Citation Nr: A21013805 Decision Date: 08/17/21 Archive Date: 08/17/21 DOCKET NO. 190506-8357 DATE: August 17, 2021 REMANDED Entitlement to service connection for tinnitus, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had active duty service in the United States Army from February 2003 to August 2005, and from September 2006 to March 2010. The Board notes that the rating decision on appeal was issued in July 2018. In March 2019, the Department of Veterans Affairs (VA) Regional Office (RO) issued a statement of the case (SOC) and in May 2019, the Veteran elected the modernized review system. 84 Fed. Reg. 138, 177 (Jan. 18, 2019) (to be codified at 38 C.F.R. § 19.2 (d)). She requested direct review of the evidence considered by the Agency of Original Jurisdiction (AOJ) when she opted into the Appeals Modernization Act (AMA). As a procedural matter, the Board notes that the July 2018 rating decision originally denied service connection for tinnitus. In August 2018, the Veteran filed another claim for service connection for tinnitus as secondary to her PTSD. An August 2018 rating decision again denied service connection for tinnitus. As the Veteran submitted new evidence within a year of the July 2018 rating decision, this evidence tolled the rating decision from becoming final. See 38 C.F.R. § 3.156(b) (providing that if new and material evidence is received within one year after the date of mailing of an RO decision, it will be "considered as having been filed in connection with the claim which was pending at the beginning of the appeal period"); Young v. Shinseki, 22 Vet. App. 461, 466 (2009) (holding that new and material evidence received within one year of an RO decision prevents that decision from becoming final). Although the Board regrets the delay, a remand is warranted before an appellate decision can be rendered in the matter. Entitlement to service connection for tinnitus, to include as secondary to service-connected PTSD, is remanded. The Veteran contends that her tinnitus is secondary to his PTSD. A May 2018 VA examination was administered and demonstrated a diagnosis for tinnitus. The Veteran reported onset of symptoms a year prior after starting a medication. The examiner opined the Veteran's tinnitus was not caused by or a result of military noise exposure because onset was reported one year ago following use of a certain medication. In August 2018, the Veteran submitted medical literature detailing side effects of the medication Prazosin Hydrochloride. Notably, tinnitus was a noted side effect reported in less than one percent of patients. In an August 2018 statement, the Veteran indicated that her tinnitus was caused by her medication Prazosin prescribed for nightmares, and onset of symptoms began shortly after her provider increased the dosage of her medication to its current effective level. An August 2018 VA addendum opinion was obtained. The examiner provided a negative nexus opinion and indicated the following: Tinnitus is not a common side effect of Prazosin Hydrochloride. Prazosin is an alpha-adrenergic blocker, typically used to control high blood pressure. Tinnitus as a side effect occurs between 0.1% to 1% of the time. According to the last review (4/24/18) of an article published at www.rxlist.com, "fewer than 1% of patients reported tinnitus (in some instances, exact causal relationships have not been established)." Therefore, the Veteran's tinnitus is less likely than not proximately due to or the result of the Veteran's medication for PTSD. The Board finds the August 2018 opinion is inadequate. First, the examiner accepted tinnitus as a side effect, although uncommon, of the medication Prazosin and has been reported by less than 1 percent of patients. However, the examiner failed to discuss why or how the Veteran's reported symptoms would not be considered within the relatively small percentage of patients who have experienced tinnitus as a side effect of Prazosin. Second, the examiner failed to provide an aggravation opinion for the secondary service connection claim. As such, an addendum opinion is warranted to determine the etiology of the claimed tinnitus. The matter is REMANDED for the following action: Obtain a VA medical addendum opinion for the Veteran's tinnitus. The electronic claims file and a copy of this Remand must be made available to and be reviewed by the evaluator in conjunction with the examination. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay statements. The examiner must indicate on the report that such review was undertaken. The examiner must provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the Veteran's tinnitus was proximately due to OR aggravated by the service-connected PTSD. The examiner must provide separate findings and rationales relating to causation and aggravation. "Permanent worsening" of a non-service-connected disability is not required to establish secondary service connection on the basis of aggravation. Ward v. Wilkie, 31 Vet. App. 233 (2019). The examiner should discuss why the Veteran's reported tinnitus symptoms would not be a side effect of the medication Prazosin, even though medical literature supports a causal relationship in less than 1 percent of patients. The examiner must provide a rationale in support of all opinions provided. If any opinion cannot be provided without resorting to speculation, the examiner must explain why this is so. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Asfaw, Associate 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.