Citation Nr: 1309837 Decision Date: 03/22/13 Archive Date: 04/01/13 DOCKET NO. 04-09 055 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas THE ISSUES 1. Entitlement to service connection for alcohol dependence and depression as secondary to service-connected anxiety disorder not otherwise specified with major depressive disorder. 2. Entitlement to service connection for osteoporosis, to include as secondary to service-connected anxiety disorder not otherwise specified with major depressive disorder. 3. Entitlement to service connection for a low back disorder, to include as secondary to service-connected anxiety disorder not otherwise specified with major depressive disorder. 4. Entitlement to service connection for cardiovascular disease, to include as secondary to service-connected anxiety disorder not otherwise specified with major depressive disorder. 5. Entitlement to service connection for a gastrointestinal disorder, to include as secondary to service-connected anxiety disorder not otherwise specified with major depressive disorder. 6. Entitlement to service connection for colon polyps, to include as secondary to service-connected anxiety disorder not otherwise specified with major depressive disorder. REPRESENTATION Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran served on active duty from December 1960 to August 1964. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2002 and May 2003 rating decisions by which the RO, in pertinent part, denied entitlement to the benefits sought herein. This appeal was previously before the Board in July 2007, January 2010, and in August 2012. In August 2012, the Board referred to the RO the issue of entitlement to an initial evaluation in excess of 30 percent for service-connected anxiety disorder, not otherwise specified, with major depressive disorder. In September 2012, the Veteran indicated in a written statement that he was satisfied with the 30 percent evaluation for the service-connected anxiety with depression. The Board has recharacterized the first issue listed above. Initially the issue was listed as entitlement to service connection for a nervous condition other than anxiety and depression, to include as secondary to service-connected anxiety disorder not otherwise specified with major depressive disorder. In its August 2012 remand, the Board asked that the Veteran clarify the nature of the nervous disorder for which he was seeking service connection. In subsequent communications, however, the Veteran merely referred to his depression for which service connection has already been granted. He did not specify a psychiatric disorder for which service connection had not already been granted. On VA examination in September 2012, the examiner diagnosed alcohol dependence as an Axis I diagnosis. The Board notes that service connection for alcohol dependence cannot be granted on a direct basis, and only secondary service connection is available for such a disability. See 38 U.S.C.A. § 105 (West 2002); 38 C.F.R. § 3.301(d) (2012); see also VAOPGCPREC 7-99, 64 Fed. Reg. 52,375 (June 9, 1999); Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2011). Hence, the issue on appeal has been recharacterized as expressed above. In reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. The issues of entitlement to service connection for alcohol dependence, osteoporosis, a low back disorder, and cardiovascular disease 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. Affording the Veteran the benefit of the doubt, a gastrointestinal disorder is aggravated by the service-connected anxiety disorder not otherwise specified with major depressive disorder. 2. Colon polyps were not incurred in or otherwise related to service, and they are not the proximate result of, due to, or aggravated by the service-connected anxiety disorder not otherwise specified with major depressive disorder. CONCLUSIONS OF LAW 1. A gastrointestinal disorder is aggravated by a service-connected disability. 38 U.S.C.A. §§ 110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012) 2. Colon polyps were not incurred in active duty service, and are not causally related to or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VCAA and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a September 2012 letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claims for service connection to include on a direct and secondary basis as well as what information and evidence must be submitted by the Veteran, what evidence VA would obtain, and of what assistance the VA could provide the Veteran in obtaining this evidence. The notice included provisions for disability ratings and for the effective date of the claims. Any defect as to the timing of the VCAA notice was cured because the RO readjudicated the claims in a January 2013 supplemental statement of the case. See Prickett v. Nicholson, 20 Vet. App. 370, 376-78 (2006) (validating the remedial measures of issuing fully compliant VCAA notification and re-adjudicating the claim in the form of a statement of the case to cure timing of notification defect). With regard to the duty to assist, the Board is satisfied that VA has made reasonable efforts to obtain relevant records and evidence. The information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service private treatment records, VA treatment records, disability records from the Social Security Administration (SSA), general medical literature, VA examination reports, and the Veteran's statements. The Veteran was afforded VA medical examinations in furtherance of his claims. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). This examination was adequate because it was performed by a medical professional based on a review of claims file, solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. Moreover, each resulting opinion was accompanied by a rationale that was consistent with the examination and the record. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. Standard of Review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (reasonable doubt to be resolved in veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Law and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Neither condition at issue herein is a "chronic disease" listed under 38 C.F.R. § 3.309(a), therefore 38 C.F.R. § 3.303(b) does not apply. See Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Thus, 38 C.F.R. § 3.303(b) does not apply. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on a veteran's behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Discussion Gastrointestinal Disorder The Veteran asserts that he suffers from a gastrointestinal condition that is secondary to the service-connected anxiety disorder not otherwise specified with major depressive disorder. The service treatment records reflect no gastrointestinal disorders and no complaints consistent with a gastrointestinal disorder. On service separation, the Veteran failed to identify any symptoms that could be construed as related to a gastrointestinal disorder. In an April 2002 written statement, the Veteran indicated that earlier that month, he began to suffer from abdominal pain and diarrhea with blood in the stool. According to him, an endoscopy revealed stomach ulcers. The Veteran asserted that these were related to his anxiety and depression. The Veteran submitted articles gleaned from the Internet that reflect an association between emotional health and gastrointestinal illnesses. May 2009 private medical records reveal a diagnosis of mild erosive esophagitis and mild gastritis. In February 2012, the Veteran was afforded a VA medical examination. In the examination report, the examiner indicated that there was no evidence to establish that gastrointestinal/acid reflux disease was due to service. The examiner noted that a July 2002 VA progress note indicated H. pylori ulcers in 1996. July 2012 private medical records indicate diagnoses of distal esophageal stricture, evidence of a previous gastric ulcer, gastritis, and duodenitis. On VA examination in September 2012, the examiner noted a diagnosis of gastroesophageal reflux disease (GERD). The examiner opined that GERD/gastritis/duodenitis was not related to service. The examiner emphasized, however, that anxiety and stress could exacerbate symptoms associated with the foregoing diagnosis. As apparent from the evidence, there is no apparent nexus between the Veteran's current GERD/gastritis/duodenitis and service. The service treatment records do not reflect symptoms associated with such a diagnosis, and the Veteran received no treatment of the gastrointestinal system until approximately 1996, many decades after service. There being no sign of a nexus between the currently diagnosed GERD/gastritis/duodenitis and service, the weight of the evidence is against a finding of entitlement to service connection for the claimed gastrointestinal disability on a direct basis. 38 C.F.R. § 3.303. Similarly, the weight of the evidence is against a finding of entitlement to secondary service connection on any basis apart from aggravation. The Veteran has submitted Internet evidence of an association between gastrointestinal illness and mental health. The articles spoke of gastrointestinal conditions as a whole and not necessarily the Veteran's particular gastrointestinal condition. That evidence, therefore, is too general to support secondary service connection. 38 C.F.R. § 3.310; Obert, 5 Vet. App. at 33; see also Beausoleil, 8 Vet. App. at 463. Furthermore, the Veteran's assertions regarding the origins of a gastrointestinal condition do not constitute competent evidence. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), determining the etiology of a gastrointestinal disorder falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The competent medical evidence, found in the cited VA examination reports, does not reflect direct causation. Namely, that evidence does not show that the Veteran's service-connected psychiatric condition caused his gastrointestinal disorder. The competent evidence, however, does reflect the distinct possibility that the service-connected psychiatric disorder is aggravating the Veteran's gastrointestinal disorder. Thus, affording him the benefit of the doubt, secondary service connection on the basis of aggravation is warranted for the currently diagnosed GERD/gastritis/duodenitis. 38 C.F.R. § 3.310; Allen, supra; see also 38 U.S.C.A. § 5107; 3.102; Gilbert, supra. Colon polyps The Veteran contends that service connection for colon polyps is warranted as secondary to his service-connected psychiatric disorder. The Board finds initially that colon polyps are not among the chronic diseases listed under 38 C.F.R. § 3.309(a), therefore 38 C.F.R. § 3.309(b) does not apply. See Walker, supra. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In this case, service treatment records do not reflect a diagnosis of colon polyps, and the Veteran does not appear to have experienced symptoms consistent with colon polyps in service. Indeed, the Veteran does not appear to contend that colon polyps are directly related to service. His assertion is that secondary service connection is in order as the colon polyps are proximately due to or a result of his service-connected psychiatric disability. On VA examination in February 2012, a VA examiner opined that colon polyps were unrelated to service because the service treatment records revealed no findings of colon polyps or treatment for that condition. The examiner further asserted that there was no evidence in the literature to suggest that colon polyps were caused by depression. On VA examination in September 2012, the examiner explained that most polyps resulted from genetic mutations in one of the colon lining cells. The examiner, therefore, opined that there was no nexus between the Veteran's colon polyps and service and that the service-connected anxiety and depression did not cause or aggravate the polyps. There is no medical opinion of record that purports to relate colon polyps to any service-connected disability. The Veteran provided articles regarding the impact of mental health upon physical health. The Court has held that a medical article or treatise "can provide important support if the medical article or treatise evidence discussed generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998). Here, however, the medical text evidence submitted by the Veteran fails to demonstrate with any degree of certainty a relationship between the Veteran's service-connected psychiatric disability and colon polyps. For these reasons, the Board finds medical text evidence unpersuasive. The Veteran appears to believe that his colon polyps are related to his service-connected psychiatric disability. Although lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435, establishing the etiology of colon polyps falls outside the realm of the common knowledge of a lay person. See Jandreau, 492 F.3d at 1377. Taken together, the two VA medical opinions show that there is no nexus between the Veteran's colon polyps and service. The first VA examiner noted that colon polyps were not present in service. The second VA examiner explained that colon polyps were caused by genetic mutations of the cells lining the colon. Because colon polyps were not present in service and were caused by subsequent genetic mutations, the Board finds that colon polyps did not manifest in service and that they are not otherwise shown to be related to service. Thus, direct service connection for colon polyps is not warranted. 38 C.F.R. § 3.303. As to the matter of secondary service connection, to include on the basis of aggravation, the second VA examiner concluded that the Veteran's service-connected psychiatric disorder did not cause or aggravate the colon polyps because colon polyps were caused by genetic mutations. The VA examiner did not state that the Veteran's mental health led to genetic mutations in the colon. Thus, based on the most persuasive evidence in this case, the Board finds that colon polyps are not proximately due to, the result of, or aggravated by the service-connected anxiety disorder not otherwise specified with major depressive disorder. As such, secondary service connection for colon polyps to include on the basis of aggravation is precluded. 38 C.F.R. § 3.310, Allen, supra. In making this determination, the Board has considered the provisions of 38 U.S.C.A. § 5107(b), but there is not such a state of approximate balance of the positive evidence with the negative evidence to otherwise warrant a favorable decision. ORDER Service connection for a gastrointestinal disorder on the basis of aggravation is granted. Service connection for colon polyps is denied. REMAND A remand is required in this case to ensure that there is a complete record upon which to decide the Veteran's claims. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c), (d) (2012). As stated in the Introduction, the Board remanded the issues remaining on appeal to the RO/AMC for further development of the evidence. As relevant herein, the RO asked that VA examinations be scheduled for opinions regarding the etiologies of the disabilities at issue herein. Specifically, the Board asked the following: The AMC/RO should schedule the Veteran for a VA medical examination(s) to determine the nature and etiology of the Veteran's claimed osteoporosis, low back disorder, cardiovascular disease, and, if properly defined, nervous disorder. The relevant documents in the claims folder should be made available to the VA examiner for review. Based upon a review of all the record, including treatment records, a history provided by the Veteran, and clinical findings, the VA examiner is requested to offer the following opinions: Is it as least as likely as not (50 percent or greater degree of probability) that the Veteran's osteoporosis is related to service or any incident of service? Is it as least as likely as not (50 percent or greater degree of probability) that the Veteran's osteoporosis was caused or aggravated by the service-connected anxiety and depression? Is it as least as likely as not (50 percent or greater degree of probability) that the Veteran's low back disorder is related to service or any incident of service? Is it as least as likely as not (50 percent or greater degree of probability) that the Veteran's low back disorder was caused or aggravated by the service-connected anxiety and depression? Is it as least as likely as not (50 percent or greater degree of probability) that the Veteran's cardiovascular disease is related to service or any incident of service? Is it as least as likely as not (50 percent or greater degree of probability) that the Veteran's cardiovascular disease was caused or aggravated by the service-connected anxiety and depression? Identify any current chronic nervous disorder other than anxiety or depression. If the Veteran has a current chronic nervous disorder other than anxiety or depression, is it as least as likely as not (50 percent or greater degree of probability) that the Veteran's nervous disorder is related to service or any incident of service? If the Veteran has a current chronic nervous disorder other than anxiety or depression, is it as least as likely as not (50 percent or greater degree of probability) that the Veteran's nervous disorder was caused or aggravated by the service-connected anxiety and depression? If the VA examiner determines a claimed disorder was aggravated, although not caused, by the Veteran's service-connected anxiety and depression, he or she should indicate the degree of such aggravation over and the above the natural course of the disorder. A rationale should be provided for any opinion or conclusion expressed. If the VA examiner is unable to provide the requested opinion with what is considered to be a generally accepted degree of medical certainty, i.e., without resorting to speculation, the reasons should be so stated. The VA examiner should in such case explain why it would be speculative to respond. In September 2012, the Veteran was afforded the requested VA medical examinations. However, the remand directives were not followed in full. Regarding osteoporosis, the September 2012 VA examiner provided a thorough and cogent rationale as to why osteoporosis was unrelated to service. The examiner also concluded that osteoporosis was not the result of or aggravated by the service-connected anxiety with depression. She did not provide a rationale for that conclusion as requested in the August 2012 Board remand directive. The Board also notes that she did not address the treatise by the National Institute of Mental health submitted by the Veteran entitled "Depression, Bone Mass, and Osteoporosis" which discusses an association between depression and the onset of osteoporosis. Regarding the claimed low back disorder, the September 2012 VA examiner diagnosed degenerative disc disease of the thoracolumbar spine and opined that the condition was not related to service or to the service-connected anxiety disorder with depression. He provided a rationale for that opinion. Unfortunately, the a examiner did not offer the requested opinion regarding whether the diagnosed low back disability was aggravated by the service-connected anxiety disorder not otherwise specified with major depressive disorder. Regarding cardiovascular disease, the Veteran was afforded a VA heart examination in September 2012. The examiner diagnosed coronary artery disease (CAD) and opined that it was unrelated to service. He provided an explanation for that conclusion. He also opined that the Veteran's CAD was not caused by or aggravated by his service-connected anxiety disorder not otherwise specified with depression. The examiner did not provide a rationale for that conclusion, as requested in the August 2012 Board remand. The Board also notes that the opinion does not address the article submitted by the Veteran entitled "Depression Affects Nervous System and Can Cause Heart Attacks." Regarding the claimed nervous disorder other than anxiety and depression, the examination appears to have been focused on evaluating the current manifestations and severity of the service-connected anxiety disorder. Notably, although the examiner diagnosed alcohol dependence, which is not a service-connected disability, the examiner did not opine regarding whether that condition was caused or aggravated by the service-connected anxiety disorder not otherwise specified with major depressive disorder. When VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As well, where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that where the remand of the Board or the Court is not complied with, the Board errs as a matter of law when it fails to ensure compliance). Here, the VA examiners who conducted the September 2012 VA examinations and who opined regarding the relevant disabilities did not respond in full to the inquiries posed and, in some cases, did not provide a rational for the conclusions offered. Thus, the VA opinions regarding the issues remaining on appeal are incomplete and, therefore, inadequate. Because the September 2012 VA examinations and opinions are not adequate for the reasons detailed above, VA did not fulfill the August 2012 remand directives, and compliance with the remand is lacking; therefore, the Board is required to remand these matters to the RO for corrective action. Stegall, supra. To ensure that the Veteran is afforded adequate VA examinations and opinions, the RO/AMC should arrange for supplemental opinions and/or examination as described below. Accordingly, the case is REMANDED to the RO/AMC for the following action: 1. Obtain a supplemental opinion from the examiners who conducted the September 2012 examinations. If a particular examiner is not available, obtain an opinion from another VA clinician based on review of the pertinent evidence. If the clinician determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The claims folder must be made available to and reviewed by the clinician. * Provide a rationale for the opinion provided in September 2012 that the Veteran's osteoporosis was not aggravated (permanently worsened beyond the natural progress of the disease) by the service-connected anxiety and depression. Address the treatise by the National Institute of Mental health submitted by the Veteran entitled "Depression, Bone Mass, and Osteoporosis" which discusses an association between depression and the onset of osteoporosis. * Is it as least as likely as not (50 percent or greater degree of probability) that the Veteran's low back disorder was aggravated (permanently worsened beyond the natural progress of the disease) by the service-connected anxiety and depression? * Provide a rationale for the opinion provided in September 2012 that the Veteran's cardiovascular disease was not aggravated (permanently worsened beyond the natural progress of the disease) by the service-connected anxiety and depression. Discuss the article submitted by the Veteran entitled "Depression Affects Nervous System and Can Cause Heart Attacks." * Is it as least as likely as not (50 percent or greater degree of probability) that the Veteran's alcohol dependence or any nonservice-connected mental disorder was caused or aggravated by the service-connected anxiety and depression? The VA examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. The VA examiner is further advised that aggravation is defined for legal purposes as a permanent worsening of the underlying condition beyond its natural progression, rather than just a temporary flare-up of symptoms. If the VA examiner determines a claimed disorder was aggravated, although not caused, by the Veteran's service-connected anxiety and depression, he or she should indicate the degree of such aggravation over and the above the natural course of the disorder. A rationale should be provided for any opinion or conclusion expressed. If the VA examiner is unable to provide the requested opinion with what is considered to be a generally accepted degree of medical certainty, i.e., without resorting to speculation, the reasons should be so stated. The VA examiner should in such case explain why it would be speculative to respond. 2. After the completion of the above, the AMC/RO should re-adjudicate the issues remaining on appeal. If any benefit sought on appeal is not granted, the Veteran and the representative should be provided with a supplemental statement of the case. An appropriate period of time should then be allowed for a response, before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the 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 or by the Court 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). ______________________________________________ LLOYD CRAMP Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs