Citation Nr: 18154107
Decision Date: 11/29/18	Archive Date: 11/29/18

DOCKET NO. 16-32 354
DATE:	November 29, 2018
REMANDED
Entitlement to service connection for bilateral hearing loss is remanded.
Entitlement to service connection for an ear condition is remanded.
Entitlement to service connection for an unexplained chronic multi-symptom illness is remanded.
Entitlement to service connection for a fatigue disorder, to include chronic fatigue syndrome (CFS), is remanded.
Entitlement to service connection for a disability manifested by memory loss, to include dementia, is remanded.
Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with depression is remanded.
Entitlement to a total disability evaluation based on individual unemployability (TDIU) is remanded.
BACKGROUND
The Veteran served on active duty in the United States Navy from January 1988 to August 1991, including service in Southwest Asia and receipt of the Combat Action Ribbon.  This matter comes before the Board of Veterans’ Appeals (Board) from a January 2014, April 2014, and October 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO).  In February 2017, the Veteran testified before the undersigned Veterans Law Judge.
REASONS FOR REMAND
1. Entitlement to service connection for bilateral hearing loss is remanded.
2. Entitlement to service connection for an ear condition is remanded.
The Veteran asserts hearing loss due to his combat service. See March 2014 VA Form 21-526EZ, Fully Developed Claim.  In an April 2014 VA examination for bilateral hearing loss and tinnitus, the examiner opined that the Veteran should be re-tested to verify results and rule out any retrocochlear issue that may cause a unilateral hearing loss.  Moreover, the examiner’s nexus opinion is inadequate, as it is based on normal hearing at service separation and does not consider the combat presumption.  As such, the Board finds that a new examination and opinion is warranted on remand.  
The Veteran asserts he has an ear condition other than hearing loss due to service.  See July 2014 VA Form 21-526EZ, Fully Developed Claim.  His service treatment records (STRs) show complaints for left ear numbness, otitis media and treatment for sinus problems.  See February and March 1988 STRs.  The Veteran complains of inability to hear out of right ear, with intermittent sinus problems.  See September 2013 Toledo CBOC Primary Care Note; February 2017 Board Hearing Transcript pg. 13.  Further, he testified he encountered recurring right ear infections at discharge that stopped once he became deaf in the right ear.  See id. at 14.  Currently, no ear conditions other than hearing loss are shown in either ear.  However, as the Board is remanding the claim for updated treatment records and a VA hearing examination, action on this claim is deferred.
3. Entitlement to service connection for unexplained chronic multi-symptom illness is remanded.
4. Entitlement to service connection for a fatigue disorder, to include chronic fatigue syndrome (CFS), is remanded.
5. Entitlement to service connection for a disability manifested by memory loss, to include dementia, is remanded.
The Veteran asserts that he has an unexplained chronic multi-symptom illness due to service.  See July 2014 VA 21-526EZ, Fully Developed Claim; July 2014 VA 21-8940 Veteran’s Application for Increased Compensation based on Unemployability.  His STRs show exposure to heavy smoke from the Burgan oil fields in Kuwait, and a notation of fatigue.  See March and April 1991 STRs.  In August 2014, the Veteran underwent a Gulf War general medical examination.  However, much of the report contains no response to specific inquiries, and the examiner determined that the Veteran’s fatigue symptoms may represent an undiagnosed illness, but then contrarily found they were likely due to his service-connected PTSD.  Thus, a new examination is needed on remand.
6. Entitlement to an initial rating in excess of 50 percent for PTSD with depression is remanded.
Regarding the PTSD with depression increased rating claim on appeal, the Veteran received his last VA examination in August 2014, and testified as to a worsening of symptoms since that time.  See April 2017 Board Hearing Transcript pg. 15.  As such, the Board finds that his claim for a higher rating must be remanded to provide him with a new VA PTSD with depression examination.  See Snuffer v. Gober, 10 Vet. App. 400 (1997).
7. Entitlement TDIU is remanded.
Action on the TDIU is deferred pending the below-requested development.  Any outstanding records should also be secured.
The matters are REMANDED for the following action:
1. Obtain all outstanding VA treatment records. 
2. With any necessary assistance from the Veteran, obtain any outstanding pertinent private treatment records, to include Bedford Family Physicians.
3. Then schedule the Veteran for a VA examination with an audiologist to determine the nature and etiology of his hearing loss and any other diagnosed ear conditions. The entire claims file, including a copy of this remand, must be provided to the examiner in conjunction with the requested opinion.  All indicated studies should be performed, and all findings should be reported in detail.
After reviewing the claims file, eliciting a history directly from the Veteran and conducting a thorough examination, the examiner should opine whether it is at least as likely as not (50 percent or greater probability):
(a) that the Veteran’s hearing loss had its onset during the service or is otherwise related to his service, to include as a result of conceded acoustic trauma coincident with his combat service.
(b) that any other diagnosed ear condition had its onset during the service or is otherwise related to his service, to include as a result of conceded acoustic trauma coincident with his combat service.
In addressing this question, please review and discuss the following within your findings: (1) the Veteran’s STRs (Feb. 1988, numbness of left ear; Mar. 1988, treatment for cold and sinus symptoms; Apr. 1991, treatment for sinus complaints) the Veteran’s testimony as to continuous recurring right ear infections at discharge that stopped once he became deaf in the right ear. (see Apr. 2017 Board Hearing Tr. at 13, 14).  Please do not rely solely on the fact that he had “normal” hearing at separation from service (non-ratable as per 38 C.F.R. § 3.385) to support any opinion.  
A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner explain why an opinion cannot be provided (e.g., the limits of the examiner’s knowledge, the limits of medical knowledge in general; or if there is additional evidence that would allow for an opinion on this matter).  
4. Then schedule the Veteran for a VA Gulf War examination to assess the nature and etiology of his chronic fatigue, memory loss and any other symptoms endorsed. After conducting these clinical examinations, the examiner is asked to address each of the following questions:
(a.) For the Veteran’s claimed chronic fatigue, memory loss and reported unexplained chronic multi-symptom illness, is the disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology (such as CFS), (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? 
(b.) If the Veteran’s chronic fatigue, memory loss or other endorsed symptoms are found to represent an objective indication of chronic disability resulting from an unknown etiology ((a)(1) above), the examiner should also describe the extent to which the illness has manifested.
(c.) If, after reviewing the Veteran and the claims file, you determine that the Veteran’s disability pattern is either a diagnosable chronic multi-symptom illness with a partially explained etiology ((a)(2) above), or a disease with a clear and specific etiology and diagnosis ((a)(3) above), then please opine as to whether it is at least as likely as not (50 percent or greater probability) related to presumed environmental exposures experienced by the Veteran during service in Southwest Asia. 
(d.) Is it at least as likely as not that any diagnosed disorder had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War?  Please discuss the April 1991 notation of fatigue in this regard.
(e.) Is it at least as likely as not that any diagnosed disorder is proximately due to service-connected PTSD? 
(f) Is it at least as likely as not that any diagnosed disorder has been aggravated (worsened beyond the natural progress of the disease) by service-connected PTSD?
A complete rationale should be given for all opinions and conclusions expressed.  If the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner explain why an opinion cannot be provided (e.g., the limits of the examiner’s knowledge, the limits of medical knowledge in general; or if there is additional evidence that would allow for an opinion on this matter).  
5. Then schedule the Veteran for a VA psychiatric examination to determine the current severity of his PTSD with depression.  The claims file, including a copy of this remand, must be provided to the examiner in conjunction with the requested opinion.  All indicated tests and studies should be conducted, and all findings reported in detail. 
 
S. BUSH
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Victoria L. Stephens, Associate Counsel

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