Citation Nr: 1305170 Decision Date: 02/12/13 Archive Date: 02/21/13 DOCKET NO. 07-34 644A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial, compensable evaluation for diminished sensation of the right side of the face (trigeminal/fifth cranial nerve), from November 30, 2006 until October 12, 2012 (as part of the claim for an initial, increased evaluation for service-connected multiple sclerosis (MS)). 2. Entitlement to an initial disability rating in excess of 10 percent for diminished sensation the right side of the face (trigeminal/fifth cranial nerve), from October 12, 2012 (as part of the claim for an initial, increased evaluation for service-connected MS). 3. Entitlement to an initial, compensable evaluation for difficulty swallowing (glossopharyngeal/ninth cranial nerve) (as part of the claim for an initial, increased evaluation for service-connected MS). 4. Entitlement to an initial disability rating in excess of 30 percent for fecal incontinence, from January 1, 2011 (as part of the claim for an initial, increased evaluation for service-connected MS). 5. Entitlement to service connection for a separate evaluation for weakness/numbness of the right upper extremity (as part of the claim for an initial, increased evaluation for service-connected MS). 6. Entitlement to service connection for a separate evaluation for vision symptoms, to include eye pain (as part of the claim for an initial, increased evaluation for service-connected MS). 7. Entitlement to service connection for a separate evaluation for a speech impairment (hypoglossal/twelfth cranial nerve) (as part of the claim for an initial, increased evaluation for service-connected MS). 8. Entitlement to special monthly compensation for loss of use of creative organ, associated with service-connected erectile dysfunction. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran had active service from August 1982 until August 1988. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a November 2004 rating decision. At that time, the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, in pertinent part, granted service connection for multiple sclerosis (MS), with a 30 percent disability rating, effective August 20, 2002. The Veteran appeared before the undersigned Veterans Law Judge at a Board hearing held at the RO in November 2008. In December 2008 and October 2009, the Board remanded the claim for further development, to include consideration of any manifestations of MS that the Veteran may have. In a January 2011 rating decision, the RO considered various separate evaluations as part of the MS claim. The RO granted service connection for depression (50 percent effective November 30, 2006) and for weakness/numbness of right lower extremity (10 percent effective November 30, 2006). The RO also granted service connection for diminished sensation of the right side of the face, erectile dysfunction, fecal incontinence and swallowing difficulty. The RO rated each of those disabilities as noncompensable, effective November 30, 2006. The RO further denied service connection for weakness/numbness of the right upper extremity (ulnar nerve), a bilateral visual disorder and impairment of speaking ability. In May 2011, the Board finally determined the issues of depression, weakness/numbness of the right lower extremity, neurogenic bladder and erectile dysfunction. The Board also determined the claim for an increased rating for fecal incontinence, for periods prior to January 1, 2011. The claims currently on appeal were remanded by the Board for additional development. In a November 2012 rating decision, the Appeals Management Center (AMC) granted a 10 percent disability rating for diminished sensation on the right side of the face, from October 12, 2012. The Veteran has not withdrawn his claim and is presumed to be seeking the maximum benefit allowed by law and regulation. AB v. Brown, 6 Vet. App. 35, 38 (1993). For the sake of clarity, the Board has separated out the issues as shown on the first pages of this decision, though all the claims stem from the Veteran's original claim for an increased rating for his service-connected MS. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the appellant's claims. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal, other than additional VA medical records. Additionally, the Board notes that the United States Court of Appeals for Veterans Claims (Court) held in Rice v. Shinseki, 22 Vet. App. 447 (2009) that every claim for a higher evaluation includes a claim for a total rating based on individual unemployability (TDIU) where the Veteran claims that his service-connected disability prevents him from working. In the present case, the Veteran has not claimed to be unemployable. Rather, his VA medical records document that he is currently working for the postal service. As such, the Board finds that Rice is not applicable to the current appeal. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to increased ratings for difficulty swallowing and fecal incontinence (from January 1, 2011); entitlement to service connection for separate evaluations for weakness/numbness of the right upper extremity, vision symptoms and a speech impairment; and entitlement to special monthly compensation for loss of use of creative organ 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. FINDINGS OF FACT 1. From November 30, 2006 until October 12, 2012, the Veteran's diminished sensation of the right side of the face (trigeminal/fifth cranial nerve) is not manifested by incomplete, moderate paralysis. 2. From October 12, 2012 the Veteran's diminished sensation of the right side of the face (trigeminal/fifth cranial nerve) is not manifested by incomplete, severe paralysis. CONCLUSIONS OF LAW 1. The criteria for an initial, compensable evaluation for diminished sensation of the right side of the face (trigeminal/fifth cranial nerve), from November 30, 2006 until October 12, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.124a, Diagnostic Code 8205 (2012). 2. The criteria for an initial evaluation in excess of 10 percent for diminished sensation of the right side of the face (trigeminal/fifth cranial nerve), from October 12, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.124a, Diagnostic Code 8205 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This appeal arises from disagreement with the initial evaluations following the grant of service connection for multiple sclerosis and subsequent grant of a separate evaluation for diminished sensation of the right side of the face (trigeminal/fifth cranial nerve). Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). As to VA's duty to assist, the Board notes that pertinent records from all relevant sources identified by him, and for which he authorized VA to request, have been obtained. 38 U.S.C.A. § 5103A. VA has associated with the claims folder the service treatment records and reports of his post-service treatment. The RO has obtained the majority of the private medical records identified by the Veteran and the Veteran has provided private medical records. The Board notes that the Veteran identified treatment from additional private physicians (in his August 2002 claim application) that VA failed to obtain (despite requesting them in September 2002). The Board, however, finds that those records would not be relevant to the present claim. The Veteran identified Dr. J. Gottlieb as providing dermatological treatment and Dr. R. Arad for orthopaedic complaints of the knee. Furthermore, the Veteran himself has provided his medical records from those physicians and those records did not indicate any treatment for the cranial nerves. As such, the Veteran is not prejudiced by VA's failure to obtain those records in regards to rating diminished sensation of the right side of the face. Additionally, per the May 2011 Board remand instructions, the RO/AMC requested that the Veteran provide additional information regarding his private medical treatment in a September 2012 letter. The RO/AMC also obtained VA medical records from April 2010 to the present and obtained a new VA examination for the cranial nerves in October 2012. As such, the development directed by the Board in the prior Board remands has been accomplished. Applicable Law Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian life. Generally, the degree of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity to the several grades of disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate Diagnostic Codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the veteran. 38 C.F.R. § 4.3. While the veteran's entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). At the time of an initial rating, as is the situation in this case, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Background Information The Veteran contends that his service-connected diminished sensation of the right side of the face (trigeminal/fifth cranial nerve) warrants a compensable rating from November 30, 2006 until October 12, 2012 and a rating in excess of 10 percent from October 12, 2012. The Veteran was examined by VA in March 2007. No reference was made to symptoms associated with the face. In an April 2008 VA neurology resident clinic note, the examiner found the Veteran's second to twelfth cranial nerves to be intact. In the April 22, 2008 VA addendum, the VA medical provider noted that the Veteran's face was symmetric. In March 2009, the Veteran received a VA examination for the cranial nerves, which included a review of the claims file. The March 2009 VA examiner noted that a February 2009 VA medical provider had found the Veteran's second to twelfth cranial nerves to be intact bilaterally and fundus within normal limits. The March 2009 VA examiner specifically examined the Veteran's cranial fifth cranial (trigeminal) and testing was normal. The examiner found a normal examination of the cranial nerves. In April 2010, the Veteran received a brain and spinal cord VA examination, which included a claims file review. The VA examiner found no evidence of cranial nerve impairment. In a December 2011 VA medical record, the VA medical provider noted that the Veteran had a normal lower cranial nerves examination. In October 2012, the Veteran received a VA examination for the cranial nerves, which included a claims file review. Following examination, the October 2012 VA examiner found the Veteran's fifth cranial nerve (trigeminal) to have incomplete, moderate incomplete paralysis. Diminished Sensation of the Right Side of the Face (Trigeminal/Fifth Cranial Nerve) For the diminished sensation of the right side of the face (as a manifestation of MS), the Veteran has a noncompensable disability rating from November 30, 2006 until October 12, 2012, and a 10 percent disability rating from October 12, 2012. In the January 2011 rating decision wherein the RO granted service connection, it rated this disability under Diagnostic Code 8205. The Board has not found a more pertinent rating code would be applicable for that disability, and the Veteran has also not argued for the use of different rating criteria. Under Diagnostic Code 8205 for paralysis of the fifth (trigeminal) cranial nerve, a 10 percent rating is assigned for moderate incomplete paralysis. A 30 percent rating is assigned for severe incomplete paralysis. Finally, a maximum, 50 percent, rating is assigned for complete paralysis. The rating criteria also note that the severity of the paralysis is dependent upon the relative degree of sensory manifestation or motor loss. 38 C.F.R. § 4.124a, Diagnostic Code 8205 and Note. From November 30, 2006 until October 12, 2012 Medical evidence of record from November 30, 2006 until October 12, 2012, repeatedly shows that the Veteran's fifth cranial nerve could not be characterized as moderate, incomplete paralysis. The March 2009 VA examiner specifically examined the fifth cranial nerve and found it to be normal. The April 2010 VA examiner found no evidence of cranial nerve impairment. The VA medical records (including from April 2008, February 2009, June 2009, and December 2011) repeatedly found the cranial nerves to be intact. Considering the pertinent evidence in light of the applicable rating criteria, the Board finds a rating a compensable disability rating for diminished sensation of the right side of the face is not warranted under Diagnostic Code 8205, as the medical evidence does not show that the Veteran had moderate incomplete paralysis, or worse, from November 30, 2006 until October 12, 2012. From October 12, 2012 The Veteran has a 10 percent disability rating for diminished sensation of the right side of the face, from October 12, 2012 (the date of his October 2012 VA examination). The October 2012 VA examiner found the fifth cranial nerve (trigeminal) to have incomplete paralysis, specifically: moderate incomplete paralysis. There is no other evidence of record pertinent to the diminished sensation of the right side of the face claim for rating purposes. As the October 2012 VA examiner did not find severe incomplete paralysis or complete paralysis, a disability rating in excess of 10 percent is not warranted under Diagnostic Code 8205, from October 12, 2012. Extraschedular Consideration Finally, the disability does not warrant referral for extra-schedular consideration. In exceptional cases where a schedular evaluation is found to be inadequate, consideration of an extra-schedular evaluation is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular evaluation is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. Here, the rating criteria are not inadequate. Higher ratings are available for the service-connected disability when it is more severe; however, the Veteran simply does not meet those criteria. The Board also finds that no exceptional or unusual factors are in evidence, as his symptoms fit squarely within the current diagnostic code. The Board finds that there is no basis for referral for consideration of an extra-schedular rating in this case. As the preponderance of the probative evidence is against the claim, the benefit of the doubt rule does not apply. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). The Veteran's claim for a compensable disability rating for diminished sensation of the right side of the face, from November 30, 2006 until October 12, 2012, is denied. Additionally, the Veteran's claim for a disability rating in excess of 10 percent, for diminished sensation of the right side of the face, from October 12, 2012, is denied. ORDER An initial, compensable evaluation for diminished sensation of the right side of the face (trigeminal/fifth cranial nerve) (as part of the claim for an initial, increased evaluation for service-connected MS), from November 30, 2006 until October 12, 2012, is denied. An initial evaluation in excess of 10 percent for diminished sensation of the right side of the face (trigeminal/fifth cranial nerve) (as part of the claim for an initial, increased evaluation for service-connected MS), from October 12, 2012, is denied. REMAND The Board previously remanded the issues of entitlement to increased ratings for difficulty swallowing (glossopharyngeal/ninth cranial nerve) and fecal incontinence (from January 1, 2011); entitlement to service connection for separate evaluations for weakness/numbness of the right upper extremity, vision symptoms and a speech impairment (hypoglossal/twelfth cranial nerve); and entitlement to special monthly compensation for loss of use of creative organ for additional development. Per Board instructions, the AMC obtained additional evidence, including VA medical records and VA examinations for the claims. Unfortunately, as pointed out in the January 2013 appellant's post-remand brief, the AMC did not provide a supplemental statement of the case after obtaining that information. The Board does note; however, that the AMC did provide a November 2012 supplemental statement of the case for the sole issue of diminished sensation of the right side of the face, which has thus been decided. The newly associated evidence is significant in amount and has been determined by the Board to be pertinent to the noted claims on appeal. Therefore, this additional evidence must be considered by the RO/AMC before further appellate review may be undertaken. See 38 C.F.R. §§ 19.31, 19.37, 20.1304. The Board further notes, that in regards to the claim for service connection for the weakness/numbness of the right upper extremity, the November 2012 peripheral neuropathy VA examination was incomplete. The VA examiner did not provide a medical opinion as to whether that disorder is etiologically related to the service-connected MS. As such, the November 2012 peripheral neuropathy VA examiner should provide an addendum opinion to address that question. If that VA examiner is not available, a new VA examiner should provide such an opinion. Additionally, the October 2012 VA eye examiner only opined that she was unable to resolve any answers to the Board requested questions without resorting to mere speculation. The examiner, however, did not indicate why she was unable to provide the requested opinions. Given the inadequacy of the October 2012 VA eye examination opinion, a new VA examination is necessary to determine whether the claimed vision symptoms, to include eye pain, are etiologically related to the service-connected MS. If the new VA examiner is also unable to come to an opinion, he/she should clearly explain why he/she was unable to come to an opinion. Additionally, in a January 25, 2012 VA medical record, the physician noted that a December 2011 MRI showed no optic nerve abnormalities, but that a full dedicated orbit study had not been done. If the new VA examiner finds that additional medical testing is necessary to make an opinion, such testing should be obtained prior to providing an opinion. The Board also notes that the October 2012 cranial nerves VA examination included consideration of a January 2012 VA speech pathology consult, in which a VA medical provider found the Veteran's voice to be within normal limits and functional for communication, but that the Veteran complained of changes in speech. The October 2012 VA examiner did not opine as to whether the Veteran had a speech impairment etiologically related to his service-connected MS. As the Veteran is claiming service connection for a speech impairment, such an opinion is necessary in the present claim. As such, the October 2012 cranial nerves VA examiner should provide an addendum opinion to address that question. If that VA examiner is not available, a new VA examiner should provide such an opinion. Additionally, in regards to the difficulty swallowing claim, the October 2012 cranial nerves VA examiner did not clearly indicate whether the Veteran had any degree of paralysis of the ninth cranial nerve. As such, the October 2012 cranial nerves VA examiner should provide an addendum opinion to address that question. If that VA examiner is not available, a new VA examiner should provide such an opinion. If a new VA examination is necessary to make such a determination, a new VA examination should be provided. As the claim is being remanded again, the Board notes that the last VA medical records associated with the claims file were from September 2012. Any VA medical records not already associated with the claims file should be obtained for review. Finally, the Board notes that the service connection claims for separate evaluations for weakness/numbness of the right upper extremity, vision symptoms and a speech impairment arose as part of the claim for an initial, increased evaluation for service-connected MS. As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Given the complicated history of these claims, it is unclear whether proper VCAA notice was provided in regards to those claims. Notice compliant with VCAA standards must thus be provided to the Veteran. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Notice compliant with VCAA standards for the claims for service connection for separate evaluations for weakness/numbness of the right upper extremity, vision symptoms and speech impairment (all as part of the claim for an initial, increased evaluation for service-connected MS) must be provided to the Veteran. 2. The RO/AMC shall request and obtain any VA medical records not already associated with the claims file, including records from September 2012 to the present. If the search for any such records yields negative results, that fact shall be clearly noted and the Veteran must be informed in writing. 3. After the above development has been accomplished, the RO/AMC shall request a medical opinion addendum from the provider of the October 2012 cranial nerves VA examination (in regards to the difficulty swallowing increased rating claim and speech impairment separate evaluation claim). The October 2012 VA examiner should provide the medical opinions outlined below. If the October 2012 VA cranial nerves examiner is unavailable, the RO/AMC should arrange for a new VA physician to provide medical opinions based on the evidence of record. The VA physician should base his/her opinion on previous examination findings, including if appropriate diagnostic studies, as well as a review of the claims file, including treatment records, the Veteran's statements, and a copy of this remand. If the VA physician determines that a new VA examination is necessary to render an opinion on any of the current claims, such an examination should be obtained prior to the formation of any opinions. The examiner is requested to render opinions addressing each of the following questions: a) Does the Veteran have a speech impairment? If so, please clarify which nerve is involved and the specific disorder/disorders diagnosed. b) If any speech impairment is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) was caused by the Veteran's service-connected multiple sclerosis? c) If any speech impairment is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) is aggravated by the Veteran's service-connected multiple sclerosis? d) If any speech impairment is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) is a manifestation of the Veteran's service-connected multiple sclerosis? e) For the service-connected difficulty swallowing, please clarify: to what degree, if any, does the Veteran have paralysis of the ninth cranial nerve (or other more appropriate nerve if applicable)? The term "at least as likely as not" does not mean within the realm of medical possibility, but rather 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. A complete explanation must be given for all opinions and conclusions expressed. The examiner is directed to reconcile his or her opinions with any on file that may conflict. If the VA examiner is unable to come to an opinion, he/she should clearly explain why he/she was unable to come to an opinion. 4. After the VA medical records have been associated with the claims file, the RO/AMC shall arrange for a new neurologic, ophthalmologic, or other appropriate examination (for the claim for a separate evaluation for vision symptoms, to include eye pain). The VA examiner should base his/her opinion on previous examination findings (including if appropriate diagnostic studies - including a full dedicated orbit study IF deemed necessary), as well as a review of the claims file, including treatment records, the Veteran's statements, and a copy of this remand. The examiner should also obtain a complete history from the Veteran and review the entire claims file, including the report of April 2010 evaluation which relates eye pain to migraine headaches. The examiner is requested to render opinions addressing each of the following questions: a) Does the Veteran have any eye impairments? If so, please clarify the diagnosis of any eye impairment(s) he may have and which eyes are involved. b) If any eye impairment is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) was caused by the Veteran's service-connected multiple sclerosis? c) If any eye impairment is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) is aggravated by the Veteran's service-connected multiple sclerosis? d) If any eye impairment is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) is a manifestation of the Veteran's service-connected multiple sclerosis? The term "at least as likely as not" does not mean within the realm of medical possibility, but rather 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. A complete explanation must be given for all opinions and conclusions expressed. The examiner is directed to reconcile his or her opinions with any on file that may conflict. If the VA examiner is unable to come to an opinion, he/she should clearly explain why he/she was unable to come to an opinion. 5. After the VA medical records have been associated with the claims file the RO/AMC shall request a medical opinion addendum from the provider of the November 2012 peripheral neuropathy VA examination (in regards to the claim for a separate evaluation for weakness/numbness of the right upper extremity). The November 2012 VA examiner should provide the medical opinions outlined below. If the November 2012 VA peripheral neuropathy examiner is unavailable, the RO/AMC should arrange for a new VA physician to provide medical opinions based on the evidence of record. The VA physician should base his/her opinion on previous examination findings, including if appropriate diagnostic studies, as well as a review of the claims file, including treatment records, the Veteran's statements, and a copy of this remand. The VA examiner should also consider the Veteran's history of a prior right elbow injury (as noted in VA medical records, including on April 22, 2008). If the VA physician determines that a new VA examination is necessary to render an opinion on the current claim, such an examination should be obtained prior to the formation of any opinions. The examiner is requested to render opinions addressing each of the following questions: a) Does the Veteran have a disorder of the right upper extremity? If so, please clarify the diagnosis of the disorder(s). b) If a disorder(s) of the right upper extremity is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) was caused by the Veteran's service-connected multiple sclerosis? c) If a disorder(s) of the right upper extremity is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) is aggravated by the Veteran's service-connected multiple sclerosis? If so, please clarify which nerve is involved. d) If a disorder(s) of the right upper extremity is found, is at least as likely as not (50 percent probability or greater) that the disorder(s) is a manifestation of the Veteran's service-connected multiple sclerosis? The term "at least as likely as not" does not mean within the realm of medical possibility, but rather 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. A complete explanation must be given for all opinions and conclusions expressed. The examiner is directed to reconcile his or her opinions with any on file that may conflict. If the VA examiner is unable to come to an opinion, he/she should clearly explain why he/she was unable to come to an opinion. 6. When the development requested has been completed, the case should again be adjudicated by the RO/AMC on the basis of the evidence of record, including any evidence not previously considered or forwarded directly to the Board. If any benefit sought is not granted, the Veteran should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs