Citation Nr: 23039698 Decision Date: 07/19/23 Archive Date: 07/19/23 DOCKET NO. 13-27 817 DATE: July 19, 2023 ORDER Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for bilateral hearing loss is denied. FINDINGS OF FACT 1. For the entire period on appeal, the Veteran's PTSD manifested by symptoms productive of anxiety, depression, isolation, hypervigilance, and statements of suicidal ideation, but did not more nearly approximate occupational and social impairment with deficiencies in most areas. 2. The persuasive weight of the evidence is against a finding that the Veteran's bilateral hearing loss is the result of his in-service noise exposure. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 50 percent for service-connected PTSD have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Codes (DC) 9411. 2. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1968 to August 1971, to include service in the Republic of Vietnam (RVN). These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In connection with this appeal, the Veteran testified at a Board hearing in February 2014. A copy of the transcript has been associated with the record. These appeals were previously remanded by the Board in June 2015 and May 2019. There has been substantial compliance with the remand directives, and there is no bar to proceeding with the appeal. Stegall v. West, 11?Vet. App.?268, 271. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). 1. Entitlement to a disability rating in excess of 50 percent for service-connected PTSD Generally, 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. 38 C.F.R. § 4.1. 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 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. 38 C.F.R. § 4.7. The basis of disability evaluations 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. Mental health disorders are evaluated under the General Rating Formula for Mental Disorders, a specific rating formula presented under 38 C.F.R. § 4.130. In addition, the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-5) provides guidance for the nomenclature employed within 38 C.F.R. § 4.130. Under the General Formula for Mental Disorders, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). In this case, the Veteran's service-connected PTSD was rated under DC 9411, as 50 percent disabling for entire relevant appeal period. A 50 percent rating is assigned for a mental disorder that results in 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; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation. 38 C.F.R. § 4.130, DC 9411. A 70 percent rating is assigned when symptoms such 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for 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; or memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, DC 9411. Turning to the medical evidence of record, in November 2009, the Veteran was afforded a VA examination. At that time, he reported difficulty sleeping, nightmares, and isolation. He denied any issues being in social situations, but that if he felt like he was not in control, he became very anxious and felt like he had to get away. He also stated that he did not like being in the middle of crowded rooms, and always had to have his back to a wall. He noted that he had strong startle reactions to loud noises, anxiety, irritability, and losing his temper easily. He added that at that time, he was working for the state of Arkansas, a job he had maintained for five years. He also noted that he worked as a repair technician prior to that for thirteen years. He reported frequent suicidal thoughts, but he denied any actual desire or intent to take his own life, adamantly denying any intent or plan. He denied any drug or alcohol abuse or any homicidal ideation. He was found to be casually dressed and groomed, cooperative, and pleasant. He displayed mild anxiety, and rarely smiled, but made good eye contact. His speech was logical and coherent, within normal limits with respect to rate and rhythm. He was alert and oriented to all spheres, with logical thought processes. His memory was largely intact, and he denied any hallucinations or delusions. His insight and judgment were adequate, and he denied any homicidal ideation. He was found competent by the VA examiner. In December 2010 VA treatment notes, he reported depression and frequent suicidal ideation. He reported that he thought about the best way to do it but denied any plans and any previous suicide attempts. He denied any homicidal ideations. In February 2011 VA treatment notes, he was noted to have symptoms of recurrent memories and avoidance which began in RVN. The examiner also found that he had longstanding depression, which was not responding to his medications, with the exception of a slight help with short term memory. He denied any suicidal or homicidal ideation, he was casually dressed and groomed, and was polite and cooperative. His mood was appropriate, and his speech was normal. He was alert and oriented to all spheres, and his recent and remote memory were intact, as well as his judgment and insight. In May 2012 private treatment notes, he denied any depression or hallucinations. He was also oriented to all spheres, and his mood was appropriate. In January 2013 private treatment notes, he was oriented to all spheres, with an appropriate mood. He was also found to be negative for depression or hallucinations. In January 2013, he was also afforded a VA examination. He reported at that time that he had been married for 30 years, and that he would go out to eat and go shopping with his wife, but that sometimes, his depression impacted his relationship with his wife. He denied having any friends but reported having one son. He stated that he maintained his job with the state for the preceding eight years, working as a computer technician, but added that he had some difficulty with his temper. He reported depression, isolation, and generally not feeling very excited about his life. He noted that he really only spent time with his wife, and that he had issues with anxiety in social situations. He added that he generally avoided going out in crowds unless he was with his wife. He reported getting approximately six to seven hours of sleep per night, but that he had occasional nightmares. He stated that he only drank socially. He was found to have symptoms of chronic sleep impairment and depression but was competent to manage his financial affairs. The examiner noted that the Veteran met the criteria for PTSD and that he was being treated for depression, which was more prominent than his anxiety at that point. The examiner also noted that his PTSD symptoms were mild, and that his PTSD manifested as occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. In March and April 2013 VA treatment notes, he denied any suicidal or homicidal thoughts or ideations, but reported attempts in the past. He reported little interest or pleasure, feeling depressed, trouble falling or staying asleep, feeling tired, and feeling bad about himself nearly every day. He was appropriately dressed and groomed, with good eye contact, cooperative, and with normal motor movements. His mood was "not good," and his affect was stable. He had linear and relevant thought processes and denied any hallucinations or delusions. He reported longstanding depression, with worsening symptoms since an increase in his medication was effectuated. At his February 2014 Board hearing, he reported experiencing chronic suicidal thoughts, isolation, a lack of social life, issues with memory and concentration. He also reported irritability, anger, and anxiety. In July and August 2014 VA treatment notes, he denied any suicidal or homicidal ideation, but reported a depressed mood "pretty much all of the time." He also reported diminished pleasure, loss of energy, feelings of worthlessness and inappropriate guilt, intrusive thoughts, occasional nightmares, social isolation and avoidance, irritability, and hypervigilance. He denied any delusions or hallucinations, and thoughts of self-harm. He was appropriately dressed and groomed, with good eye contact and normal motor movements. He was cooperative, with a decent mood, constricted affect, goal-directed and relevant thought processes. In October 2016 VA treatment notes, he reported that he had not been evaluated in over one year, but denied any changes in his symptoms, but that he was able to cope "pretty well." He noted that he avoided situations where he is not in control, such as crowded places and social gatherings. He added that he felt hypervigilant all the time, and that holidays were difficult, noting that he felt anxious before a family gathering. He reported feelings of worthlessness and guilt all the time, and a decline in energy levels. He noted that he slept most of the night with medication, but that he continued to occasionally have nightmares about being captured. He reported thoughts of suicide "all the time" but that they were not so much about ending his life, but instead, about how he would do it to minimize harm to those around him. He denied any active thoughts of suicide, intent, or plan. He noted that both he and his wife had recently retired, and care for his grandson during the day. He was well groomed, with appropriate eye contact, and cooperative. He had no psychomotor activation or slowing, and his mood was average, with the Veteran reporting he had good and bad days. His affect was pleasant, congruent, and had a full range of emotions. His speech and thought processes were normal. He denied any suicidal or homicidal ideations, delusions or hallucinations. He was alert and oriented to all spheres, his memory was intact, and his attention and concentration were appropriate. In October 2018, he reported chronic PTSD and depression, but stated that he had learned to manage it. He stated that he did not want therapy. He reported nightmares. He was cooperative, with some depression and a mildly restricted affect. His speech was normal, and his thought processes were linear, and goal directed. He denied any suicidal or homicidal ideations, delusions, or hallucinations. He was alert and oriented to all spheres, his memory was intact, and his attention and concentration were normal. In November 2019, he was afforded another VA examination. He reported experiencing recurrent, intrusive, and distressing nightmares. He also stated that he experienced prolonged psychological distress when exposed to trauma. He worked to avoid memories, thoughts, and feelings related to his time in service. He had exaggerated negative beliefs about himself and the world around him, with decreased interest and participation in formally pleasurable activities. He reported feelings of detachment, and difficulty experiencing positive emotions. He stated that he was excessively irritable, hypervigilant, and that he had decreased concentration due to sleep disturbances. He denied any real changes since his last VA examination. He stated that he continued to have essentially no social life, other than telephone contact with one friend with whom he felt a sense of connection because they also struggled with panic and anxiety. He reported being married to his wife for the past 35 years, with one stepson and one biological son. He noted that he received periodic visits with their two grandsons. He added that he got very anxious in social situations, especially in crowds or family get togethers. He stated that he avoided going out when possible. Occupationally, he reported retiring approximately seven years prior. He noted that his mental health status was about the same as it was at the time of his last VA examination. He noted that thanks to his medications, his moods were fairly stable in that he never felt good or bad. He noted that he did not get sad, and he did not get excited. He denied any legal or behavioral problems, adding that he got angry easily but that he was able to control it. He stated that he was clean and sober since approximately 1985, aside from an occasional social drink. He reported symptoms of anxiety, panic attacks occurring weekly or less often, chronic sleep impairment, flattened affect, and suicidal ideation. He was assessed as clean, well groomed, and dressed appropriately. His affect was somewhat blunted, but he had no abnormalities of speech or language. There was no behavioral evidence of confusion or trouble thinking clearly. He was cooperative. With regard to his suicidal ideation, he again clarified that he spent considerable time thinking about how to go about committing suicide. In particular, he noted that he thought about how to make it look like an accident; however, he denied any intent or plan, and noted that he would never commit suicide because he did not want to hurt those he left behind. He was assessed as being an increased, but not imminent risk. The examiner found that his PTSD manifested as occupational and social impairment with reduced reliability and productivity. In August 2020 VA treatment notes, the Veteran noted that he had not been seen since late 2018 for his PTSD symptoms. He reported that his symptoms were stable since last contact, and that his mood had ups and downs. He noted that stress from the pandemic keeping him from seeing his grandchildren was causing stress. However, he denied any severe or persistent depression. He continued to report the chronic passive suicidal ideation that he said he had experienced for decades but denied any intent or plan. The examiner noted that he had good barriers and a safety plan. He reported sleeping well with medication, but that he had chronic issues with avoidance, hypervigilance, and intrusive memories. However, he added that he had learned how to manage this in his day-to-day life. In September 2021 VA treatment notes, he reported feeling stable, but that he continued to experience stress from the pandemic. He added that he was handling it the best that he could, and that he realized it impacted everyone. He stated that some days, he felt "blah" but that he took it day by day. He denied anhedonia and reported joy from fishing with his son. He reported the same chronic suicidal ideations, but denied any intent or plan, and added that he felt safe currently. He stated that his anxiety was up and down, but that his PTSD symptoms were stable. In March 2022 VA treatment notes, he continued to report stable symptoms. His mood was noted to be situational, with ups and downs, but he denied any severe depression. He had some reduction to interests, but enjoyment in things like seeing his grandson. He reported the same enduring suicidal ideations, but continued to deny any intent, plan, or preparatory behavior. He added that he slept well with medication. He reported residual hypervigilance, avoidance, and intrusive memories, but he felt that he managed well. As outlined above, for the relevant appeal period, it seemed that the Veteran attended somewhat regular treatment sessions for his condition and the Board has considered the manifestations of his condition throughout the relevant appeal period even if not every relevant treatment record is outlined in detail above. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (holding that the Board is not required to comment upon every piece of evidence contained in the record). Upon review of the totality of the record, the Board finds that a rating of 70 percent is not warranted for the relevant appeal period. With respect to his symptoms, the lay and medical evidence of record demonstrates that the Veteran consistently exhibited a depressed mood; anxiety; and occasional nightmares with indications of chronic of suicidal thoughts without intent or plan. In this regard, he was continuously assessed by examiners and never found to be a risk for suicide, with the Veteran himself noting that he would not carry it out. Additionally, the Veteran has exhibited no panic attacks, memory loss, obsessional rituals, near consistent panic or depression affecting his ability to function independently, impaired impulse control, spatial disorientation, neglect of personal appearance or hygiene, an inability to maintain relationships, apparent, persistent communication impairments, disorientation to his person, place or time, grossly inappropriate behavior, memory loss, delusional or hallucinatory perceptions, or homicidal ideation. While he reported suicidal ideation at his Board hearing and with examiners, the Board notes, importantly, that the many treatment records for the relevant time period instead reflect denials of any such intent or plan. In this regard, the Board notes that, while the record shows that the Veteran reported some symptoms associated with a higher rating, such as suicidal ideations, it must be emphasized that even with consideration of these symptoms, the totality of the Veteran's disability picture did not demonstrate that his service-connected PTSD resulted in symptoms productive of occupational and social impairment with deficiencies in most areas. See Mauerhan v. Principi, 16 Vet. App. at 442-43. Despite the Veteran's psychiatric symptoms, which sometimes included hypervigilance, exaggerated startle response, depressed mood, anxiety, mild panic attacks, isolation, and suicidal ideations, the VA examination and treatment records reflect that the Veteran's mental status examinations were largely unremarkable with normal judgment, memory, interactions, and speech. Additionally, the record reflects that the Veteran continued to be in a loving, long-term relationship with his wife of many decades, had good relationships with his son and grandchildren, and maintained a stable job for many years until his retirement, albeit with some issues. Importantly, this does not support or illustrate occupational and social impairment with deficiencies in most areas. While there were deviations in his moods and functioning, the persuasive weight of the evidence as a whole does not support a consistent or significant worsening or improvement of his mental health. The Board finds that the VA treatment records and examinations, conducted throughout the appeal period, in this case are probative and persuasive. Again, the Veteran was seen fairly regularly, and his mental health assessed throughout the entire span of his appeal period. These treatment notes reflect in-person evaluations of the Veteran's behavior, with consideration of his lay statements as well as relevant medical and treatment history and provide professional assessments as to his needs going forward, as well as sufficiently detailed findings such that the Board can make a fully informed decision on the Veteran's claim. In sum, the Board finds that the most persuasive weight of the evidence supports the 50 percent rating currently assigned for the Veteran's PTSD, for the period on appeal. The Veteran's symptoms manifested in symptoms of a frequency, severity, and duration so as to result in, at most, occupational and social impairment with reduced reliability and productivity. Thus, the benefit of the doubt rule is not for application, and the appeal is denied. 38 U.S.C. § 5107 (b); Lynch, 21 F.4th 776. 2. Entitlement to service connection for bilateral hearing loss Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing direct service connection generally requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. 38 C.F.R. § 3.303. Impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; when the auditory thresholds for at least three of the above frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Additionally, the threshold for normal hearing is between 0 and 20 decibels and that higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The absence of in-service evidence of hearing loss is not fatal to a claim for service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability (i.e., one meeting the requirements of 38 C.F.R. § 3.385, as noted above) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. Hensley v. Brown, 5 Vet. App. at 159. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d at 1376-77. When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1376-77. A veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal," and does not require that the evidence be in exact equipoise. Evidence is in approximate balance when the evidence in favor of and opposing the veteran's claim is found to be almost exactly or nearly equal. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021). First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). Bilateral hearing loss was diagnosed at VA examinations. See C&P Exam (December 2019); VA Examination (January 2013). Second, the Board finds that there was an in-service event, injury or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran has reported significant noise exposure during service in the form of mortar attacks, small arms fire, and general noise exposure without hearing protection. He added that he slept in RVN next to a big generator with a bad muffler on it, worked in a radio trailer powered by generators, and that he had to whistle specific frequencies in a high frequency tone as part of his military occupational specialty (MOS). Although his STRs do not reflect any issues with hearing during service, personnel records reflect that the Veteran's MOS was a radio repairman. Post-service, to include in the testimony provided at his Board hearing, he contended that he did not have significant post service exposure. Accordingly, the Board finds that there was noise exposure during service. The second element of service connection is met. Third, the Board finds that the evidence of record does not support a finding that the bilateral hearing loss is related to active service. At service entrance in November 1968, an audiogram revealed the following puretone thresholds in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 0 -5 -5 X 10 LEFT 5 -5 -5 X 15 At separation in July 1971, the audiogram revealed the following puretone thresholds in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 25 15 10 X 5 LEFT 20 15 10 X 10 Post service treatment notes from November 2006 and June 2008 reflected that he had normal hearing without complaints by the Veteran. In April 2009 VA treatment notes, he requested an evaluation for tinnitus, but reported that his hearing was fair. He was found to have slight sensorineural hearing loss from 250-2000 Hz and moderately severe loss bilaterally. There was no significant difference in the ears. His word recognition scores were excellent, and his acoustic immittance was normal. In October 2009, he was afforded a VA examination, where he reported difficulty hearing, which he attributed to noise exposure during service in the firing range. He denied pre-military noise exposure and noted that post-military noise exposure was typical with only home lawn equipment, but that he used muffs when using this equipment. The examiner noted that his entrance audiogram was normal, and that his separation audiogram revealed a mild high frequency shift. Following a review of the in-service testing results, MOS, and current clinical values, the examiner determined that the Veteran's bilateral hearing loss was less likely than not the result of service. The examiner reasoned that on entrance, the Veteran had normal hearing in the 250-2000 Hz range and then moderately severe hearing loss in the 3000-8000 Hz range, and that at separation, he had normal hearing in the 250-2000 Hz and moderate to mild loss in the 6000-8000 Hz range. The examiner noted that both military hearing tests indicated thresholds in the normal range from 500-4000 Hz range, with no significant threshold shift between 500-6000 Hz for either ear from enlistment to separation, making it less likely that his current hearing loss was related to service. In January 2013, he was afforded another VA examination. Following a review of the record, the examiner determined that the Veteran's bilateral hearing loss was less likely than not the result of service. The examiner reasoned that the audiological tracing at enlistment and separation were within normal limits. The examiner noted that the enlistment audiogram showed results within normal limits between 500-2000 Hz, and at 4000 Hz for both ears. The separation audiogram also showed results within normal limits from 500-2000 Hz and 4000-6000 Hz. The examiner noted that a comparison of the enlistment and separation audiogram revealed no significant changes in hearing for either ear, particularly in the high frequencies where a noise-induced hearing loss would occur. Additionally, the examiner reiterated that the Veteran's hearing was within normal limits at separation. In December 2019, he was afforded a VA examination. He reported at that time that he did not hear well, it was hard to watch TV loudly, aggravating those around him. He noted that he had trouble hearing his wife's voice, could not enjoy music, had to keep his phone on a high volume, and that background noise in a crowd tended to wipe out his hearing. Following a review of the record, the examiner opined that the Veteran's bilateral hearing loss was less likely than not the result of service, reasoning that the Veteran served in the Army from November 1968 to August 1971, with an MOS as a system repairman which is conceded to have moderate noise exposure. The examiner acknowledged the Veteran's reports of military noise exposure, including gunfire, rocket attacks, artillery, mortar fire, large generators, radio tones and static, heavy trucks, and helicopters, all without hearing protection. The examiner noted that according to service treatment records, his hearing sensitivity was within normal limits at both entrance and separation. However, positive threshold shifts were noted at 500 Hz, 1000 Hz, and 2000 Hz, when the frequencies were compared between entrance and separation. Nonetheless, the examiner noted due to tonotopicity of the basilar membrane, and the proximity of the higher frequencies' placement on the basilar membrane nearer to the oval window, hazardous noise exposure resulting in acoustic trauma typically results in damage first to the higher frequencies, before traveling down the basilar membrane ot the mid-frequencies and finally to the lower frequencies. Furthermore, the examiner noted, that the report of medical history at separation indicated ear, nose, and throat trouble with a history of tonsillitis and earache from childhood and hay fever for over two years. The examiner stated that tonsilitis and earache with hay fever symptoms could result in a slight conductive component, which would better explain threshold shifts limited to the lower-to-mid frequency range, than would acoustic trauma. Therefore, the examiner noted that it was less likely than not that his hearing loss was due to service. In August 2020, an addendum VA opinion was obtained. Once again, the examiner found that it was less likely than not that the Veteran's hearing loss was related to service. The examiner reasoned again that enlistment and separation audiograms were within normal limits, and that a comparison of the two revealed no significant threshold shift, particularly in the high frequencies where one would expect to see a shift for noise-induced hearing loss. The examiner acknowledged the Veteran's statements of hearing loss after returning from service; however, the examiner reiterated that these statements did not match the objective findings that clearly showed hearing to be within normal limits. Based on the foregoing, the Board finds that service connection for bilateral hearing loss is not warranted. In this regard, the Board attaches significant probative value to the 2019 and 2020 etiological opinions, as they provided a significant supporting explanation that addressed all relevant evidence of record. An adequate medical examination report or opinion must "sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion." Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). The examiner reflected that the separation audiogram failed to demonstrate a significant threshold shift, with findings within normal limits, and measured those findings against accepted medical principles in rendering an opinion as to how acoustic trauma would impact audiogram results, to include the configuration of different types of hearing loss. Furthermore, the examiners specifically considered the Veteran's lay statements regarding his in-service noise exposure but considered this in light of the medical evidence of record. Additionally, the most recent examiner determined, based on a review of medical literature, that audiograms were the most objective evidence available without discounting the Veteran's statements about his service experiences. Furthermore, the Board notes that the available treatment records contain statements and admissions from the Veteran himself that he did not experience hearing loss until, at the earliest, 2008. The Board has also considered contradictory or qualifying aspects of the 2006 IOM report referenced by the VA audiologist when the issue is expressly raised by the veteran or reasonably raised from a review of the record. See McCray v. Wilkie, 31 Vet. App. 243, 249 (2019). Although the issue of differing aspects of the IOM report was not raised by the Veteran, because the most recent examiner in part based his opinion on the finding that the Veteran's enlistment and separation audiograms which showed no acoustic trauma, and thus weighs against a finding of delayed onset hearing loss, the Board will discuss it herein. The report itself states that there is no sufficient scientific basis for the existence of delayed onset hearing loss, but also goes on to say that "[t]here is not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one's lifetime, long after the cessation of that noise exposure" and that "definitive studies to address this issue have not been performed." Here, the VA examiners essentially reiterated the finding that there was not a basis for the existence of delayed-onset hearing loss in humans and discussed the lack of probative value of animal-based studies regarding human hearing loss, as the immediate audiograms were the most probative. Given the IOM panel's determination that delayed-onset hearing loss would be unlikely, and the other cited medical works, the examiner found delayed-onset hearing loss to be unlikely in the Veteran's specific case. The Board finds that the examiner's conclusions, based on his medical expertise and review of available literature, as well as the particular medical history and circumstances of this Veteran, address the concerns raised in McCray. The Board acknowledges the Veteran's belief that his bilateral hearing loss is the result of his active service. He is competent to describe his experience of decreasing hearing acuity. However, the Board finds his statements while obtaining treatment in 2006 and 2008 wherein he denied hearing impairment, to be more persuasive than his statement describing hearing loss since service made decades later and in connection with a claim for VA monetary benefits. As such, the Board attaches more probative value to the medical evidence in the claims file depicting hearing within normal limits during active service and the documented onset of relevant symptomology many years after separation. The Board further affords more probative weight to the VA examiners' opinions which are supported by adequate rationale. The third element of service connection is thus not met. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the most persuasive evidence of record is against the Veteran's claim, the doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (providing that only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). K. MILLIKAN Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Yacoub, 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.