner found no evidence of nasal obstruction, nasal polyps, septal deviation, permanent hypertrophy of turbinates from rhinitis, or tissue loss, scarring or deformity of the nose. In April 2013 the Veteran underwent a VA Sinusitis/Rhinitis and other Conditions of the Nose, Throat, Larynx and Pharynx examination with an accompanying DBQ. The examiner noted that the Veteran had diagnoses of chronic sinusitis, chronic laryngitis, and benign or malignant neoplasm. The examiner noted that the Veteran suffered from hoarseness and inflammation of the vocal cords or mucous membranes. However, he did not find that the Veteran had thickening or nodules of the vocal cords, submucous infiltration of the vocal cords, or vocal cord polyps. While the examiner noted that the Veteran previously had malignant neoplasms, such had been treated. In February 2021 the Veteran underwent an additional VA Sinusitis/Rhinitis and other Conditions of the Nose, Throat, Larynx and Pharynx examination with an accompanying DBQ. The examiner noted that the Veteran had diagnoses of non-allergic rhinitis, chronic laryngitis, and sinusitis. The Veteran reported that he suffered from hoarseness, clogged sinuses, difficulty breathing at night, and head plugged in the mornings. In regard to the Veteran's chronic laryngitis, the examiner noted that the Veteran experienced hoarseness and inflammation of the vocal cords. The examiner did not find inflammation of the mucous membrane, thickening of the vocal cords, nodules of the vocal cords, submucous infiltration of the vocal cords or vocal cord polyps. The examiner further noted no other pharyngeal or laryngeal conditions. Finally, the examiner did not note any neoplasms. Following a review of the relevant evidence of record, the Board concludes that the Veteran is not entitled to a rating in excess of 10 percent disabling for his service-connected chronic laryngitis. In this regard, the Board finds that such disability is manifested by hoarseness marked with inflammation of the cords or mucous membrane. All the examinations of record, in September 2011, April 2013 and February 2021, noted that the Veteran suffered from hoarseness. Furthermore, the April 2013 and February 2021 examiners also noted that the Veteran suffered from inflammation of the vocal cords or mucous membranes. While the April 2013 examiner noted that the Veteran previously had a malignant neoplasm, he also noted that such had been treated with no further indication of any neoplasms benign or malignant. Therefore, the Board finds that the Veteran's current 10 percent rating is warranted. The Board notes that the remainder of the record fails to establish that the Veteran experiences thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy, which is necessary for a higher 30 percent rating. None of the examiners of record found evidence of thickening or nodules of cords, polyps, submucous infiltration. And as previously noted, while the April 2013 examiner reported that the Veteran had a prior malignant neoplasm, he also noted that such had completed treatment. Finally, the subsequent examination in February 2021, revealed no evidence of any neoplasms benign or malignant or any pre-malignant changes on biopsy. Finally, treatment records also do not reflect that the Veteran has any of the above signs or symptoms. Therefore, a higher 30 percent rating is not warranted. The Board has considered all potentially applicable diagnostic codes in accordance with Schafrath, 1 Vet. App. at 594; however, the evidence does not show symptoms that could be separately rated higher under another diagnostic code. 38 C.F.R. § 4.130. Indeed, when a disorder is listed in the Rating Schedule, rating by analogy is not appropriate. Copeland v. McDonald, 27 Vet. App. 333, 336-37 (2015). In light of the evidence above, the Board finds that the Veteran experiences hoarseness as a result of his laryngitis but does not experience thickening or nodules of cords, polyps, submucous infiltration, or pre-malignant changes on biopsy. Therefore, the evidence is against his claim seeking a rating in excess of 10 percent for chronic laryngitis. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Entitlement to an initial rating of 70 percent disabling, but no higher, for the entire appeal period for service-connected PTSD, is granted. The Veteran contends that his service-connected PTSD is worse than is reflected by his currently assigned ratings. The Veteran is currently in receipt of a 10 percent rating from September 7, 2012, and a 70 percent rating from October 7, 2020, for his PTSD. The Veteran was granted service connection for PTSD in an October 2013 rating decision. The RO assigned a 10 percent disability rating effective September 7, 2012. Subsequently, the RO readjudicated the Veteran's claims in an August 2014 rating decision. The Veteran filed a notice of disagreement with the initial rating in September 2014. In addition, during the pendency of the appeal, the RO increased the Veteran's rating to 70 percent disabling effective October 7, 2020. The Veteran's service-connected PTSD is evaluated under the criteria of Diagnostic Code 9411, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. The General Rating Formula for Mental Disorders provides for a 10 percent rating for occupational and social impairment due to mild or transient symptoms, which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating contemplates occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairments of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 11617 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms [,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126 (a). In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the United States Court of Appeals for Veterans Claims (Court) held that the language of the General Rating Formula "indicates that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas." However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran's service-connected psychiatric disability, and their resulting social and occupational impairment. The Board notes that the revised DSM-5, which, among other things, eliminates Global Assessment of Functioning (GAF) scores, applies to appeals certified to the Board after August 4, 2014, as is the case here. See 79 Fed. Reg. 45, 093 (Aug. 4, 2014). Consequently, the Board will not consider any previously assigned GAF scores in determining the outcome of this case. See Golden v. Shulkin, No. 16-1208 (February 23, 2018). After a review of the record, the Board finds that the Veteran is entitled to an initial rating of 70 percent, but no higher, for the entire appeal period, for his service-connected PTSD. In September 2013 the Veteran underwent a VA PTSD examination with an accompanying DBQ. The examiner noted that the Veteran met the diagnostic criteria for PTSD. Furthermore, the examiner found that the Veteran's PTSD caused him occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The Veteran reported that he was divorced after 13 years of marriage and that he had lived with his current girlfriend for approximately 18 years. He stated that they had a good relationship and that he also had one child from his previous marriage. He stated that he did have problems with relationships both at home and work due to his PTSD. He reported that he worked in construction and had for approximately 2 years and had worked in a warehouse for approximately 16 years previously. The Veteran's girlfriend reported that the Veteran angered easily, fought in his sleep, and got emotional when talking about Vietnam. Upon examination, the examiner noted that the Veteran experienced recurrent distressing dreams and made an effort to avoid activities, places or people that aroused recollections of his time in Vietnam. Furthermore, the Veteran suffered from difficulty falling or staying asleep, hypervigilance and an exaggerated startle response. The examiner noted no other PTSD symptoms. In October 2020 the Veteran underwent an additional VA PTSD examination with an accompanying DBQ. The examiner noted that the Veteran met the diagnostic criteria for PTSD, and alcohol use disorder. The examiner found that the Veteran's PTSD caused occupational and social impairment with reduced reliability and productivity. The Veteran reported that he lived with his girlfriend of 23 years and that they had an ok relationship. He also stated that he had one son and that their relationship was good. He noted that he had a couple good friends. The Veteran reported that he suffered from irritability with unprovoked outbursts of anger, hypervigilance, exaggerated startle response, problems with concentration, nightmares, and sleep disturbance. Upon examination the examiner noted that the Veteran suffered from depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impairment of short- and long-term memory, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, and impaired impulse control, such as unprovoked irritability with periods of violence. The examiner further noted that the Veteran was responsive, cooperative, and fully oriented. He was appropriately dressed and groomed and his personal hygiene was adequate. His posture was normal as well as his motor behavior and eye contact. His speech was fluent and his voice quality was clear. His thought process was coherent and goal directed and there was no evidence of any delusions, hallucinations, or disordered thinking. His mood was euthymic and his affect congruent. Treatment records throughout the appeal period reflect that the Veteran received some counseling. He reported struggling with tossing and turning at night with increased agitation, night sweats, and stressful dreams. He also reported nightmares, flashbacks, and avoidance of memories. He noted that he often had negative thoughts about himself and feelings of guilt. He noted that he had difficulty experiencing positive feelings. He stated that he was hypervigilant, easily startled, and had difficulty concentrating. However, during mental status evaluations he was routinely found to be appropriately dressed and groomed. His eye contact was normal and his behavior was cooperative. His speech was normal and his mood euthymic with a congruent affect. His thought process was within normal limits and his thought content was logical and linear. There was never any evidence of delusions or hallucinations. His memory was intact and his cognition/orientation was within normal limits. His insight and judgment were good and his concentration was adequate. Finally, while the Veteran routinely denied any suicidal or homicidal ideation, he did endorse on multiple occasions passive suicidal ideation. He also noted that he sometimes wanted to "fall asleep and not wake up." Throughout the appeal the Veteran submitted lay statements indicating his belief that his PTSD and resulting symptoms are worse than is indicated by his currently assigned ratings. Period prior to October 7, 2020 Following a review of the relevant evidence of record, the Board concludes that prior to October 7, 2020, the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation, difficulty falling or staying asleep, nightmares, hypervigilance, irritability, and an exaggerated startle response, without more severe manifestations that more nearly approximate total occupational and social impairment As indicated previously, a 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. With respect to the symptomatology considered in the assignment of a 70 percent rating, the probative evidence of record reveals that while there are numerous denials of active suicidal intent or plan, the Veteran did endorse a history of suicidal ideation at various times in his treatment records prior to October 7, 2020. The Veteran and his girlfriend also noted that he was generally irritable and quick to anger. Furthermore, while he reported a good relationship with his girlfriend, they both indicated that his symptoms greatly and negatively impacted his relationships both at home and at work. Furthermore, while acknowledging that VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of the Veteran's service-connected psychiatric disability, the Court recently indicated that suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas. See Bankhead, 29 Vet. App. at 10. Here, the Veteran not only reported suicidal ideation as well negative thoughts about himself and difficulty experiencing positive feelings, but he also noted a desire to "just fall asleep and not wake up." Thus, resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for a 70 percent rating for PTSD has been met prior to October 7, 2020. However, the Board finds that the criteria for a 100 percent rating under the General Rating Formula are not met. In this regard, the evidence does not show that the Veteran has total social and occupational impairment due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Indeed, the record does not reflect that the Veteran's PTSD symptoms have resulted in total social and occupational impairment. The Board further notes that the evidence of record reflects that the Veteran has additional symptomatology that is not enumerated in the rating schedule, including exaggerated startle response, nightmares, and hypervigilance. See Mauerhan, supra. However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 70 percent under the General Rating Formula as they are not of such a duration, severity, or frequency to result in total occupational and social impairment. Ultimately, the Board finds that the Veteran's PTSD does not warrant a rating in excess of 70 percent. Ultimately, the Board finds that a 70 percent rating for PTSD is warranted prior to October 7, 2020; however, the evidence is against a rating in excess of 70 percent. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Period beginning October 7, 2020 Following a review of the relevant evidence of record, the Board concludes that the Veteran is not entitled to a rating in excess of 70 percent disabling for his service-connected PTSD beginning October 7, 2020. In this regard, the Board finds that such disability is manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as irritability, hypervigilance, exaggerated startle response, problems with concentration, nightmares, depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impairment of short and long term memory, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, and impaired impulse control, such as unprovoked irritability with periods of violence, without more severe manifestations that more nearly approximate total occupational and social impairment. In this regard, the Board finds that such symptomatology, to specifically include the Veteran's irritability, problems with concentration, depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impairment of short and long term memory, disturbances of mood and motivation, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, impaired impulse control, such as unprovoked irritability with periods of violence, as well as the frequency, severity, and duration of his psychiatric symptoms are contemplated in his 70 percent rating. As indicated previously, a 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Based on the evidence of record, the Board finds that the Veteran's PTSD does not result in total occupational and social impairment. In this regard, the evidence does not show that the Veteran has total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In this regard, there was no evidence of delusions, or significant cognitive impairment found on mental status examinations. The VA examination conducted in October 2020 and the mental status examinations conducted throughout the appeal period in question found the Veteran's thought process and content to be logical and coherent, and without impairment or delusions. There is no indication in the record that the Veteran suffered perceptual disturbance such as delusions, hallucinations, mania, or psychosis. Furthermore, the Veteran has not displayed grossly inappropriate behavior or persistent danger of hurting himself or others. Again, while the Veteran has reported irritability and even anger, there is no indication that he has resorted to violence, let alone that he poses a threat to himself or others. And finally, the record reflects that the Veteran has always been noted to be alert and oriented, clean, and well-groomed and no indication of memory loss for names of close relatives, own occupation, or own name. The Board further notes that the evidence of record reflects that the Veteran has additional symptomatology that is not enumerated in the rating schedule, including exaggerated startle response, nightmares, and hypervigilance. See Mauerhan, supra. However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 70 percent under the General Rating Formula as they are not of such a duration, severity, or frequency to result in total occupational and social impairment. Ultimately, the Board finds that the Veteran's PTSD does not warrant a rating in excess of 70 percent. Therefore, as the Veteran's PTSD symptoms, as detailed previously, are contemplated by his 70 percent rating, and absent more severe symptoms, a higher rating is not warranted for the period beginning October 7, 2020. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. Other Considerations In reaching its conclusions, the Board acknowledges the Veteran's belief that his symptoms are more severe than the current disability ratings reflect. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert, 21 Vet. App. at 462. The Board finds the medical evidence in which professionals with medical expertise examined the Veteran's disabilities, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than his own reports regarding the severity of such conditions. The Board has considered whether staged and additional staged ratings under Fenderson, supra, and Hart, supra, are appropriate for the Veteran's service-connected disabilities; however, the Board finds that the currently assigned ratings for his conditions represent the earliest dates of increase in his symptomatology and that the remainder of his symptomatology referable to such disabilities has been stable throughout each period of the appeal. Therefore, assigning staged or further staged ratings is not warranted. REASONS FOR REMAND Entitlement to service connection for left ear hearing loss is remanded. Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); Duenas v. Principi, 18 Vet. App. 512 (2004); Robinette v. Brown, 8 Vet. App. 69 (1995); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). For below noted reasons, the Board finds that an additional VA medical opinion is needed to determine the nature and etiology of the Veteran's claimed left ear hearing loss. The Veteran alleges that he suffered acoustic trauma while in the service and that such caused bilateral sensorineural hearing loss. The Veteran is already service-connected for right ear hearing loss and bilateral tinnitus, so in-service acoustic trauma has already been conceded. As far as a current disability, the Veteran underwent a VA hearing examination in October 2020. The audiological testing revealed hearing loss in both ears that constitutes a disability for VA purposes. See 38 C.F.R. § 3.385. As far as a nexus between the Veteran's current hearing loss and his service, the October 2020 examiner opined that while the Veteran had sensorineural hearing loss in both ears, his left ear hearing loss was less likely than not caused by or a result of an event in service. The examiner provided the rationale that the Veteran's service records were silent for any hearing loss and that the Veteran's left ear hearing loss did not develop for many years following his discharge. The examiner stated that hearing loss from trauma was immediate and that there was no support for delayed onset. The Board finds that the examiner failed to provide an adequate explanation supported by medical rationale for his stated opinion as he failed to thoroughly discuss the possibility of delayed onset. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Veteran's representative in April 2022 provided an article discussing medical research in support of delayed onset noise-induced hearing loss. Therefore, on remand, a new VA examination should be conducted to determine the nature and etiology of the Veteran's left ear hearing loss which considers all relevant evidence. Due to the amount of time which will pass on remand, updated treatment records should be obtained and associated with the record. The matters are REMANDED for the following action: 1. Obtain updated treatment records. 2. The Veteran should be afforded a VA examination to determine the etiology of his claimed left ear hearing loss. The record should be made available to and be reviewed by the examiner. The examiner is asked to furnish an opinion with respect to the following questions: a) The examiner should identify whether the Veteran has left ear hearing loss. b) The examiner should offer an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any currently diagnosed left ear hearing loss, had its onset during any period of service, or is otherwise related to such periods of service, to include the Veteran's conceded in-service acoustic trauma. The examiner must discuss all relevant evidence of record to include the October 2020 VA examination AND the article referenced in the Veteran's April 2022 Brief (Acceleration of age-related hearing loss by early noise exposure: evidence of a misspent youth -PubMed (nih.gov)- Dr Sharon G. Kujawa). The examiner is asked to provide a complete rationale for all opinions and conclusions reached. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Unger, 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.