Citation Nr: 0823292 Decision Date: 07/15/08 Archive Date: 07/23/08 DOCKET NO. 05-25 027 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for Lyme disease. 2. Entitlement to service connection for gall bladder disease. 3. Entitlement to special monthly compensation (SMC) for loss of use of a creative organ. 4. Entitlement to service connection for residuals of a right shoulder injury. 5. Entitlement to service connection for a low back disability. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. M. Marcus, Associate Counsel INTRODUCTION The appellant is a veteran who served for twenty years on various periods of active duty, active duty for training (ACDUTRA) and inactive duty training (INACDUTRA), to include March 1992 to July 1992, March 1994 to March 1995, May 2000 to November 2000 and May 2002 to September 2002. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The veteran had a formal hearing before the RO in December 2005 and the transcript is of record. During the pendency of this appeal, the veteran raised arguments indicating his service-connected psychiatric disabilities have worsened and that he is entitled to service connection for Crohn's disease. These issues have never been adjudicated by the RO and, therefore are REFERRED to the RO for proper adjudication. The issues of entitlement to service connection for right shoulder and low back disabilities are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. The VA will notify the veteran if further action is required on his part. FINDINGS OF FACT 1. The veteran does not currently have Lyme disease or residuals of such. 2. The veteran was not on active duty, was not traveling to or from any duty, and was not approved for ACDUTRA in February 1999, the time he underwent a cholecystectomy (removal of his gall bladder). 3. The preponderance of the evidence indicates the veteran's symptomatic gallbladder disease, necessitating the 1999 cholecystectomy, was either manifested during active duty or was aggravated beyond the natural progression of the disease due to his military service. 4. The veteran has not lost the use of a creative organ as the result of service-connected disability. CONCLUSIONS OF LAW 1. The veteran's claimed Lyme disease was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002 and Supp. 2008); 38 C.F.R. §§ 3.303, 3.304 (2008). 2. The veteran's gall bladder disease is a result of service-connected GI conditions, which were aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002 and Supp. 2008); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2008). 3. The criteria for SMC based on the loss of use of a creative organ have not been met. 38 U.S.C.A. § 1114(k) (West 2002 and Supp. 2008); 38 C.F.R. § 3.350(a) (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2006). The notice requirements were met in this case by a letter sent to the veteran in September 2004. That letter advised the veteran of the information necessary to substantiate his claim, and of his and VA's respective obligations for obtaining specified different types of evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b) (2006). The veteran has not alleged that VA failed to comply with the notice requirements of the VCAA, and he was afforded a meaningful opportunity to participate effectively in the processing of his claim(s), and has in fact provided additional arguments at every stage. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005). Since the Board has concluded that the preponderance of the evidence is against the claim for service connection, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot, and no further notice is needed. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). That was done in this case. The Board also concludes VA's duty to assist has been satisfied. The veteran's service medical records and VA medical records are in the file. Private medical records identified by the veteran have been obtained, to the extent possible. The veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The Board notes the veteran's representative indicates private treatment records referenced in a January 2005 VA examination related to the veteran's Lyme disease claim that were not obtained. The Board finds the records would not substantiate the claim at issue here and, therefore, delaying the adjudication of the claims to obtain them would not best serve the veteran. That is, during a January 2005 VA examination the veteran indicated he was treated with antibiotics in August 2000 by a civilian doctor after he had suspected tic bites in the military. At the same time, however, the veteran acknowledges that the civilian doctor never diagnosed the veteran with Lyme's disease. Further, the January 2005 examiner found no evidence that the veteran currently has Lyme's disease. What is of consequence here is whether the veteran has a current diagnosis related to some aspect of the veteran's military history. The records from the referenced civilian doctor, by the veteran's own admission, would not substantiate that aspect of the veteran's claim. This is explained more thoroughly below. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The veteran was afforded medical examinations to obtain an opinion in regard to his gall bladder and Lyme's disease claims. Since those are the only claimed conditions at least arguably shown in the service medical records, VA's duty to assist by obtaining a medical opinion extends only to this claim. Cf. Duenas v. Principi, 18 Vet. App. 512, 517 (2004) ("Because some evidence of an in-service event, injury, or disease is required in order to substantiate a claim for service connection and because a post-service medical examination could not provide evidence of such past events, a medical examination conducted in connection with claim development could not aid in substantiating a claim when the record does not already contain evidence of an in-service event, injury, or disease."). Further examination or opinion is not needed on the creative organ claim because, at a minimum, there is no persuasive and competent evidence that the claimed condition may be associated with the veteran's military service. This is discussed in more detail below. Thus, the Board finds that VA has satisfied the duty to assist the veteran. In the circumstances of this case, additional efforts to assist or notify him in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). VA has satisfied its duties to inform and assist the veteran at every stage of this case. Therefore, the Board may proceed to consider the merits of the claims. Service Connection Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). This may be shown by affirmative evidence showing inception or aggravation during service or through statutory presumptions. Id. When a disease is first diagnosed after service, service connection can still be granted for that condition if the evidence shows it was incurred in service. 38 C.F.R. § 3.303(d). The veteran's contentions are explained as to each claimed condition below. In general, the Board acknowledges that the veteran is competent to give evidence about what he experienced; for example, he is competent to discuss his current pain and other experienced symptoms. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because he does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). For the majority of his claims, the veteran is alleging that his current conditions are the result of in-service events or injuries incurred during his active Army and Air Force service and not during his inactive time periods. To the extent he is alleging that his current conditions are a result of an injury or disease diagnosed and treated during times when he was not on active duty, the Board notes that only "veterans" are entitled to VA compensation under 38 U.S.C.A. §§ 1110 and 1131. To establish status as a "veteran" based upon a period of active duty for training (ACDUTRA), a claimant must establish that he was disabled from a disease or injury incurred or aggravated in line of duty during that period of ACDUTRA. 38 C.F.R. § 3.1(a), (d); Harris v. West, 13 Vet. App. 509, 511 (2000); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). The fact that a claimant has established status as a "veteran" for purposes of other periods of service (e.g., the veteran's period of active duty in the Army and Air Force) does not obviate the need to establish that the claimant is also a "veteran" for purposes of the period of ACDUTRA where the claim for benefits is premised on that period of ACDUTRA. Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). The term "active military, naval, or air service" includes: (1) active duty; (2) any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty. 38 U.S.C.A. § 101(2), (24); 38 C.F.R. § 3.6(a). The claimant in this case is a "veteran" based on his active duty service from March 1992 to July 1992 (where he was on ACDUTRA), March 1994 to March 1995, May 2000 to November 2000 and May 2002 to September 2002. Therefore, he is entitled to "veteran" status and the full benefit of VA resources for any compensation claim based on that period of service. However, to the extent any of his claims are not based on that period of service, but on his period of inactive service, the claims must fail. In order for the appellant to achieve "veteran" status and be eligible for service connection for disability claimed during his inactive service, the record must establish that he was disabled during active duty for training due to a disease or injury incurred or aggravated in the line of duty or he was disabled from an injury incurred or aggravated during inactive duty training. See Mercado- Martinez v. West, 11 Vet. App. 415, 419 (1998); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). Lyme Disease The veteran alleges he suffered from tic bites in August 2000 during active duty and was treated with antibiotics for Lyme disease both in the military and by a civilian doctor. He claims he still currently suffers from Lyme disease. In order to prevail on the issue of service connection there must be medical evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in- service occurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet. App. 341, 346 (1999). The veteran's service medical records confirm the veteran was treated for suspected tic bites, but the veteran was never diagnosed with Lyme disease. Similarly, the veteran alleges he was privately treated with antibiotics during this time, but acknowledges his private physician never confirmed a diagnosis of Lyme disease. After service, his medical records, private and at the VA, are completely silent as to any complaints, treatments or diagnoses for Lyme disease. The veteran was afforded a VA examination in January 2005 where the examiner noted the veteran's history of tic bites, but found no evidence of Lyme's disease currently. Specifically, current "serological test" for Lyme's disease was negative. The Board considered the veteran's statement that he had in fact suffered from Lyme's disease in the military. Whether he did, however, is not of consequence. First and foremost, to establish service connection in the absence of a presumption, there must be medical evidence of a current diagnosis. There is no such evidence here. Indeed, there is medical evidence to the contrary and the veteran himself acknowledges he has never been affirmatively diagnosed with Lyme's disease. Rather, he claims he suffered from flu-like symptoms subsequent to noticing a few tics on his body and was treated with antibiotics thereafter. Since that time the veteran claims to have diffuse joint pain on and off, but the joint pain has never been attributed to Lyme's disease or any incident of service. There simply is no medical evidence indicating the veteran currently has Lyme's disease. In summary, the Board finds that service connection for Lyme's disease is not warranted. No objective evidence exists confirming a current diagnosis of the condition nor attributed such a condition to any aspect of his active military service. Direct service connection, in this case, requires objective evidence of a current disease or disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); see also, Hickson, supra. The most probative evidence of record is against such a finding in this case. In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim, and the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). Gall Bladder Disease Here, the veteran is currently service-connected for a variety of GI conditions, to include inflammatory bowel disease, gastroesophageal reflux disease (GERD), hiatal hernia and pancreatitis, rated together as 100 percent disabling. The veteran alleges that these conditions, specifically pancreatitis, led to his gall bladder disease requiring the cholecystitis in February 1999. Alternatively, he argues his gall bladder disease was directly manifested during his military service. As stated above, direct service connection is established where there is medical evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet. App. 341, 346 (1999). In the alternative, service-connection may also be established for any disability which is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc), reconciling, Leopoldo v. Brown, 4 Vet. App. 216 (1993), and Tobin v. Derwinski, 2 Vet. App. 34 (1991). That is, secondary service connection may be established by a showing that a service-connected condition caused the condition or aggravated the condition beyond the natural progression of the disease. See 38 U.S.C. § 5103A(d) (2002); 38 C.F.R. § 3.310(a)(2)(b) (stating that service connection on a secondary basis may be established by a showing that the current disability was either caused by or aggravated by a service-connected disability); Schroeder v. West, 212 F.3d 1265 (Fed. Cir. 2000) (requiring the VA to investigate all possible in-service causes of a veteran's current disability, including those unknown to the veteran). The veteran's military and civilian medical records indicate the veteran suffered from a variety of GI conditions since the age of 15. Complaints and treatment for abdominal pain, pancreatitis and gastritis (among others) are prevalent amongst the veteran's service medical records. It is clear the veteran suffered from these conditions prior to, during and in between his periods of active duty. The Board finds noteworthy that an individual can be service- connected for an injury incurred during inactive service, but not for a disease. See VAOPGCPREC 86-90 (July 18, 1990); Brooks v. Brown, 5 Vet. App. 484, 485-486 (1993). The claimed gall bladder removal is a result of a disease, not an injury. In other words, the fact that the appellant was enlisted in the Army at the time of his surgery does not automatically mean his claim is granted. The veteran alleges the claim should be granted because his gall bladder disease manifested itself during his military service or, in the alternative, is secondary to his other service-connected GI conditions. The RO denied the veteran's claim because the actual removal of the gall bladder took place in February 1999, a time when the veteran was not on active duty. The relevant inquiry, however, is not when did the surgery occur, but whether the veteran's symptomatic gall bladder disease, necessitating the cholecystectomy, was incurred in or aggravated by any aspect of his military service, to include secondary to any service- connected condition. The Board finds it was. Surgical records from February 1999 indicate a cholecystectomy was necessary due to symptomatic gall bladder disease noting a significant history of years of epigastric abdominal pain and pancreatitis. A January 2002 surgical consultation indicates the veteran's cholecystitis caused his pancreatitis, a condition for which he is currently service- connected. The medical evidence as a whole, again, indicates the veteran has a long-standing GI condition resulting in numerous diagnoses, to include: GERD, pancreatitis, gastritis and hiatal hernia. The veteran was afforded a VA examination in October 2004 to ascertain what, if any, of the veteran's multiple GI conditions could be attributed to his military service. The examiner opined as follows: It is my opinion that veteran has been having symptoms related to GERD and gastritis since his 15 and 16th year which are aggravated by military service. I am unable to give baseline manifestations and amount aggravation. Other conditions like irritable bowel syndrome, pancreatitis, gallbladder disease and hemorrhoids are most likely manifested during his military service. The examiner's opinion is highly relevant, but the Board notes the conclusions are not fully supported by the medical chronology in the veteran's file. That is, the record makes clear that the veteran's numerous GI conditions were long- standing problems starting prior to his military service. It is unclear which specific conditions were pre-existing the military and which manifested during or thereafter. Ultimately, however, the chronology is irrelevant because currently the veteran is service-connected for all these conditions, to include pancreatitis. The medical evidence attributes the veteran's cholecystectomy, at least in part, to pancreatitis. The October 2004 examiner, moreover, indicates the veteran's gallbladder disease most likely manifested during the veteran's military service. Because of the interval nature of the veteran's active military service, the RO did not accept the October 2004 examiner's opinion as consistent with the record. The veteran, however, is at the very least entitled to the benefit of the doubt. The Board finds the veteran's removal of the gall bladder is due to gall bladder disease that directly manifested during the veteran's military service, or, at the very least, is secondary to already service-connected conditions, to include pancreatitis. In short, the Board concludes the preponderance of the evidence is in favor of the veteran's claim and, therefore, service connection for gall bladder disease is warranted. Special Monthly Compensation (loss of use of a creative organ) SMC is a special statutory award, in addition to awards based on the schedular evaluations provided by the diagnostic codes in VA's rating schedule. Claims for SMC, other than those pertaining to one-time awards and an annual clothing allowance, are governed by 38 U.S.C.A. § 1114 (k) through (s) and 38 C.F.R. §§ 3.350 and 3.352. Pertinent to the veteran's claim here, SMC is payable at a specified rate if the veteran, as the result of service- connected disability, has suffered the anatomical loss or loss of use of one or more creative organs. 38 U.S.C.A. § 1114(k) (West 2002 and Supp. 2008), 38 C.F.R. § 3.350(a). Loss of a creative organ will be shown by acquired absence of one or both testicles (other than undescended testicles) or ovaries or other creative organ. 38 C.F.R. § 3.350(a)(1)(i). In this case, the veteran alleges impotence as a result of the February 1999 cholecystectomy (gall bladder removal), which the Board service-connected in this decision. Even so, the Board finds no medical evidence of loss of use of a creative organ attributed to any service-connected condition, to include the cholecystectomy. Service connection is currently in effect for a variety of GI conditions, to include removal of a gall bladder, inflammatory bowel disease, GERD, hiatal hernia and pancreatitis. The veteran is also service-connected for psychiatric disabilities, to include major depressive disorder, and hemorrhoids. The veteran's medical records are silent as to any treatment or diagnoses of impotence. The only mention of sexual dysfunction in the record is a February 2004 clinical notation of "significant problems with his interpersonal relationship with his wife..." during a consultation with a private D.O. seen for joint-related problems, and not for impotence directly. At that time, the D.O. recommended the veteran contact behavioral medicine. It does not appear from the record the veteran ever sought any formal treatment for his complaints. Psychiatric records also mention vague references to marital problems, but are negative for complaints, treatment or a diagnosis of loss of use of a creative organ. Aside from vague references to marital discord, there simply is no medical evidence indicating the veteran has impotence. Certainly, no medical professional has ever indicated a causal connection between the alleged impotence and any of the veteran's service-connected conditions, to include the cholecystectomy. In short, there is no competent medical opinion of record that affirmatively shows loss of use of a creative organ or relates such to any service-connected disability. In essence, the evidence of a nexus between the claimed loss of use of a creative organ and a service-connected disability is limited to the veteran's own statements. This is not competent evidence of the alleged diagnosis and nexus since laypersons, such as the veteran, are not qualified to render an opinion concerning medical causation. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Accordingly, the Board concludes that the preponderance of the evidence is against the claim. ORDER Entitlement to service connection for Lyme disease is denied. Entitlement to service connection for gall bladder disease is granted subject to the laws and regulations governing monetary awards. Entitlement to SMC for loss of use of a creative organ is denied. REMAND The veteran alleges he currently has right shoulder and low back disabilities due to an in-service motor vehicle accident in June 2003. Military records confirm that the veteran suffered a right shoulder injury during INACDUTRA in a vehicle rollover accident. At the time, MRIs revealed minimal tendonitis and cervico-trapexial fibromalgia. The veteran also complained of back pain following the accident and was treated with 7 sessions of physical therapy for his shoulder, neck and low back. The veteran was afforded a VA examination in October 2004 where the examiner found a normal cervical spine, right shoulder and lumbar spine. Although the history of the injury was noted, no residuals were found. The RO denied the veteran's claims for service connection for right shoulder and low back disabilities based on the examiner's finding of no current diagnoses. In response, the veteran submitted private medical records indicative of continuing complaints and treatment for low back pain and "manifestations" of arthritis of the joints, to include his shoulder and his low back. Specifically, private treatment records from 2002 from a private D.O. indicate treatment and complaints for low back pain without radiculopathy, although no diagnosis was rendered. In August 2005, Dr. Mosley-Williams, submitted a statement indicating as follows: I evaluated [the veteran] for joint pain. He has inflammatory bowel disease with extra-intestinal manifestations of arthritis that include pain, swelling and stiffness of his ankles, bilateral foot joints and of knees intermittently. On exam today, he had limited and painful mobility of shoulders, LS spine and hips. . . His joints are minimally tender and warm. This suggests the presence of longstanding chronic inflammation. Dr. Mosley-Williams' statement does not conclusively indicate diagnoses of chronic conditions of the shoulder and lumbar spine, but it does raise the possibility that there is current pathology of these joints. It also raises the possibility that there is a connection between the veteran's right shoulder and low back conditions with his service- connected GI disabilities. These things were not considered by the October 2004 VA examiner (or the RO) and, therefore, a new VA examination is indicated. The RO should also make efforts to obtain the veteran's full treatment records from Dr. Mosley-Williams as they clearly are relevant to the claims at issue here. Accordingly, the case is REMANDED for the following action: 1. Ask the appellant to complete release forms authorizing VA to request his treatment records from any private facility treating his low back and/or shoulder disabilities, to include Dr. Mosley-Williams. These medical records should then be requested, and the RO should specify that actual treatment records, as opposed to summaries, are needed. All efforts to obtain these records, including follow-up requests, if appropriate, should be fully documented. 2. After obtaining the above records, to the extent available, schedule the veteran for a musculoskeletal examination for the claimed conditions of right shoulder and low back disabilities After reviewing the file, the examiner should render an opinion as to the following: * Whether the veteran currently has a diagnosable right shoulder or low back condition(s); * Whether it is at least as likely as not that any found diagnosis is related to the June 2003 motor vehicle accident or any other direct incident of the military; and * Whether it is at least as likely as not that any found diagnosis was caused or aggravated by any of the veteran's GI conditions, specifically commenting on Dr. Mosley-Williams' August 2005 statement. The claims folder must be reviewed by the examiner and the examiner should provide a complete rationale for any opinion given without resorting to speculation specifically resolving any conflicting medical evidence in the record, to include the October 2004 VA examination and Dr. Mosley-Williams' August 2005 statement. It would be helpful if the examiners would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 3. After the above is complete, readjudicate the veteran's claims, also considering whether the veteran is entitled to service connection for right shoulder and low back disabilities secondary to his service-connected GI conditions. If the claims remain denied, issue a supplemental statement of the case (SSOC) to the veteran and his representative, and they should be given an opportunity to respond, before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the appellant until further notice. However, the Board takes this opportunity to advise the appellant that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The appellant is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. These claims must be afforded expeditious treatment. ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs