James E. Savage v. Eric K. Shinseki

UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS
NO . 09-4406
JAMES E. SAVAGE, APPELLANT ,
V.
ERIC K. SHINSEKI,
SECRETARY OF VETERANS AFFAIRS, APPELLEE.
On Appeal from the Board of Veterans’ Appeals
(Argued July 28, 2010 Decided November 3, 2010)
David J. Lowenstein, of Richmond, Virginia, with whom Daniel G. Krasnegor, also of
Richmond, Virginia, was on the brief for the appellant.
Catherine A. Black, with whom Will A. Gunn, General Counsel; R. Randall Campbell,
Assistant General Counsel; and David L. Quinn, Deputy Assistant General Counsel, all of
Washington, D.C., were on the brief for the appellee.
Before KASOLD, Chief Judge,1 and HAGEL and DAVIS, Judges.
HAGEL, Judge: James E. Savage appeals through counsel that part of an October 22, 2009,
Board of Veterans' Appeals (Board) decision that denied entitlement to a disability rating for bilateral
hearing loss in excess of 10% between November 14, 2002, and March 17, 2009, and in excess of
20% from March 18, 2009.2 The matter was referred to a panel of the Court to resolve whether VA
has a duty to seek clarification of private medical examinations or VA progress notes. The Court
concludes that, in some circumstances, VA does have a duty to return for clarification unclear or
insufficient private examination reports or VA progress notes, or the Board must explain why such
1
Judge Kasold became Chief Judge on August 6, 2010.
2
The Board also dismissed Mr. Savage's appeal of entitlement to a disability rating in excess of 10% for another
disability. Mr. Savage makes no argument regarding that portion of the Board's decision, and the Court therefore deems
any appeal of that claim abandoned. See Grivois v. Brown, 6 Vet.App. 136, 138 (1994) (holding that issues or claims
not argued on appeal are considered abandoned).
clarification is not needed. Because the Board failed to seek clarification of the private examination
reports and VA progress notes or explain why such clarification was not necessary under the
circumstances in this case, the Court will vacate the October 2009 Board decision and remand the
matter for further development and readjudication consistent with this decision.
I. FACTS
Mr. Savage served on active duty in the U.S. Army from March 1953 to February 1955. In
October 1975, Mr. Savage was assigned a noncompensable disability rating for bilateral hearing loss.
A. Audiological Evaluations and Regional Office Adjudications
In an attempt to obtain an increased disability rating, Mr. Savage underwent numerous
audiology evaluations between 2001 and 2009. These examinations, which are summarized below,
were conducted by both private and VA examiners.
In November 2002, Mr. Savage sought an increased disability rating. In support of his claim,
he submitted two private audiological evaluations: A November 2001 evaluation that diagnosed
"[b]ilateral severe conductive hearing loss"with word recognition, or speech discrimination, scores
of 92% in the right ear and 84% in the left (Record (R.) at 741, 743); and a July 2002 evaluation that
diagnosed bilateral "mild to moderately severe mixed" hearing loss and showed word recognition
scores of 92% in each ear (R. at 742).
A January 2003 VA audiological evaluation showed moderate bilateral mixed hearing loss.
During that evaluation, Mr. Savage's pure tone threshold average was 43.75 decibels in the right ear
and 41.25 decibels in the left; his speech discrimination score was 80% in the right ear and 70% in
the left. The diagnosis was "bilateral mixed loss" and his speech discrimination scores, based on the
"Maryland CNC Word list," were 80% in the right ear and 70% in the left ear. R. at 713.
In a February 2003 rating decision, a VA regional office assigned a 10% disability rating,
effective November 14, 2002, based on the January 2003 VA examination. Mr. Savage filed a
Notice of Disagreement with that decision in March 2003.
Mr. Savage then submitted private audiological evaluations dated July 2003, December 2004,
and June 2006. The July 2003 evaluation found "[b]ilateral, moderate, mixed hearing loss, flat,"
with "excellent" speech discrimination bilaterally. R. at 665. The December 2004 evaluation stated
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that Mr. Savage had "[b]ilateral, moderate, flat, mixed hearing loss" and "excellent" speech
discrimination bilaterally with scores of 100% discrimination "in quiet." R. at 556-57. The June
2006 evaluation demonstrated "moderate bilaterally symmetrical mixed hearing loss" with "good to
excellent" speech discrimination bilaterally. R. at 361. In particular, Mr. Savage demonstrated 84%
word recognition in his right ear and 96% in his left.
A March 2007 VA report of a hearing evaluation stated that Mr. Savage reported
experiencing fluctuating hearing daily. Audiological testing showed "moderately-severe rising to
moderate" mixed hearing loss in his right ear and "moderately-severe rising to moderate primarily
conductive" hearing loss in his left ear. R. at 272. The audiologist noted that Mr. Savage's word
recognition scores were 96% in his right ear and 100% in his left. A July 2007 VA progress note
stated that Mr. Savage was seen for a hearing aid assessment. Testing revealed mild to moderately
severe mixed hearing loss in both ears. The audiologist wrote: "Audiometric pure-tone thresholds
are fairly similar to those obtained" during the March 2007 evaluation. R. at 259.
A September 2007 VA audiological examination showed pure tone threshold averages of 50
decibels in the right ear and 52.5 decibels in the left ear, with word recognition scores of 92% in the
right ear and 88% in the left. The examiner concluded that Mr. Savage suffered from moderately
severe hearing loss bilaterally.
A May 2008 private audiological examination found "a right borderline moderate-severe/left
severe mixed hearing loss with mild asymmetry between the puretone thresholds" with 100% speech
discrimination bilaterally in quiet. R. at 116, 118.
A March 2009 VA contract audiological examination found pure tone threshold averages of
65 decibels in the right ear and 66.25 decibels in the left ear, with speech discrimination scores of
96% in each ear.
In a March 2009 Supplemental Statement of the Case, the regional office increased Mr.
Savage's disability rating to 20%, effective March 18, 2009, the date of the most recent VA
examination. The regional office found no evidence of worsened hearing prior to the March 2009
VA examination.
An August 2009 VA progress note stated that audiological testing indicated "a moderate to
moderately-severe mixed hearing loss" in the right ear and "a moderate to severe mixed hearing loss"
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in the left ear, with "good" speech discrimination scores of 96% in the right ear and 92% in the left.
R. at 18-19. In September 2009, another VA progress note stated that audiological testing conducted
was consistent with the results obtained during the August 2009 evaluation, and that Mr. Savage had
"moderate to mod[erate]-severe mixed loss" in his right ear and "severe mixed loss" in his left ear.
R. at 18. In September 2009, Mr. Savage appealed to the Board.
B. October 2009 Board Decision
In October 2009, the Board issued the decision on appeal, denying entitlement to a disability
rating for bilateral hearing loss in excess of 10% between November 14, 2002, and March 17, 2009,
and in excess of 20% from March 18, 2009. The Board first determined that VA had satisfied its
duty to assist Mr. Savage. In particular, the Board noted that Mr. Savage's claims file contained VA
and private medical records and that Mr. Savage had been provided VA audiological examinations
in January 2003, September 2007, and March 2009. The Board stated:
At the most recent [VA] examination, the examiner described the effects of [Mr.
Savage's] condition on his occupation and on his daily activity. Throughout the
appeal, [Mr. Savage] has submitted statements describing his difficulties with
communication. On review, the functional impairments associated with [Mr.
Savage's] hearing loss are essentially noted in the record and the Board finds that
further examination is not necessary.
R. at 7.
The Board then explained:
The basic method of rating hearing loss involves audiological test results of organic
impairment of hearing acuity as measured by the results of controlled speech
discrimination tests (Maryland CNC), together with the average hearing threshold
level as measured by pure tone audiometry tests in the frequencies of 1000, 2000,
3000, and 4000 Hertz.
R. at 9; see 38 C.F.R. § 4.85(a) (2010). The Board then stated:
The Board acknowledges that private records show continued treatment for hearing
loss and the need for hearing aids. These records include various audiograms
documenting the severity of the Veteran's hearing loss. On review, it is unclear
whether the speech discrimination testing was conducted using the Maryland CNC
test and therefore, these examinations are not considered adequate for VA rating
purposes. Thus, the Board's discussion will focus on the VA compensation and
pension examinations, which contain the necessary information for evaluating the
Veteran’s hearing loss disability.
4
R. at 9.
Based solely on the January 2003 and September 2007 VA examinations outlined above, the
Board determined that Mr. Savage was not entitled to a disability rating in excess of 10% between
November 14, 2002, and March 17, 2009. Based solely on the March 2009 VA examination, also
outlined above, the Board determined that the criteria for a disability rating in excess of 20% from
March 18, 2009, was not warranted. Regarding the August 2009 VA progress note, outlined above,
the Board stated: "Audiometric values were not provided and it is unclear whether word recognition
testing was conducted pursuant to the Maryland CNC. Therefore, this evaluation is not adequate for
rating purposes." R. at 11. The Board noted that the September 2009 VA progress note stated that
audiology testing was "consistent with the previous results." Id.
C. Arguments of the Parties
On appeal, Mr. Savage makes two arguments. First, he contends that the Board failed to
comply with VA's duty to assist in that the Board rejected the private audiological examinations and
March 2007 and August 2009 VA progress notes because they were "unclear" regarding the testing
used without returning the examinations and seeking clarification. He asserts that the Board violated
38 C.F.R. §§ 4.2 and 19.9. Second, Mr. Savage argues that the Board's reasons or bases for rejecting
the private examinations and VA progress notes are inadequate because the Board failed to explain
why clarification was not warranted.
In response, the Secretary argues that the Board's duty to obtain clarification of medical
examinations applies only to VA compensation and pension examinations, not private examination
reports or VA progress notes. Further, the Secretary contends that the Board's duty to assist by
obtaining clarification of unclear medical examinations is triggered only when such clarification is
necessary to decide the claim, and the Board in this case had sufficient medical evidence to reach
a conclusion. The Secretary also asserts that the Board provided adequate reasons or bases for
rejecting the private examinations and the VA progress notes.
II. ANALYSIS
Mr. Savage contends that VA had a duty to return the private audiological examinations and
VA treatment records that it stated were "unclear" to clarify the type of audiological testing
5
performed before rejecting them as inadequate. He argues that VA's duty to assist, bolstered by two
regulations, requires such action on the part of VA. In this case, because these reports reasonably
appear to contain information that is not otherwise in the record and that may potentially help
substantiate Mr. Savage's claim, the Board should have sought clarification of the private medical
reports or explained clearly and adequately why it did not.
A. Duty To Assist
"The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence
necessary to substantiate the claimant's claim for a benefit under a law administered by the
Secretary." 38 U.S.C. § 5103A(a)(1). The Secretary is exempt from this responsibility only where
"no reasonable possibility exists that such assistance would aid in substantiating the claim."
38 U.S.C. § 5103A(a)(2). Although section 5103A enumerates particular duties required of the
Secretary, including providing a medical examination or opinion where one "is necessary to make
a decision on the claim," 38 U.S.C. § 5103A(d)(1), it also makes clear that the Secretary is not
limited to those enumerated duties in assisting claimants in obtaining information and evidence to
substantiate their claims. See 38 U.S.C. § 5103A(g) ("Nothing in this section shall be construed as
precluding the Secretary from providing such other assistance under subsection (a) to a claimant in
substantiating a claim as the Secretary considers appropriate."). Except where specifically limited,
the enumerated duties are subordinate to the overall statutory duty to provide reasonable assistance
to the claimant.
Pursuant to his duty to assist, the Secretary has promulgated various regulations that, we
believe it fair to infer, he believes constitute "reasonable efforts" to assist claimants. Among these
regulations are 38 C.F.R. § 19.9 and 38 C.F.R. § 4.2.
1. 38 C.F.R. § 19.9Section 19.9(a) of title 38 of the Code of Federal Regulations provides: "If further evidence,
clarification of the evidence, correction of a procedural defect, or any other action is essential for a
proper appellate decision, a [Board member] shall remand the case to the agency of original
jurisdiction, specifying the action to be undertaken." As Mr. Savage notes in his brief, the Court
addressed the Board's duty to obtain clarification of evidence under § 19.9 in Tyrues v. Shinseki:
6
The plain language of § 19.9 does not limit the Board to seeking clarification of the
evidence, nor has the Court adopted the "mandatory clarification" interpretation of
§ 19.9 that the appellant advances in his brief. Rather, the regulation contemplates
situations in which the Board may choose to obtain "further evidence" instead of
requiring clarification of the existing evidence; and, it is well established that the
Board has the discretion to determine whether further development is needed to make
a decision on a claim.
23 Vet.App. 166, 182 (2009) (citations omitted), appeal docketed, No. 2010-7011 (Fed. Cir. Nov.
3, 2009). In Tyrues, the appellant argued that the Board failed to satisfy its duty to assist him by not
seeking clarification of a VA medical opinion either before or in addition to ordering a new VA
medical examination. The Court found that the Board had provided inadequate reasons or bases for
ordering a new VA medical examination–and for expressly directing that the new examination be
performed by a different physician than the one who had performed the initial examination–rather
than simply seeking clarification from the initial physician. Id. at 183-84. The Court remanded the
appellant's claim for the Board to either seek clarification from the initial physician or provide
adequate reasons or bases for its decision not to seek such clarification. Id. at 184.
Mr. Savage attempts to distinguish his case from Tyrues, arguing that, here, the Board did
not remand his claim to develop further evidence but instead "decided the claim without attempting
to seek any clarification, knowing full well[] that the [rejected] audiogram results may have included
the Maryland CNC test." Appellant's Brief (Br.) at 7. It is clear from Tyrues that Mr. Savage's
argument that § 19.9 compels VA to obtain clarification of evidence is incorrect, see 23 Vet.App.
at 182, and it is clear from the language of the regulation itself that remand for clarification or further
development is required only where it is reasonable and "essential to a proper decision," 38 C.F.R.
§ 19.9(a). Any suggestion from the Secretary, however, that Tyrues limits VA's duty to seek
clarification (or explain why clarification is not warranted) to VA medical examination reports is not
supported by the Court's analysis in that case.
Section 19.9 may not be read in isolation, but rather should be read in the larger context of
VA's duty to develop a claim. After all, the regulation is entitled "Remand for further development."
As statutory section 5103A makes clear, the Secretary is required to make "reasonable efforts" to
assist a claimant in developing his claim, and regulatory § 19.9 makes clear that part of those
"reasonable efforts" includes seeking clarification of unclear "evidence," which necessarily includes
7
medical examination reports of all kinds. If VA opts not to seek such clarification, but rather to
develop new evidence, Tyrues makes it plain that VA–either the regional office or the Board–must
thoroughly explain why, a task the Board failed to undertake in this case. See Tyrues, 23 Vet.App.
at 184.
2. 38 C.F.R. § 4.2Section 4.2 of title 38 of the Code of Federal Regulations provides, in pertinent part:
Different examiners, at different times, will not describe the same disability in the
same language. Features of the disability which must have persisted unchanged may
be overlooked or a change for the better or worse may not be accurately appreciated
or described. It is the responsibility of the rating specialist to interpret reports of
examination in the light of the whole recorded history, reconciling the various reports
into a consistent picture so that the current rating may accurately reflect the elements
of disability present. Each disability must be considered from the point of view of the
veteran working or seeking work. If a diagnosis is not supported by the findings on
the examination report or if the report does not contain sufficient detail, it is
incumbent upon the rating board to return the report as inadequate for evaluation
purposes.
Mr. Savage asserts that this regulation requires VA to obtain clarification of private examination
reports, while the Secretary contends that VA's duty to obtain clarification of medical examinations
under § 4.2 applies only to VA examinations.
a. Plain Language
We begin with the plain language of the regulation. See Otero-Castro v. Principi,
16 Vet.App. 375, 380 (2002) (holding that, in interpreting a statute or regulation, the "'starting point
is its language'" (quoting Good Samaritan Hosp. v. Shalala, 508 U.S. 402, 409 (1993))); Black &
Decker Corp. v. Comm'r of Internal Revenue, 986 F.2d 60, 65 (4th Cir. 1993) ("Regulations, like
statutes, are interpreted according to the canons of construction."). To that end, the Secretary
contends that the phrase "examination report" in § 4.2 is a "term of art" that "refers exclusively to
reports compiled by Compensation and Pension medical examiners assigned to perform
examinations pursuant to 38 U.S.C. § 5103A(d)." Secretary's Br. at 7. In support of his argument,
the Secretary offers the VA Adjudication Procedures Manual (M21-1MR), in particular the section
on "Reviewing Department of Veterans Affairs (VA) Examination Reports." M21-1MR, pt. 3,
subpt. iv, ch. 3, § D(18). This assertion, however, is unsupported by anything other than the
8
Secretary's own statement, made for the first time in this litigation, that this is so. Although it is true
that Section D is titled "Examination Reports" and sections 18(g) and (f) specifically discuss when
a VA examination report is insufficient for rating purposes and when it should be returned for
clarification, that section does not anywhere suggest that only VA examination reports can or should
be returned for clarification.3 Nor does it state that the term "examination reports" as used in VA
regulations applies only to Compensation and Pension examination reports generated by VA.
Accordingly, especially in light of the statutory duty to provide reasonable assistance to claimants,
this argument must fail.
The Court notes that 38 C.F.R. § 3.1, "Definitions," which defines the "terms of art" relevant
to veterans benefits, does not contain a definition of "examination reports," suggesting that those
words are to be given their usual meaning. As the Court stated in Tropf v. Nicholson:
[A] statute is ambiguous only when the application of the ordinary meaning of the
words and rules of construction to the plain language of the regulation fails to answer
the question at issue. . . . Without standard word meanings and rules of construction,
neither Congress nor the Secretary can know how to write authorities in a way that
conveys their intent and no practitioner or–more importantly–veteran can rely on a
statute or regulation to mean what it appears to say.
20 Vet.App. 317, 321 n.1 (2006); see Black & Decker Corp., 986 F.2d at 65 ("Regulations, like
statutes, are interpreted according to the canons of construction."); see also Am. Tobacco Co. v.
Patterson, 456 U.S. 63, 68 (1982) ("[W]e assume 'that the legislative purpose is expressed by the
ordinary meaning of the words used.'" (quoting Richards v. United States, 369 U.S. 1, 9 (1962)));
Gardner v. Derwinski, 1 Vet.App. 584, 586 (1991) ("Determining a statute's plain meaning requires
examining the specific language at issue and the overall structure of the statute."), aff'd sub nom.
Gardner v. Brown, 5 F.3d 1456 (Fed. Cir. 1993), aff'd, 513 U.S. 115 (1994). An examination report
in the context of § 4.2, then, is any report made based upon a medical examination and offered in
support of a veteran's claim. That necessarily includes private examination reports.
3
The Court also notes that there is some precedent for returning non-VA medical reports for clarification in a
separate portion of M 21-1MR. Part 3, subpart iv, chapter 5 indicates that VA reviewers should request clarification of
any "inadequate non-VA hospital report" received from a state hospital, a county hospital, a municipal hospital, a
contract hospital, or a private hospital. M21-1MR, pt. 3, subpt. iv, ch. 5, § 7. Moreover, M21-1MR provides, VA
examinations are to authorized only "if a satisfactory corrected [non-VA hospital] report cannot be obtained within a
reasonable period of time." Id.
9
Although not argued by the Secretary, the Court recognizes that § 4.2 was enacted in 1976,
at a time when the law required that all private medical opinions submitted in support of claims for
compensation be confirmed by VA medical examinations. See 38 C.F.R. § 3.326(d) (1975) (limiting
VA's ability to accept an otherwise adequate private physician's statement without the need for
additional VA examination only "for rating the pension claim of a veteran, widow, or widower, a
claim for aid and attendance allowance by a widow, widower, or parent, or a claim by a child based
on permanent incapability of self-support"). That requirement no longer exists, however, while the
language of § 4.2 remains wholly unchanged. See 38 C.F.R. § 3.326(c) ("Provided that it is
otherwise adequate for rating purposes, a statement from a private physician may be accepted for
rating a claim without further examination."); compare 38 C.F.R. § 4.2 (1976) with 38 C.F.R. § 4.2(2010).
The Secretary is, of course, free to amend his regulations to accord with his desired
interpretation, in accordance with proper notice and comment procedures, see 5 U.S.C. § 553, and
to the extent the amended regulations do not conflict with the statutory mandate of section 5103A,
but he has not done so. He may not attempt to subvert the plain language of his regulation simply
by taking a litigating position that the regulation means something other than what it says. See Auer
v. Robbins, 519 U.S. 452, 462 (1997) (holding that agency positions adopted in response to litigation,
or those adopted as a "'post hoc rationalization' advanced by an agency seeking to defend past agency
action against attack" are not entitled to deference from the Court (quoting Bowen v. Georgetown
Univ. Hosp., 488 U.S. 204, 212 (1988))); Martin v. Occupational Safety & Health Review Comm'n,
499 U.S. 144, 156 ("'[L]itigating positions' are not entitled to deference when they are merely
appellate counsel's 'post hoc rationalizations' for agency action, advanced for the first time in the
reviewing court.").
b. 38 C.F.R. § 3.326(a)
The Secretary next asserts that his position is also supported by 38 C.F.R. § 3.326(a) (2010),
which provides: "Where there is a claim for disability compensation or pension but medical evidence
accompanying the claim is not adequate for rating purposes, a Department of Veterans Affairs
examination will be authorized." The Secretary argues that this regulation demonstrates that when
adjudicators are "faced with unclear medical evidence[,] they are expected to request a VA
10
examination, which cures the problem of inadequate medical evidence and fully develops the
record." Secretary's Br. at 5. In other words, the Secretary contends that § 3.326(a) requires that VA
develop new, adequate medical evidence in the form of a VA medical examination, not clarify
existing inadequate medical evidence. The Court does not believe that § 3.326 provides authority
for the proposition that VA need not seek clarification of unclear or inadequate private medical
examinations merely because they are not sponsored by VA. Instead, that regulation simply gives
the Secretary the authority to provide a VA medical examination to further develop the evidence
necessary to decide the claim.4 Nothing in that regulation prohibits VA from also (or instead)
seeking clarification of a private medical examination, and such an interpretation is consistent with
Tyrues. See Tyrues, 23 Vet.App. at 184.
c. 38 U.S.C. § 5103A(d)
The Secretary next argues that VA's duty to assist–particularly its duty to provide medical
examinations–also supports his position that § 4.2 does not require clarification of private medical
examinations or VA progress notes. The Secretary correctly states that VA is required to provide
a medical examination only where one is necessary to decide the claim. See 38 U.S.C.
§ 5103A(d)(1)(a). Further, the Secretary notes that an examination is necessary to decide the claim
"where the record raises an indication of a current disability and an in-service injury, but 'does not
contain sufficient medical evidence to make a decision on the claim.'" Secretary's Br. at 5 (quoting
38 U.S.C. § 5103A(d)(2)).
The Secretary's contention that § 5103A(d) somehow means that clarification of private
examination reports is never required must fail. First, subsection (d) on its face addresses only when
VA is required to provide a medical examination, not when clarification of private medical
examination reports might be necessary. Second, subsection (d) of section 5103A does not stand
alone; subsection (a) of section 5103A requires the Secretary to also undertake reasonable efforts to
obtain evidence needed to substantiate the claim. Although it is correct that a VA medical
examination report might appear to include the information necessary to properly decide the claim,
the Secretary fails to recognize that a VA medical examination may not reveal the precise
4
The Court recognizes that a VA medical examination is required under certain circumstances. See 38 U.S.C.
§ 5103A(d) (discussed further below); 38 C.F.R. § 3.159(c)(4) (2010).
11
information that reasonably is available from a private examination report if clarified, and that, as
clarified, would be needed to properly substantiate the claim. This scenario is particularly relevant
in the case of staged ratings where the results of a VA examination conducted at a later time will not
necessarily reproduce the results from a private examination conducted years earlier. See Fenderson
v. West, 12 Vet.App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial
disability rating is assigned). Under such circumstances, where the information in the private report,
if clarified, reasonably might help substantiate the claim (because it provides information favorable
to the claimant that is not otherwise included in the record), the duty to assist by undertaking
reasonable efforts to obtain evidence needed to substantiate the claim is not fulfilled until such
clarification is sought or the Board explains why such clarification is not necessary. Moreover, it
is axiomatic that the claim generally cannot be decided properly until the duty to assist has been
fulfilled. See Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990) (recognizing the Secretary's duty to
"assist [a veteran who makes a facially valid claim for benefits] in developing the facts pertinent to
the claim" and then to determine whether the evidence supports the claim, is in equipoise, or is
against the claim).
d. Caselaw
The Secretary next contends that his position is supported by caselaw, citing Padgett v.
Shinseki, 23 Vet.App. 306, 311 (2009); Nieves-Rodriguez v. Peake, 22 Vet.App. 295, 302 (2008);
Bowling v. Principi, 15 Vet.App. 1, 12 (2001); DeLuca v. Brown, 8 Vet.App. 202, 206 (1995), as
proof. None of those cases, however, limits the applicability or rationale of § 4.2 to VA
examinations alone. In fact, Padgett states that "the law and regulation are well-established with
respect to the Board's duty to assign due weight to the evidence and to return an inadequate medical
examination"–without specifying whether the duty to return an inadequate examination is limited
to VA examinations–and references § 4.2 only in a parenthetical to a citation. 23 Vet.App. at 311.
The citation to § 4.2 in Nieves-Rodriguez appears in a section on the adequacy of VA medical
examinations, but that case does not address the limitation the Secretary attempts to read into the
regulation. Bowling and DeLuca simply cite § 4.2 for its plain language and do not address whether
there is any limitation on the types of medical examinations to which that regulation applies.
12
The Secretary also asserts that, in Daves v. Nicholson, the Court "implicitly acknowledged"
that § 4.2 applies only to VA examinations. Secretary's Br. at 6. The Secretary relies on the
following passage:
[I]n disability compensation claims, the Secretary must provide a medical
examination or opinion if there is competent evidence of a current disability, an
indication that the disability may be associated with service, and insufficient
medical evidence to render a decision on the claim. If the examination report does
not contain sufficient detail, "it is incumbent upon the rating board to return the
report as inadequate for evaluation purposes." 38 C.F.R. § 4.2 (2006).
21 Vet.App. 46, 50 (2007) (citations omitted). The Secretary states: "The context of the Court's
reference and citation to section 4.2 demonstrates an understanding that clarification is necessary in
the context of VA examination reports only, not when faced with inadequate private treatment
records or VA[] progress notes." Secretary's Br. at 6 (emphasis added). The Court fails to see how
the Secretary reaches his conclusion from this passage, or from the context of the passage, based on
the facts of Daves. In that case, the Court found that the Board erred in not returning a VA
examination for clarification where the examiner stated that further testing was needed to reach a
medical conclusion. Id. at 51. The question whether the duty to return an examination report for
clarification arises in the case of a private examination report or VA progress note was simply not
before the Court in Daves, and the Secretary errs by reading such a finding into that opinion. The
fact that the Court has, so far, only applied § 4.2 in the context of VA medical examination reports
does not mean that the regulation, or its rationale, is applicable only to VA medical examination
reports.5 See McGee v. Peake, 511 F.3d 1352, 1357 (Fed. Cir. 2008) (noting that the passage of the
Veterans' Judicial Review Act imposed a statutory duty on the Secretary to assist the veteran in the
development of facts pertinent to his claim and to ensure that the veteran had the opportunity to
develop the record "so that all relevant issues would be considered by the [Board] prior to judicial
review," and noting that the Veterans Claims Assistance Act "further defined the VA's obligation
to fully develop the record" by requiring VA to "make all reasonable efforts to obtain relevant
records (including private records)"); Gilbert, 1 Vet.App. at 55.
5
The Court notes that several single-judge cases have, in fact, applied § 4.2 to private examination reports, a
fact that necessitated panel review of this issue.
13
3. Other Concerns
The Court is well aware, as the Secretary pointed out at oral argument, that VA examiners
are uniquely within the control of the Secretary, such that completing requests for clarification of
medical examination reports falls within the examiners' job duties, while VA has no such control
over private examiners. We are not persuaded, however, that this limitation renders the regulations
at issue, or the rationale behind the regulations, inapplicable where the medical examination reports
of private physicians are unclear. All that control means is that VA can require its examiners to
perform legitimate examinations or to clarify the reports of those examinations that are insufficient
for rating purposes. See 38 C.F.R. § 4.2 (2010). Nothing in § 4.2, or any other VA regulation,
prevents VA from sending a letter to the private examiner stating that the examination report is
unclear or insufficient and why and requesting further information or clarification. See 38 U.S.C.
§ 5103 (g). If no response is received, VA may continue on the path of adjudication, weighing the
accumulated evidence of record as usual.6
Moreover, the Secretary fails to explain, and the Court cannot understand, why or how a
request for further information or clarification from a private examiner would be burdensome or
unreasonable. Accordingly, pursuant to section 5103A(a), when a private examination report
reasonably appears to contain information necessary to properly decide a claim but it is "unclear" or
"not suitable for rating purposes," and the information reasonably contained in the report otherwise
cannot be obtained, VA has a duty to ask the private examiner to clarify the report, or the Board must
explain why such clarification was not needed.
6
This statement should not be read to limit in any way VA's self-imposed duty to make more than one request
to obtain private records identified by a claimant, provided by 38 C.F.R. § 3.159:
VA will make reasonable efforts to obtain relevant records not in the custody of a Federal department
or agency, to include records from . . . private medical care providers . . . . Such reasonable efforts
will generally consist of an initial request for the records and, if the records are not received, at least
one follow-up request. A follow-up request is not required if a response to the initial request indicates
that the records sought do not exist or that a follow-up request for the records would be futile. If VA
receives information showing that subsequent requests to this or another custodian could result in
obtaining the records sought, then reasonable efforts will include an initial request and, if the records
are not received, at least one follow-up request to the new source or an additional request to the
original source.
38 C.F.R. § 3.159(c)(1) (2010) (emphasis added). This statement should also not be read to limit the applicability of
this regulation under the circumstances of this or similar cases.
14
4. Summary
Based on the foregoing discussion, the Court holds that nothing in VA's statutes or
regulations, or in this Court's caselaw, limits VA's authority or duty to return inadequate medical
examination reports to only those reports prepared by VA medical examiners. Accordingly, when
VA concludes that a private medical examination report is unclear or insufficient in some way, and
it reasonably appears that a request for clarification, both as limited elsewhere in this opinion, could
provide relevant information that is otherwise not in the record and cannot be obtained in some other
way, the Board must either seek clarification from the private examiner or clearly and adequately
explain why such clarification is unreasonable. See 38 U.S.C. §§ 5103A(a), 7104(d)(1); Tyrues,
23 Vet.App. at 184; 38 C.F.R. §§ 4.2, 19.9(a).
Having found that §§ 4.2 and 19.9 do not limit the Secretary's duty to seek clarification only
to VA medical examination reports, the Court recognizes that these regulations provide guidelines,
not specific rules, regarding when examinations should be returned as inadequate (e.g., "[I]f a
diagnosis is not supported by findings on the examination report . . . ." (38 C.F.R. § 4.2); "[I]f further
evidence, clarification of the evidence, correction of a procedural defect, or any other action is
essential for a proper decision . . . ." (38 C.F.R. § 19.9)). Other than outlining the Secretary's duty
to provide assistance to claimants and the Board's responsibility to provide adequate reasons and
bases for its findings and conclusions, the statutes and regulations provide no other guidance
regarding how we are to balance the obligations of assistance and explanation with the burden placed
on VA to provide assistance, other than that such assistance must be "reasonable." The Court also
acknowledges, as the Secretary argues, that VA has very little ability to compel non-VA medical
personnel to comply with its request or to force compliance within a reasonable time frame, which
could delay the prompt adjudication of the claim. Consequently, because the Court has determined
that, in some circumstances, there exists a requirement to seek further information from a non-VA
medical professional who has provided an examination report, the Court must provide guidance to
the Board regarding what is reasonable assistance in such circumstances.
In that vein, we are mindful of the burden that might be placed on VA if it were required to
conduct an extensive inquiry of private medical examiners. It should be clearly understood, then,
that we do not interpret VA statutes and regulations as establishing a broad requirement that VA
15
inquire of private medical experts regarding the opinions expressed in their examination reports or
the general bases therefor. Indeed, we do not expect that clarification of a private examination report
will be necessary in most instances. Thus, the interpretation we express with respect to clarification
of private examination reports is not as broad as the mandate to clarify VA examination reports when
such reports meet the rather general conditions set forth in § 4.2.
Rather, our holding is limited to those instances in which the missing information is relevant,
factual, and objective–that is, not a matter of opinion–and where the missing evidence bears greatly
on the probative value of the private examination report. In this case, for example, whether the
Maryland CNC Test was used by the private examiner in the 2003, 2004, 2006, and 2008 hearing
tests is relevant because it is the only test that VA will consider in evaluating a person's hearing
disability, and because the time between the private examinations and VA examinations is lengthy
enough that staged ratings may apply. In other words, the question of which speech recognition test
was used is a factual, objective one to which there is a yes or no answer; the question of whether the
Maryland CNC Test was used does not in any way rely on the opinion of the examiner.
After considering these factors, should VA determine that seeking clarification would be
unreasonable or that the missing information is located elsewhere in the record or may be more easily
obtained by some other means without compromising the favorable character of the private
examiner's opinion, VA must clearly and adequately explain that decision.7 See 38 U.S.C.
§ 7104(d)(1); Tyrues, 23 Vet.App. at 184.
B. October 2009 Board Decision
Having determined that VA's duty to seek clarification of an unclear or insufficient medical
examination report is in no way limited to VA examination reports, we now turn to the Board's
treatment of the private medical examination reports in this case. We conclude that, under the
circumstances of this case, the Board had a duty to seek clarification of the private medical
examination reports. See 38 U.S.C. § 5103A(a); 38 C.F.R. §§ 4.2, 19.9.
7
Although our discussion in this matter focuses almost entirely on private medical examination reports, our
decision today applies equally to VA progress or treatment notes.
16
1. Board Findings Regarding Private Audiological Examination Reports
Here, the Board refused to consider any aspect of the four private audiological evaluations–
dated July 2003, December 2004, June 2006, and May 2008–in evaluating the severity of Mr.
Savage's hearing loss throughout the pendency of his claim. The Board did not discuss the contents
of those evaluations except to generally acknowledge that they showed "continued treatment for
hearing loss and the need for hearing aids" and contained audiograms that documented the severity
of Mr. Savage's hearing loss. R. at 9. Instead, the Board found that the private examinations were
"not considered adequate for VA rating purposes" because it was "unclear whether the speech
discrimination testing was conducted using the Maryland CNC test," as required by the rating
schedule. Id. Despite the Secretary's assertion at oral argument that the Board also rejected the
private examination reports because they did not contain audiometry readings that could be "plugged
into" the rating schedule, a review of the Board decision demonstrates that the Board rejected the
private examinations solely because it was unclear whether the Maryland CNC Test had been used
to obtain the word recognition scores. The Board's decision to adjudicate Mr. Savage's claim without
seeking clarification of favorable private medical examination reports and instead relying solely on
VA audiological evaluations is troublesome for many reasons.
a. Staged Ratings
First, and perhaps most importantly, when, as here, there is a prolonged adjudication period,
the Board must consider the possibility of staged ratings. See Fenderson, 12 Vet.App. at 126. This
is especially important in light of Mr. Savage's statements to VA that his hearing loss fluctuated
regularly. Here, there is a lengthy period of time–between February 2003 and September
2007–during which the only available evidence of the severity of Mr. Savage's hearing loss is three
private examination reports, rendering those reports particularly crucial to properly evaluating Mr.
Savage's disability. Although the Board paid lip service to applying staged ratings, in that it
considered two distinct periods of time, the Court finds it hard to believe that the Board could
adequately evaluate the severity of Mr. Savage's hearing disability between November 2002 and
March 2009 based solely on the January 2003 and September 2007 VA examinations. Given the
impossibility of developing new evidence that could address the severity of Mr. Savage's disability
17
during that time, it was especially important for the Board to ensure that the evidence that did exist
relevant to that period–VA or private–was developed as thoroughly as possible.
b. Nature of Missing Information
Second, the private examination reports rejected by the Board were detailed reports clearly
based on objective testing, rather than general opinions lacking unbiased foundation. See Stefl v.
Nicholson, 21 Vet.App. 120, 124 (2007) (stating that a medical opinion "must support its conclusion
with an analysis that the Board can consider and weigh against contrary opinions"); Ardison v.
Brown, 6 Vet.App. 405, 407 (1994) (holding that a medical examination is adequate where it is
based upon consideration of the veteran's prior medical history and examinations and also describes
the disability in sufficient detail so that the Board's "'evaluation of the claimed disability will be a
fully informed one'" (quoting Green v. Derwinski, 1 Vet.App. 121, 124 (1991))). Moreover, the
private examination reports were rendered by what appear to be, on their face, competent and
experienced specialists; the Board expressed no concerns over the qualifications of the private
examiners.
In light of the Board's outright dismissal of the private medical examination reports in the
absence of this evidence, it is clear that, had this information been obtained, the Board would have
been able to properly determine the probative value of the private examination reports. If
clarification resulted in a statement that the Maryland CNC Test was used, the private examination
reports would have been competent evidence that the Board would have had to weigh against the
other evidence of record. If clarification resulted in a statement that a different type of word
recognition test was used, the Board could have then discounted the private medical examination
reports and weighed the remainder of the evidence without taking the private reports into
consideration.
c. Burden on VA To Obtain the Missing Information
Third, the single fact missing from the private examinations–a statement of whether the
Maryland CNC Word Recognition Test was used–is an objective fact not subject to interpretation
or opinion that can easily be obtained by contacting the private examiners. In other words, the
burden on VA in obtaining this missing information is minimal.
18
In sum, under the facts of this case, we conclude that it was error for the Board not to seek
clarification of the private audiological examinations submitted by Mr. Savage or to explain why
clarification was not needed.
2. Consideration of Prejudicial Error
Having found error, the Court is required to "take due account of the rule of prejudicial
error." 38 U.S.C. § 7261(b); see Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004). At oral
argument, the Secretary invited the Court to conclude that, even had the Board assumed–or sought
and received clarification–that the Maryland CNC Word Recognition Test was used, Mr. Savage's
word recognition scores provided in the private examination reports would not change the outcome
of the Board's decision. The Court declines the Secretary's invitation.
The Court recognizes that the "[a]ssignment of disability ratings for hearing impairment is
derived by a mechanical application of the rating schedule" to a claimant's audiometric examination
results. Lendenmann v. Principi, 3 Vet.App. 345, 349 (1992); see 38 C.F.R. § 3.385 (2010) (stating
that, for VA purposes, "impaired hearing will be considered to be a disability" only when hearing
loss examination results reach certain auditory thresholds). However, this Court has made clear that
"VA and the [Board] possess specialized expertise in identifying and assessing the medical nature
of a claimed condition." Butts v. Brown, 5 Vet.App. 532, 539 (1993) (en banc). The Court will not
presume to be able to read Mr. Savage's private audiological examination reports, particularly the
portions identifying his pure tone thresholds at the various frequency levels, and determine that, even
had the Board considered those reports, the outcome would be the same and that the Board's error
was therefore harmless. To the extent that no pure tone threshold averages (necessary to the
application of the rating schedule) are given on the private examination reports, the Board should
either compute them using the puretone threshold information given in the examination reports, if
the Board has such expertise, or seek clarification of that information.
Accordingly, the Court will vacate the Board's decision and remand the matter for the Board
to either seek clarification of the private audiological examination reports or explain why such
clarification is not needed.
19
III. CONCLUSION
Upon consideration of the foregoing, the October 22, 2009, Board decision is VACATED
and the matter is REMANDED for further development and readjudication consistent with this
decision.
20