Source: https://va-claim.com/2018/01/25/bilateral-hearing-loss-tinnitus-denied-diabetes-mellitus-granted-and-chondromalacia-patella-right-knee-status-post-arthroscopy-and-chondroplasty-a-right-knee-disability-remanded-citati/
Timestamp: 2018-05-28 03:06:04
Document Index: 79035741

Matched Legal Cases: ['§ 20', '§ 19', '§ 1110', '§ 3', '§ 1110', '§ 3', '§ 1110', '§ 3', '§ 5100', '§ 3', '§ 1110', '§ 3', '§ 3', '§ 3', '§ 1154', '§ 1101', '§ 3', '§ 3', '§ 3', '§ 3', '§ 3', '§ 3', '§ 3', '§ 3', '§ 3', '§ 3', '§ 5107', '§ 3', '§ 3', '§ 3', '§ 3', '§ 3', '§ 3', '§ 3', '§ 3', '§ 3', '§ 5107', '§ 1110', '§ 3', '§ 3', '§ 1101', '§ 3', '§ 4', '§ 4', '§ 4']

Bilateral hearing loss, tinnitus [DENIED], diabetes mellitus GRANTED], and chondromalacia patella, right knee, status post arthroscopy and chondroplasty (a “right knee disability”) [REMANDED] Citation Nr: 1754196 – VAClaims.org ~ A Non-Profit Non Governmental Agency
Citation Nr: 1754196
DOCKET NO. 12-31 603	)	DATE
3. Entitlement to service connection for diabetes mellitus.
4. Entitlement to a rating in excess of 10 percent for chondromalacia patella, right knee, status post arthroscopy and chondroplasty (a “right knee disability”).
The appellant is a Veteran who served on active duty from March 1998 to September 2000.
These matters are before the Board of Veterans’ Appeals (Board) on appeal from a January 2012 rating decision by the Muskogee, Oklahoma RO. In April 2015, a videoconference Board hearing was held before the undersigned; a transcript of the hearing is in the claims file.
This case was before the Board in September 2015, at which time the Board denied the right knee rating claim and remanded the service connection claims to the RO for additional development. Thereafter, the Veteran filed an appeal to the United States Court of Appeals for Veterans Claims (Court). In August 2016, the Veteran’s attorney representative before the Court and VA’s General Counsel filed with the Court a Joint Motion for Partial Remand (Joint Motion) to vacate the Board’s September 2015 decision with respect to the Board’s denial of an increased rating for the Veteran’s service-connected right knee disability; the motion was granted by the Court the same month.
In January 2017, the right knee rating issue returned to the Board for further consideration in compliance with the directives of the August 2016 Joint Motion and Court Order. Notably, one of the service connection issues remanded by the Board in September 2015 was resolved during processing of the remand, as the RO’s December 2015 rating decision granted the claim of entitlement to service connection for a bilateral ankle disability. In January 2017, the Board remanded the right knee rating issue along with the service connection issues to the RO for additional development of the evidentiary record.
The Board’s January 2017 remand additionally addressed an issue of entitlement to an initial rating in excess of 10 percent for left ankle strain and an issue of entitlement to an initial rating in excess of 30 percent for PTSD / major depression prior to March 26, 2013. The Board took jurisdiction over these issues in January 2017 only for the limited purpose of directing the issuance of a statement of the case (SOC). The Board now notes that the RO issued SOCs on these issues in February 2017. Additionally, the RO issued another SOC in February 2017 addressing an issue of entitlement to an increased rating for left ankle strain. However, the Veteran did not perfect an appeal of these issues to the Board with a timely filed Substantive Appeal following the issuance of the SOCs, and these matters are not in appellate status before the Board at this time. Governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing and, after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200.
The Board observes that the claims-file includes a January 2016 VA Form 21-0958 submitted by the Veteran to initiate an appeal of a denial of “payment for unauthorized medical expenses” in January 2015. This matter is not otherwise well documented in the claims-file and would feature a different Agency of Original Jurisdiction (AOJ) than that from which the appeal before the Board originates. The Board is aware of the Court’s holding in Manlincon v. West, 12 Vet. App. 238 (1999), but the Board finds that it is not appropriate to take jurisdiction over this issue that is not fully documented in the available record and features a separate AOJ not otherwise involved in the appeal addressed by the Board at this time. Nevertheless, the Board notes that the Veteran’s January 2016 notice of disagreement is date stamped as having been received at the RO rather than a VA Medical Center that may be handling the medical reimbursement matter; it is not clear (including in a check of the Board’s Veterans Appeals Control and Locator System (VACOLS)) that the Veteran’s attempt to initiate that appeal has been processed. The matter of ensuring that the Veteran’s January 2016 notice of disagreement concerning a medical expense reimbursement issue is forwarded to the correct VA facility for proper consideration is hereby referred to the AOJ. 38 C.F.R. § 19.9(b) (2017).
As discussed in more detail below, the Board finds that there has been substantial compliance with the directives of the January 2017 remand with regard to the issues on appeal resolved by this Board decision. See Stegall v. West, 11 Vet. App. 268, 271 (1998).
The issue of entitlement to a rating in excess of 10 percent for a right knee disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ).
1. The Veteran experienced temporary hearing loss of the left ear during service, medically attributed to an infection, which resolved prior to separation without chronic residuals. Hearing loss was not otherwise manifested during service or within one year of service; the preponderance of the evidence is against a finding that the Veteran’s current bilateral hearing loss is etiologically related to an event, injury, or disease in service (including the Veteran’s in-service ear infection and hazardous noise exposure).
2. Tinnitus was not manifested during service or within one year of service; the preponderance of the evidence is against a finding that the Veteran’s tinnitus is etiologically related to an event, injury, or disease in service.
3. It is reasonably shown that the Veteran was medically diagnosed with diabetes mellitus and prescribed treatment featuring metformin and insulin within one year of his separation from active duty service.
1. Bilateral hearing loss was not incurred in or aggravated by active service, nor may it be presumed to have been incurred therein. 38 U.S.C. §§ 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.159, 3.304, 3.307, 3.309 (2017).
2. Tinnitus was not incurred in or aggravated by active service, nor may it be presumed to have been incurred therein. 38 U.S.C §§ 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.159, 3.304, 3.307, 3.309 (2017).
3. Resolving reasonable doubt in favor of the Veteran, diabetes mellitus is presumed to have been incurred during active military service. 38 U.S.C. §§ 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2017).
With respect to the Veteran’s claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015).
The Board notes that it has reviewed all of the evidence in the Veteran’s record. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as to the claims.
Service Connection for Hearing Loss and Tinnitus
A veteran is entitled to service connection for a disability resulting from a disease or injury incurred or aggravated during active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).
A disease diagnosed after discharge may still be service connected if all the evidence establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994).
In each case where a veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of such veteran’s service as shown by such veteran’s service record, the official history of each organization in which such veteran served, such veteran’s medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a).
Certain chronic diseases, including sensorineural hearing loss and tinnitus (as organic diseases of the nervous system), may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309.
For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).
Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (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. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is needed where the determinative question is one requiring medical knowledge. Id.
Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2).
The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The determination of whether a veteran has a service-connectable hearing loss is governed by 38 C.F.R. § 3.385, which states that hearing loss will be considered to be a “disability” when the threshold level in any of the frequencies 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; or the thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores are less than 94 percent. 38 C.F.R. § 3.385.
The Board points out that the absence of in-service evidence of hearing loss, including one meeting the requirements of 38 C.F.R. § 3.385, is not always fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Hensley also provides that 38 C.F.R. § 3.385 does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service if there is sufficient evidence to demonstrate a medical relationship between a Veteran’s in-service exposure to loud noise and his current disability.
When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990).
The Veteran contends that he currently suffers from bilateral hearing loss disability and tinnitus that each had first onset during his military service and is a consequence of acoustic trauma experienced during service.
Preliminarily, the Board finds that the Veteran has been diagnosed with tinnitus during the pendency of the claim on appeal, including in the August 2011 VA examination report.
In determining whether the Veteran has a current hearing loss disability in this case, the Board notes that the November 2015 VA examination report presents listed diagnostic findings of “Sensorineural hearing loss” for both ears, but the audiometric threshold data presented in the report does not show hearing loss meeting VA’s standards codified in 38 C.F.R. § 3.385. In the November 2015 VA examination testing, no threshold level in any pertinent frequency was 40 decibels or greater, neither ear featured thresholds for at least three of the pertinent frequencies of 26 decibels or greater, and speech recognition scores were not less than 94 percent (both ears had 100 percent scores on speech discrimination testing). The November 2015 report includes the note explaining that “[t]he Veteran may have hearing loss at a level that is not considered to be a disability for VA purposes. This can occur when the auditory thresholds are greater than 25 dB at one or more frequencies in the 500-4000 Hz range.” The report further notes: “The Veteran may have impaired hearing, but it does not meet the criteria to be considered a disability for VA purposes.”
An earlier August 2011 VA examination report shows VA audiometric thresholds that do meet the 38 C.F.R. § 3.385 standards to be considered disabling, but the examiner explained that the clinical testing did not establish any diagnosis because “a diagnosis is not possible because of unreliable response during testing.” A February 2016 private audiology examination report presents a diagnosis of hearing loss disability in both ears accompanied by audiometric threshold findings that meet the 38 C.F.R. § 3.385 standards to be considered disabling. However, in an April 2017 medical opinion, the VA examiner who prepared the November 2015 VA examination report explains that the private audiologist who prepared the February 2016 report is known to VA to produce findings significantly at variance with those of other audiologists.
Based on the above, the Board finds that the evidence in this case raises significant uncertainty as to whether the Veteran has a hearing loss disability qualifying for VA compensation under the 38 C.F.R. § 3.385 standards. However, further attention to this uncertainty is unnecessary at this time as the Board finds that the preponderance of the probative evidence weighs against finding that any manner of current hearing loss is etiologically linked to the Veteran’s military service in this case. The Board is able to resolve this appeal on the basis of the evidence weighing against an etiological link / nexus to service, making it unnecessary to further resolve the question of whether the Veteran may currently have qualifying hearing loss disability under the 38 C.F.R. § 3.385 standards. For the purposes of the analysis in this decision only, the Board shall assume that the Veteran has a current qualifying hearing loss disability for VA compensation purposes. The Board now turns its attention to the analysis of the critical etiological link / nexus element of the case.
The Veteran’s service treatment records show that the Veteran’s hearing acuity was monitored with attention from a hearing conservation program, including as documented by an April 2000 hearing conservation examination report with examination findings and a notation that the Veteran was “Routinely Noise Exposed.” Associated reference audiograms in the Veteran’s service treatment records show that the Veteran was noted to be “Routinely Exposed to Hazardous Noise.”
Additionally, the service treatment records document that the Veteran experienced ear symptoms medically attributed to infection. A December 1998 service treatment record shows that the Veteran was seen with symptoms of “L ear pain sinus stuffiness.” At that time, the Veteran stated “ear pain symptoms have lasted for about 18 months, progressively getting worse,” and that he “states he has had blood discharge out of his L ear about 5 days ago, pt states additional ‘clear’ fluid discharges too.” Notably, the December 1998 report notes that the Veteran “states he is experiencing hearing loss in left ear,” and the Veteran was experiencing problems with his equilibrium. Examination revealed tenderness to palpation of the sinus cavities and the left ear with edema, redness, and swelling. The medical assessment was “Ear infection.” A March 1999 service treatment record shows that the Veteran was being treated for an illness (“phaemonia”) with various symptoms including “fluid both ears” and “TTP” (tenderness to palpation) of the “L ear.”
Consistent with the Veteran’s December 1998 report of experiencing left ear hearing loss, the documented in-service audiometric data confirms that the Veteran had left ear hearing loss meeting the 38 C.F.R. § 3.385 standards to be considered disabling during part of the Veteran’s period of service, including as shown in the November 1998 reference audiogram data noted on the April 2000 hearing conservation data report. The service treatment records further document that the audiometric data indicative of hearing loss resolved prior to the April 2000 audiometric testing associated with the processing of the Veteran’s separation from service.
The April 2000 service treatment records feature evaluations of the Veteran in connection with processing his separation from service. The April 2000 service treatment records show that the Veteran’s hearing thresholds were monitored during service, with documentation of the specific audiometric testing data. Reference audiometric data is associated with these records, and the service treatment records further include the Veteran’s hearing acuity assessment with audiometric threshold data recorded at the Veteran’s February 1998 service enlistment examination. The documented audiometric testing results during service shows significant variations in the Veteran’s hearing thresholds over time, with the April 2000 report showing that the Veteran’s hearing thresholds had dropped (reflecting comparatively greater hearing sensitivity) compared to the November 1998 reference audiogram (which itself indicated an increase in hearing thresholds, especially in the left ear, reflecting a decrease in hearing sensitivity relative to that shown on the February 1998 service enlistment examination). The April 2000 audiometric examination report shows that despite prior variations in hearing acuity, the Veteran’s hearing thresholds towards the conclusion of his period of service did not represent hearing loss disability under VA’s standards codified in 38 C.F.R. § 3.385. The April 2000 report does not otherwise suggest that any disability of the ears was medically assessed.
The April 2000 service treatment records further contain documentation of a medical examination in which the Veteran’s ears and eardrums were medically assessed to be clinically normal. Notably, the Veteran completed a medical history questionnaire and specifically denied experiencing or having ever experienced any ear problems (marking “No” for having ever had “Ear, nose, or throat trouble.” The associated “Report of Medical Assessment” shows that the Veteran denied having any other manner of medical problems involving his ears, as he reported problems featuring his knees and denied having any other injury or illness on active duty for which he did not seek medical care.
An August 2011 VA examination report documents that the Veteran described the onset of hearing loss and tinnitus symptoms during military service, specifically “since 08/1999” when “a Halon bottle in Bradley malfunctioned, discharging within 6 inches of left ear.” The Veteran described that “the tinnitus is recurrent/intermittent.” The August 2011 VA examiner expressed an inability to provide significant diagnostic and etiological findings (aside from diagnosing tinnitus based upon the Veteran’s description of symptoms) “due to veteran’s inconsistencies during testing protocol.”
During the April 2015 Board hearing, the Veteran presented testimony regarding his recollection of being exposed to acoustic trauma during service. Discussion on the record during the hearing included noting that VA has conceded and acknowledged the Veteran’s exposure to acoustic trauma in service.
A November 2015 VA “Hearing Loss and Tinnitus” examination report, prepared for the purposes of informing adjudication of these issues on appeal, presents a conclusion indicating that the Veteran’s hearing loss and tinnitus (in two separate opinions sharing a common analytical rationale) are unlikely related to the Veteran’s in-service noise exposure because “[t]he veteran[‘]s report of delayed onset tinnitus and hearing loss due to military noise exposure is not consistent with research and textbooks regarding noise induced hearing loss and tinnitus.” Notably, the Veteran had previously indicated that he experienced the onset of symptoms during his military service (including at an August 2011 VA examination), and it is not entirely clear that he actually significantly changed this account during the November 2015 VA examination. The November 2015 VA examination report elsewhere ambiguously notes that “onset of tinnitus was after acoustic trauma during military service,” and does not otherwise identify onset of hearing loss. The Board’s January 2017 remand explained that the November 2015 VA examination report, considered prior to later supplemental amendment, was unclear as to whether the November 2015 VA examiner’s rationale for the presented negative etiology opinion was based upon a correct accounting of the Veteran’s testimony concerning the onset of his hearing loss and tinnitus.
The November 2015 VA examination report explains the author’s rationale by asserting that “[r]esearch studies have shown that hazardous noise exposure has an immediate effect on hearing and does not have delayed onset nor is it progressive or cumulative.” The November 2015 VA examiner also bases his conclusion upon the fact that “hearing [was] within normal limits at enlistment and separation with no significant hearing threshold shift for the frequencies used for disability determination.” However, as explained in the Board’s January 2017 remand, the other part of the November 2015 VA examiner’s cited basis for the conclusions drawn was inadequately explained to the extent it appeared to rely upon a common interpretation of a significant medical study that has been called into question by the Court. Significantly, the research and medical literature cited in the November 2015 VA examination report features: “2005 finding f[ro]m the Institute of Medicine’s landmark study: Noise & Military [S]ervice[].” The referenced report is Noise and Military Service: Implications for Hearing Loss and Tinnitus, Institute of Medicine (National Academies Press 2006) (“IOM report”), which “concluded that based on current scientific data of cochlear physiology, there is no evidence for delayed onset hearing loss secondary to noise exposure.”
A February 2016 examination report with medical opinion from Dr. W, a private audiologist (originally added to the claims-file in March 2017) confirms diagnoses of bilateral sensorineural hearing loss and bilateral persistent tinnitus. The authoring audiologist opined: “It is more likely than not that both the veteran’s hearing loss and persistent bilateral tinnitus are related to his duties in the military.” The opinion cites that “[h]is duties in the infantry exposed him to multiple noise sources that cause acoustic trauma …. a common cause of sensory hearing loss.” The opinion also explains that “[d]amage to the hearing mechanism within the inner ear results from explosions near the ear, gunshots, or long-term exposure to loud noises. Hearing loss and tinnitus are the most common symptoms of acoustic trauma.” This report concludes that the Veteran’s hearing loss is “related” to his military noise exposure without reconciling or addressing the Veteran’s documented in-service audiometric data that the November 2015 VA examiner noted as showing that the Veteran’s hearing acuity was not significantly degraded during service.
As discussed in the Board’s January 2017 remand, the Board observes that it is a matter of public record that the Court, albeit in a non-precedential manner, has repeatedly noted that medical opinions citing this Institute of Medicine (IOM) report in this manner appear to misstate or incompletely contemplate the IOM report’s pertinent conclusions. See Lemmons v. McDonald, No. 15-3043, 2016 WL 6311289 (Vet. App. October 28, 2016) (non-precedential); Blackwood v. McDonald, No. 14-1148, 2015 WL 403642 (Vet. App. Jan. 29, 2015) (non-precedential). The Court has repeatedly directed attention to the fact that, although the IOM report states “based on the anatomical and physiological data available on the recovery process following noise exposure, it is unlikely” that the onset of hearing loss begins years after noise exposure occurs (IOM report at 47), this statement does not reflect the full extent of the report’s findings pertinent to the matter. While a portion of the IOM report found there is no evidence of delayed onset hearing loss due to noise exposure, another portion of the same IOM Report found that “an individual’s awareness of the effects of noise on hearing may be delayed considerably after the noise exposure.” (IOM report at 203-04.) The Court has directed attention to the fact that the IOM report’s language may support a theory of service connection involving delayed onset of a Veteran’s perception of hearing loss such that a VA examiner’s citation of the report should contemplate all of the pertinent aspects of its findings.
In light of the attention to this language presenting a more complete understanding of the IOM report’s pertinent conclusions, the Board’s January 2017 remand sought further discussion of the matter from the VA examiner, to ensure that the medical opinion provided in this case contemplated the complete pertinent findings of the cited IOM report. The November 2015 VA examiner’s key assertion that “[t]he veteran[‘]s report of delayed onset tinnitus and hearing loss due to military noise exposure is not consistent with” the findings of the IOM report is not adequately explained without a discussion that contemplates the portion of the IOM report that indicates that a Veteran’s awareness of hearing loss may be delayed considerably after noise exposure.
In substantial compliance with the terms of the Board’s January 2017 remand directives, an amendment to the November 2015 VA examination report was prepared by the same VA examiner in April 2017. The VA examiner re-affirmed that the Veteran’s hearing loss and tinnitus were “less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness.” The VA examiner explained that review of the claims-file revealed that “the Veteran had no hearing loss during military service and no significant hearing threshold shift from entrance to separation ….” The VA examiner notes that there is “no mention of tinnitus in the military medical records….” The VA examiner further explains: “Regarding the reported ear pain and hearing loss in the cfile, a middle ear infection is a non-recurring medically treatable problem which does not produce a permanent hearing loss as evidenced by the normal hearing with no threshold shift at separation.” The VA examiner discusses that, to the extent of any suggestion of “delayed onset tinnitus and hearing loss,” any contention of such being “due to military noise exposure is not consistent with research and textbooks regarding noise-induced hearing loss and tinnitus.” The VA examiner again discusses that “[r]esearch studies have shown that hazardous noise exposure has an immediate effect on hearing and does not have delayed onset nor is it progressive or cumulative.”
The VA examiner goes on to raise concerns regarding the fact that the private opinion “given by [Dr. W] was made without review of the cfile and the hearing thresholds are grossly different from those obtained by the VAMC audiologist.” The VA examiner notes that “[t]he VAMC quit using [Dr. W] years ago due to this exact issue. His hearing thresholds and opinions were consistently different from other providers.” In contrast to Dr. W’s opinion supporting the claim, the VA examiner reiterated that the basis for the VA examiner’s negative etiology opinion is rooted in review of the pertinent documented in-service medical findings: “As previously stated[,] the Veteran had no hearing loss during military service and no significant hearing threshold shift from entrance to separation and there is no mention of tinnitus ….” With reference to those facts, the VA examiner concluded: “[T]herefore, hearing loss and tinnitus are not a result of military service.”
This case features conflicting medical opinions in that the February 2016 private medical opinion supports the claim by asserting that the Veteran’s current hearing loss and tinnitus are etiologically linked to the Veteran’s military service, whereas the VA examiner authoring the November 2015 and April 2017 VA medical opinions found that the Veteran’s current hearing loss and tinnitus are unlikely to be etiologically linked to his military service. The Board finds that the authors of the conflicting opinions are both competent to present such opinions, and there is no significant contention to the contrary in this case.
In comparing the probative and persuasive value of the conflicting opinions, the Board notes that the February 2016 private medical opinion is not informed by review of the claims-file and the private expert offers no discussion addressing the significant in-service audiometric data which the VA expert identified as significant in establishing that the Veteran’s in-service ear and hearing problems were acute and transitory rather than chronic, and that the Veteran did not have a chronic hearing loss disability when he separated from service. The February 2016 private medical opinion does not address the significant fact that the Veteran specifically denied experiencing any ear problems during medical evaluation associated with the processing of his separation from service and was medically found to be free of any hearing or ear disability during the processing of his separation from service. Because the February 2016 private medical opinion is not informed by review of the claims-file and does not reconcile its conclusion with the significant contrary evidence of record, the Board finds that the probative value of the February 2016 private medical opinion is significantly diminished.
In contrast, the VA medical opinion presented in the November 2015 and April 2017 reports is informed by review of the pertinent contents of the claims-file and does discuss the contrary evidence of record. In this regard, the VA expert notes that the Veteran experienced hearing loss complaints during service, but with further consideration of (1) the documented in-service attribution of the ear symptoms (including temporary left ear hearing impairment) to an infection, and (2) the details of the Veteran’s audiometric testing data recorded during service with no hearing loss disability present when the Veteran was medically evaluated during the processing of his separation from service. The VA expert thus explains that any current hearing loss and tinnitus are unlikely related to the events of military service with citation of clinical data and medical principles, including with attention to addressing the Veteran’s documented in-service temporary hearing loss. The Board finds that the medical opinion of the VA audiologist is of greater probative value than the February 2016 private medical opinion; the VA audiologist’s opinion is supported by a more thoroughly informed, explained, and persuasive rationale. Accordingly, the Board finds that the most probative and persuasive medical opinion on the question of the etiology of the Veteran’s hearing loss and tinnitus weighs against the Veteran’s claims of entitlement to service connection for hearing loss and tinnitus.
The Board finds that the evidence in this case does not establish chronic hearing loss or tinnitus during service, nor any continuity of symptomatology of hearing loss or tinnitus from the time of service to the present. The Board finds it highly significant that the Veteran’s account of his symptom history identifies that his hearing loss and tinnitus symptoms began in August 1999; this is what the Veteran specifically described to the August 2011 VA examiner. However, while the Veteran experienced some documented temporary symptoms involving hearing loss during service (medically associated with an infection, as documented in the service treatment records), the contemporaneous evidence shows that the Veteran had no symptomatology or disability involving his ears by April 2000 when he was undergoing medical evaluations for the processing of his separation from service. It is significant that the Veteran was clinically examined and found to have no hearing loss disability or other manner of diagnosis or abnormality of the ears at that time, and it is significant that the Veteran specifically denied having any symptoms or problems involving his ears at that time. To the extent that the Veteran’s testimony and contentions suggest a continuity of hearing loss and/or tinnitus symptomatology from service to the present, the Board finds that this is not credibly shown. The Veteran’s contemporaneously documented denial of any pertinent ear symptoms in April 2000 contradicts his later statement that he has experienced his current hearing loss and tinnitus since August 1999. The Board finds that the Veteran’s contemporaneously documented April 2000 denial of any ear symptoms is more probative than his statements from many years later recalling a continuity of such symptomatology from August 1999 onward.
The Board finds that chronic hearing loss was not diagnosed during service, and no continuity of hearing loss symptomatology is credibly shown to connect the Veteran’s in-service experience of hearing loss to any current chronic hearing loss disability. Additionally, the Board finds that tinnitus was not diagnosed during the Veteran’s service, and no continuity of tinnitus symptomatology is credibly shown to connect any alleged in-service tinnitus to the Veteran’s current tinnitus diagnosis. Thus, service connection is not established in this case on the presumptions for chronic disabilities. See 38 C.F.R. §§ 3.307, 3.309.
The Board finds that the April 2017 opinion substantially complies with the Board’s January 2017 remand directives to the extent that the VA examiner has presented analysis that resolves the concerns that gave rise to the January 2017 remand directives. The January 2017 Board remand identified a concern involving the VA examiner’s understanding that the Veteran is claiming a post-service delayed onset of hearing loss and tinnitus; the Board noted that the Veteran appeared to have actually asserted that his hearing loss and tinnitus had onset during service. In the April 2017 addendum opinion, the VA examiner has emphasized (through repetition) the factual predicate that the Veteran did not have chronic hearing loss or tinnitus during service, a fact established through citation of contemporaneously documented clinical findings during service and further supported by the Veteran’s own contemporaneously documented denial of ear problems during the processing of his separation from service. The Board finds that the VA examiner’s understanding that the Veteran did not have chronic hearing loss or tinnitus during service is supported by the evidentiary record, including the in-service audiometric data cited by the VA examiner. The Board finds that the Veteran’s more recent testimony suggesting that chronic hearing loss and tinnitus pathologies have been continuously symptomatically apparent to him since service (specifically August 1999) is not credibly shown in light of the contrary contemporaneous evidence, including the Veteran’s own April 2000 statements and April 2000 medical findings. Accordingly, because the evidence supports finding that the Veteran did not have chronic hearing loss or tinnitus during service, the VA examiner’s characterization of the Veteran’s contentions as including a delayed post-service onset of hearing loss and/or tinnitus due to in-service events was appropriate. This is because (1) the Veteran’s assertion that he suffers from chronic hearing loss and tinnitus due to in-service events, combined with (2) the evidence showing that the Veteran did not have chronic hearing loss or tinnitus during service, logically results in the understanding that the remaining avenue to establish entitlement to service connection is the implicit contention that post-service onset of hearing loss and/or tinnitus was due to service without having had onset during service. The VA examiner’s analysis resolves both component questions: the question of whether the Veteran had onset of hearing loss and tinnitus during service is resolved with citation of the pertinent contemporaneous in-service documentation, and the remaining question of whether any post-service onset of hearing loss and/or tinnitus could nevertheless the etiologically linked to service is resolved with citation to medical principles supported by medical literature.
The Board’s January 2017 remand also noted that the IOM Report on noise exposure states that it is “unlikely” that the onset of hearing loss begins years after noise exposure occurs, but also states that “an individual’s awareness of the effects of noise on hearing may be delayed considerably after the noise exposure.” The VA examiner’s emphasis (through repetition) upon the documented in-service clinical testing results showing no hearing loss and no significant auditory threshold shift during service makes it clear that the VA examiner is not dependent upon the Veteran’s perception of hearing loss; the VA examiner identifies a basis for concluding that the Veteran did not have onset of chronic hearing loss during service that is independent of the Veteran’s level of “awareness” of hearing loss, relying upon objective results of in-service clinical audiometric testing. Thus, the IOM Report’s finding that “an individual’s awareness of the effects of noise on hearing may be delayed considerably after the noise exposure” does not undermine the VA examiner’s analysis. The IOM Report’s medical finding that it is unlikely that the onset of hearing loss begins years after noise exposure is appropriately cited by the VA examiner as weighing against the Veteran’s theory of entitlement to service connection in this case.
The Board finds that the most probative medical evidence of record weighs against finding that any current hearing loss or tinnitus disability in this case is etiologically linked to the Veteran’s military service, including his in-service noise exposure and his temporary hearing loss symptoms attributed to an infection during service. The only other indication of record that any current hearing loss or tinnitus disability in this case may be etiologically linked to the Veteran’s military service is presented by the Veteran’s own testimony and contentions. As discussed above, the Board finds that the Veteran’s testimony suggesting a continuity of symptomatology of hearing loss and/or tinnitus from service to the present is not credibly shown in this case; such testimony is contradicted by the Veteran’s contemporaneously documented statements denying any ear problems approaching his separation from service and is contradicted by objective audiometric testing approaching his separation from service. To the extent that the Veteran otherwise asserts his belief that he incurred a chronic hearing loss disability during his military service, the Board notes that the evidence of record does not demonstrate that the Veteran has the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation with respect to his hearing loss, which requires specialized testing to diagnose. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). While the Veteran is competent to report experiencing tinnitus, he is not competent to provide an opinion on the etiology of his tinnitus. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007). Therefore, to the extent that the Veteran may allege a causal relationship, the Board notes that such statements are beyond his competence. Kahana v. Shinseki, 24 Vet. App. 428 (2011).
The preponderance of the evidence is against the claims of entitlement to service connection for hearing loss and for tinnitus, and the benefit-of-the-doubt standard of proof does not allow for a grant of either of these issues on appeal. 38 U.S.C. § 5107 (b).
A veteran is entitled to service connection for a disability resulting from a disease or injury incurred or aggravated during active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). A disease diagnosed after discharge may still be service connected if all the evidence establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).
Certain chronic disabilities (including diabetes mellitus) may be presumed to have been incurred in service if manifested to a compensable degree within a specified period of time postservice (one year for diabetes). 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309.
During the April 2015 Board hearing, the Veteran explained his contention that he had onset of his diabetes mellitus during his active duty military service. The Board finds that the evidence of record establishes that the Veteran is currently diagnosed with diabetes mellitus (including as documented in his VA medical records), and the Veteran’s service records contemporaneously show that the Veteran had some manner of in-service medical attention and assignment alteration due to “diabetic conditions” (noted in an April 2000 memorandum associated with a Physical Evaluation Board). An August 1999 service treatment record also documents that the Veteran told a medical provider that he had been diagnosed with diabetes: “pt states also now diagnosed [with] diabetes, pending possible medical board.” The Veteran has also testified, including at his April 2015 Board hearing, that he was diagnosed and treated for diabetes during his active duty military service. An April 2015 letter from the Veteran’s former spouse also presents testimony that “[i]n late 1999, he was diagnosed by a military physician with diabetes. He was relocated from the Infantry division to light duty at a gym on post.”
The Veteran has directed attention to in-service laboratory testing data as potentially corroborative of his assertions. The Board notes that the Veteran’s service treatment records contain a series of “Lab Test Details” reports from 1998 through 2000 that include several urine and serum tests recording glucose levels, some of which appear to have been flagged as showing abnormally high glucose levels (amongst various other laboratory test data entries). In its January 2017 remand of this issue, the Board discussed that the evidence of record reasonably establishes that the Veteran had some manner of diabetic health concern during active duty service. The Board remanded the issue for a new VA medical opinion to address the pertinent evidence to better enable the Board to proceed with informed appellate review of the claim.
The resulting April 2017 VA examination report discusses that “Diagnostic labs show glucose was 115 on 2/24/1999, 116 on 6/15/1998, No A1C levels were noted in service and urine was negative for glucose.” The VA examiner found that “[b]y review, the veteran’s two glucose levels in service are not diagnostic of diabetes.” The VA examiner concluded that “[i]t is likely the veteran developed diabetes after military discharge. Estimated onset 7/26/2016 by date of review,” and the VA examiner cited that “[o]n 7/26/16 (After service) glucose was 209 and A1C was 8.7.” The VA examiner concluded: “Documentation on record does not support a diagnosis of diabetes during military service nor within one year of discharge. A nexus is not established.”
Significantly, however, the Board notes that the April 2017 VA examination report with medical opinion does not address the Veteran’s recent February 2017 submission of a private medical report from October 2000 showing that the Veteran was diagnosed with “Diabetes Mellitus” and prescribed treatment including with “metformin + insulin.” This October 2000 medical report is signed by a medical doctor under the letterhead of Herod Family Practice, and appears to provide contemporaneous medical corroboration of the Veteran’s testimony regarding the timing of his original medical diagnosis of diabetes, at least to the extent of showing he was medically diagnosed with diabetes within the presumptive one year period following his separation from active service.
The Board finds no reason not to accept the recently submitted October 2000 private medical report at face value. At face value, it appears to establish a proper competent medical diagnosis of diabetes mellitus, being treated with metformin and insulin, within the presumptive one year period following the Veteran’s separation from service. This corroborates other suggestive indications of record, and appears consistent with documentation suggesting the development of diabetic health concerns during service. The Board finds that none of the evidence of record persuasively explains a reason to doubt the apparent October 2000 diagnosis of diabetes mellitus, including the April 2017 VA examination report which does not address the October 2000 diagnosis in its medical opinion.
In conclusion, the Board finds that the evidence is at least in equipoise with regard to indicating that that the Veteran was medically diagnosed with diabetes mellitus at a compensable level within the presumptive one year period following his separation from service. Accordingly, the Board finds that the evidence supports a grant of service connection for diabetes mellitus in this case.
The Board previously remanded the issue of entitlement to an increased rating for right knee disability in January 2017 for further development. One of the concerns addressed by the January 2017 remand was the need for a VA examination to be prepared in this case in a manner compliant with the Court’s holding in Correia v. McDonald, 28 Vet. App. 158 (2016). Regrettably, the Board finds that the resulting April 2017 VA examination report does not present the information needed to comply with that Court holding and the directives of the Board’s January 2017 remand.
In Correia, the Court held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include certain range of motion testing whenever possible in cases of joint disabilities. The last sentence of 38 C.F.R. § 4.59 provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. The Court further indicated that whether a joint is weight-bearing is a medical question that has to be answered by the examiner, not the adjudicator. The Board concludes, in accordance with the findings of the Joint Motion, that the findings presented by the existing VA examination reports of record do not meet the specifications of Correia.
Unfortunately, the Board’s review of the new April 2017 VA examination report reveals that its findings do not meet the specifications of Correia. The April 2017 VA examination report merely states, in the “Remarks” section, that “Joint testing per Correia v. McDonald … requirements was performed as medically appropriate.” None of the findings/results requested by the Board’s remand directives were provided or otherwise discussed, and the absence of such findings/results was not otherwise explained. The Board is unable to conclude that the requirements of Correia or the terms of the Board’s January 2017 remand directives have been substantially complied with in this case. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (“A remand by … the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders.”); see also Dinnellan v. Shinseki, 24 Vet. App. 167, 176 (2010) (finding that a VA examiner’s response to questions in a Board remand order “inadequately addresses the questions posed to her and that the Board should have ensured compliance with its previous remand order by obtaining a medical opinion that addressed the remand order”).
Additionally, the Board notes that the Board’s January 2017 remand directives requested “a medical opinion as to whether the Veteran’s right knee disability has manifested in recurrent subluxation or lateral instability during any time since December 2009.” In this regard, the Board requested:
In providing this opinion, please discuss (and attempt to reconcile) the conflicting findings of the November 2013 VA fee-basis examination report (showing no instability on clinical testing, but asserting that there was “evidence or history of recurrent patellar subluxation/dislocation” of the right knee) and the February 2016 VA fee-basis examination report (asserting repeatedly that there is no history of subluxation or dislocation of the right knee).
The resulting April 2017 VA examination report responds to this request by merely stating: “there is no objective evidence of record to support assertion of subluxation or dislocation. No instability noted on day of exam.” During the processing of this remand, a new VA examination report shall have the opportunity to more clearly comply with the directives of the January 2017 Board remand by discussing consideration of the conflicting findings referenced in those directives. The new examination report should discuss (and attempt to reconcile) the conflicting findings of the November 2013 VA fee-basis examination report (showing no instability on clinical testing, but asserting that there was “evidence or history of recurrent patellar subluxation/dislocation” of the right knee), the February 2016 VA fee-basis examination report (asserting repeatedly that there is no history of subluxation or dislocation of the right knee), and the Veteran’s own lay statements describing his experience of any manifestations of right knee instability.
The Court also recently issued a significant opinion addressing whether a VA examiner is permitted to decline to offer an estimate as to additional functional loss during flare-ups if the veteran is not undergoing a flare-up at the time of the examination. In Sharp v. Shulkin, No. 16-1385 (September 6, 2017), the Court recently held that the Board may accept a VA examiner’s assertion that he or she cannot offer such an opinion without resort to speculation only after it determines that the examiner’s conclusion is not based on the absence of procurable information or on a particular examiner’s shortcomings or general aversion to offering an opinion on issues not directly observed. It must be clear that such an opinion is not procurable based on a lack of knowledge among the “medical community at large” and not merely on a lack of expertise, insufficient information, or unprocured testing on the part of the specific examiner. Accordingly, in directing the needed new VA examination in this case, the Board shall also present instructions to ensure compliance with the recent holding in Sharp.
The Board briefly observes that an August 2017 VA examination report with findings concerning the right knee disability has been added to the claims-file after the most recent AOJ adjudication of this issue in the May 2017 Supplemental Statement of the Case. However, the findings presented in the August 2017 VA examination report do not resolve the concerns, discussed above, regarding the inadequacy of the VA examination findings of records. This is true despite the author’s finding of no joint instability and an attempt to address Correia concerns by remarking that there was “no evidence of pain on passive range of motion testing” or upon “non-weight bearing testing of the right knee.”
1. The AOJ should associate with the claims file any outstanding pertinent treatment records, including additional VA treatment records (such as those that may have been created since the last such update of the claims-file).
2. After the record is determined to be complete, the AOJ should afford the Veteran a VA examination to determine the current severity of his right knee disability (in compliance with the previously uncompleted directives of the Board’s January 2017 remand). The Veteran should be interviewed and all indicated tests and studies should be accomplished. All findings should be reported in detail. The Veteran’s claims folder must be reviewed by the examiner in conjunction with the examination. The examiner is asked to offer responses to the following:
a) The examiner should identify and completely describe all current symptomatology. The examiner should specifically state range of motion findings pertinent to the Veteran’s right knee disability. Pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016), the examination should record the results of range of motion (1) on BOTH active and passive motion, (2) in weight-bearing and non-weight-bearing, and (3) of the opposite undamaged joint (to the extent applicable/possible). If the examiner is unable to conduct the required testing he or she should clearly explain why that is so.
b) The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups. The examiner should assess OR ESTIMATE the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. If the Veteran is not having a flare-up when examined, the examiner should determine whether he or she can estimate, given the Veteran’s description of symptoms, what his range of motion would be on flare-up. If it is not feasible to offer such an opinion to any degree of medical certainty without resort to speculation, the examiner must provide a specific explanation for why this is so. If such an opinion is not procurable based on a lack of knowledge, then the inability to offer such an opinion must be based on a lack of knowledge among the “medical community at large,” and not merely a lack of expertise, insufficient information, or unprocured testing on the part of the examiner.
c) The examiner should elicit information as to the frequency, duration, and severity of any associated symptomatology, and loss of function in daily activities, including work and physical activity.
d) The examiner should review the prior VA examination reports of record concerning the Veteran’s right knee disability (in particular, the April 2013, November 2013, February 2016, April 2017, and August 2017 VA examination reports). The examiner should attempt to render, if possible to do so without resorting to mere speculation, a retrospective opinion that identifies the ranges of motion of the Veteran’s right knee in active motion, passive motion, weight-bearing, nonweight-bearing, and in comparison to the opposite undamaged joint (to the extent applicable/possible) at each time the right knee was previously examined with range of motion testing for rating purposes. The examiner should also attempt to render, if possible to do so without resorting to mere speculation, a retrospective opinion that identifies the additional functional impairment on repeated use or during flare-ups (in terms of the degree of additional range of motion loss) at each time the right knee was previously examined with range of motion testing for rating purposes. If it is not possible to provide such opinions / estimations without resorting to mere speculation, the examiner should please so state and provide an explanation as to why such opinions / estimations cannot be given.
e) To assist in ensuring compliance with the directives of the Court-endorsed Joint Motion in this case, the VA examiner is further asked to please review the current clinical findings and the Veteran’s pertinent documented medical history (featuring the prior right knee VA fee-basis examination reports of April 2013, November 2013, and February 2016) to offer a medical opinion as to whether the Veteran’s right knee disability has manifested in recurrent subluxation or lateral instability during any time since December 2009. In providing this opinion, please discuss (and attempt to reconcile) the conflicting findings of the November 2013 VA fee-basis examination report (showing no instability on clinical testing, but asserting that there was “evidence or history of recurrent patellar subluxation/dislocation” of the right knee), the February 2016, April 2017, and August 2017 VA fee-basis examination reports (asserting repeatedly that there is no history of subluxation or dislocation of the right knee), and the Veteran’s own lay statements describing his experience of any manifestations of right knee instability. If the examiner is unable to do so, the examiner must indicate why.
f) To facilitate informed appellate adjudication satisfying the requirements of the Joint Motion, the examiner is asked to offer an opinion on the question of whether the Veteran’s description of any symptoms suggestive of recurrent subluxation or lateral instability of the right knee is consistent with the nature of the Veteran’s diagnosed right knee disability and the objective clinical findings, even if instability is not detected at the time of a clinical examination of the knee.
The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. If an opinion cannot be provided without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made.
3. The AOJ should then review the record and readjudicate the claim remaining on appeal. If any issue on appeal remains denied to any extent, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and his representative an opportunity to respond, and return the case to the Board.
Posted in Board of Veterans Appeals (BVA), Initial Appeal Denied, Initial Appeal Granted, Initial Appeal RemandedTagged bilateral hearing loss, chondromalacia patella, chondroplasty (a "right knee disability"), diabetes mellitus, right knee, status post arthroscopy, tinnitus
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