Citation Nr: 1310074 Decision Date: 03/25/13 Archive Date: 04/02/13 DOCKET NO. 10-40 605 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a stomach disorder (including peptic ulcer disease, gastroesophageal reflux disorder (GERD) and gastritis), to include as secondary to service-connected schistosomiasis. 2. Entitlement to service connection for an acquired psychiatric disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant & F.B. (translator) ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran had active service from December 1950 to October 1951. Other earlier service, reportedly with the National Guard, is noted in the record, but is unverified. This matter comes before the Board of Veterans' Appeals (BVA or Board) from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. The RO continued previous denials of service connection for a stomach condition (peptic ulcer) and for depressive neurosis, psychotic level with hysterical features claimed as secondary to left testicle atrophy (38 U.S.C.A. § 1151). In June 2011, the Board determined that the Veteran's psychiatric disorder claim was for direct service connection and not a new and material evidence claim and remanded both claims for additional development. In August 2012, the Board reopened the claim for service connection for a stomach disorder and remanded that claim and the claim for service connection for a psychiatric disorder for additional development. 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 already considered by the Appeals Management Center (AMC) in the February 2013 supplemental statement of the case. 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 issue of entitlement to service connection for a psychiatric disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The evidence of record is against a finding that the Veteran's has a stomach disorder related to his active duty service, including as secondary to his service-connected schistosomiasis. CONCLUSION OF LAW The criteria for the establishment of service connection for a stomach disorder, including as secondary to service-connected schistosomiasis, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duty to Notify and Assist With regard to the claim for service connection, VA has met the duty to notify and assist the claimant in substantiating this claim for VA benefits, as provided by the Veterans Claims Assistance Act of 2000 (VCAA). 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). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record that is necessary to substantiate the claim. Proper notice will inform the Veteran of what evidence VA will seek to provide, and of what evidence the claimant is expected to provide, in accordance with 38 C.F.R. § 3.159(b)(1) (2011). Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information regarding the disability rating and effective date for the award of benefits if service connection is awarded. Id. at 486. The U.S. Court of Appeals for the Federal Circuit previously held that any errors in notice required under the VCAA should be presumed to be prejudicial to the claimant unless VA shows that the error did not affect the essential fairness of the adjudication. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Under Sanders, VA bore the burden of proving that such an error did not cause harm. Id. In the case Shinseki v. Sanders, 129 S.Ct. 1696 (2009), however, the U.S. Supreme Court held that the Federal Circuit's blanket presumption of prejudicial error in all cases imposed an unreasonable evidentiary burden upon VA. Rather, in Shinseki v. Sanders, the Supreme Court suggested that determinations concerning prejudicial error and harmless error should be made on a case-by-case basis. Id. As such, in conformance with the precedents set forth above, on appellate review the Board must consider, on a case-by-case basis, whether any potential VCAA notice errors are prejudicial to the claimant. Here, VA satisfied the VCAA duty to notify by way of a letter sent to the Veteran in November 2008 that fully addressed all of the notice elements and was sent prior to the initial RO decision in this matter. Through the letter, VA informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. VA also informed him that his service connection claim must be supported by evidence indicating a current disability, evidence that the injury or disease was incurred or aggravated during service, and medical evidence of a nexus between the current disability and the in-service injury or disease. VA informed him that VA would seek to provide federal records and that it was his responsibility to support his claim with appropriate evidence, though VA would help him obtain records from any non-federal sources. VA inform the Veteran that service connection can be awarded on a secondary basis, when a disorder is either caused or aggravated by a service-connected disability, in the August 2010 statement of the case. Additionally, the Veteran demonstrated actual knowledge of that theory of entitlement in his December 2010 statement of accredited representation in appealed case (In lieu of VA Form 646). With respect to the Dingess requirements, the November 2008 letter included notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and VA has complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in obtaining any outstanding records of identified VA or private medical treatment relevant to his claim, and affording him an examination when appropriate. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. With regard to records, VA has associated with the claims folder the Veteran's service treatment records, private medical records and pertinent VA medical records. The Veteran has not indicated that there exist any records of VA or private VA medical treatment relative to this claim that are not already in the claims file. The RO/AMC also accomplished the development directed by the Board in the prior remands, obtaining a new VA examination for the stomach disorder claim in August 2011 and an addendum opinion in October 2012. The RO/AMC also obtained the Veteran's more recent VA medical records and associated them with the electronic claims file. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection for a Stomach Disorder Claim The Veteran contends that he currently has a stomach disorder that developed in service or secondary to his service-connected schistosomiasis. In his February 2011 Board hearing, he reported that he has had chronic stomach problems since service. He specifically reported currently having gastroesophageal reflux disorder (GERD), which he essentially related to service. Under applicable law, service connection is granted if the evidence establishes that coincident with his service, the Veteran incurred a chronic disease or injury, or had a preexisting injury permanently aggravated, in the line of duty of his active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for certain chronic diseases, when such disease is manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If there is no showing of a chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection can also be found for any disease diagnosed after discharge, if the evidence establishes it was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires: (1) medical evidence of a current disability, (2) medical evidence, or lay testimony in some cases, that the injury or disease was incurred or aggravated during service, and (3) medical evidence of a nexus between the current disability and the in-service injury or disease. Pond v. West, 12 Vet. App. 341 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection can also be granted when a disability is the proximate result of or due to a service-connected disease or injury. 38 C.F.R. § 3.310(a). See Libertine v. Brown, 9 Vet. App. 521, 522 (1996); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additionally, the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (en banc). Establishing service connection on a secondary basis therefore requires evidence sufficient to show the following: (1) that a current disability exists and (2) that the current disability was either caused by or aggravated by a service connected disability. Id. Factual Background The Veteran's service treatment records do not document treatment for a stomach disorder, other than infections. For example, in July 1951, the Veteran received diagnoses of schistosomiasis, ancylostomiasis and trichuriasis. Schistosomiasis is an infection with flukes (trematodes). See Dorland's Illustrated Medical Dictionary 1664, 713, 1940 (30th ed. 2003). Ancylostomiasis is a hookworm disease. See Dorland's Illustrated Medical Dictionary 76 (30th ed. 2003). Trichuriasis is an infection with nematodes (round worm and eel worm). See Dorland's Illustrated Medical Dictionary 76, 1227 (30th ed. 2003). The Veteran's discharge examiner found his abdomen and viscera to be normal. The August 1951 medical board proceedings did not document any findings of a stomach disorder, other than those previously mentioned infections. Following the Veteran's October 1951 separation from service, the Veteran received treatment from VA in 1952. The examiner found the Veteran's gastrointestinal complaints to be well explained in somatization reaction and diagnosed the Veteran with conversion reaction, mixed type, somatization. The Veteran underwent a VA examination in March 1962. At that time, he complained of a stomach condition, including poor appetitive and pain across the upper abdomen. The examiner noted that the Veteran tested positive for ova a schistosoma. The examiner diagnosed him with schistosomiasis and trichuriasis. A September 1988 VA medical record documented that the Veteran had previously had a left inguinal herniorrhaphy. In December 1985, a VA medical provider diagnosed the Veteran with peptic ulcer disease. VA medical records document treatment for various stomach complaints. A July 2010 VA medical record listed GERD as one of the Veteran's problems. The VA medical provider, however, noted that the gastrointestinal review of symptoms was negative. The provider further found the abdomen to be non-tender, non-distended, soft and depressible and to have no masses or organomegaly. The provider also noted prior study, and findings of hiatal hernia, GERD below carina level, and acute sigmoid colon diverticulitis. In September 2011, the Veteran underwent a VA examination for the stomach, duodenum and peritoneal adhesions. The Veteran reported that after his separation from service he has had recurrent heartburn, dyspepsia, acid reflux and abdominal pains (which he associated with diarrhea and urgency to defecate). The Veteran reported occasional nausea and diarrheas once or twice a month, as well as heartburn, dyspepsia, belching, sore throat, and abdominal pains. The Veteran denied a history of peptic ulcer disease. Following examination, the September 2011 VA examiner diagnosed the Veteran with GERD and chronic gastritis. The examiner found no evidence of peptic ulcer disease on examination. Following claims file review, the examiner noted that despite the Veteran's and his spouse's complaints of dyspepsia and acid reflux since separation, the service treatment records did not document such complaints and the only mention of nausea, vomiting and loss of weight was the July 1952 record wherein the Veteran had been diagnosed with gastrointestinal reaction, conversion reaction, mixed type and somatization reaction. The examiner further discussed, in depth, a lack of post-service records of stomach problems and various VA and private medical records regarding gastrointestinal complaints. Based on her review of the medical evidence, the VA examiner opined that the so called stomach condition that the Veteran alleged to have started during military service and for which he was service connected was schistosomiasis. The examiner noted that the Veteran had intestinal schistosomiasis caused by S.Mansoin, which included common symptoms of chronic or intermittent abdominal pain, poor appetite and diarrhea. The September 2011 VA examiner, however, opined that the new claimed stomach disorder (GERD and gastritis) are related to hiatal hernia noticed in an upper gastrointestinal series (UGIS), poor dietary habits and alcohol consumption. It was thus her opinion that a stomach disorder had its onset many years after service and that there was no direct etiologic relationship with the diagnosis of schistosomiasis. In September 2012, the September 2011 VA examiner provided an addendum opinion, following additional review of the claims file and specifically included consideration of the Veteran's statements. The VA examiner continued her previous opinion. She found GERD to more likely than not be related to the hiatal hernia (noticed at the December 2009 UGIS and May 2011 upper endoscopy), as well as, to poor dietary habits and alcohol consumption. The examiner further noted that gastritis was more likely than not related to poor dietary habits and alcohol consumption. The examiner found those conditions to have had their onset many years after military service. The examiner found no direct etiologic relation to military service and that those disorders were not related to or aggravated by the service-connected, inactive schistosomiasis. In January 2013, the September 2011 VA examiner provided a further addendum, again noting review of the claims file and electronic medical records. The examiner noted the Veteran reports of stomach symptoms, which he claimed to have had since separation from service, but again noted that service treatment records are silent regarding such complaints during the active service and months after discharged. The examiner noted the previously service-connected intestinal schistosomiasis and found that the condition had been treated and had become inactive more than thirty years previously. The examiner also found no evidence of continuity of symptomatology after active service. The VA examiner again found that GERD and gastritis were not casually or etiologically related to service and not proximately due to or aggravated by his service-connected schistosomiasis (which is inactive). The VA examiner clarified that GERD and gastritis had their onset many years after service. Furthermore, she noted that medical literature did not support a direct etiologic relation between past schistosomiasis (currently inactive) and further development of GERD and gastritis. The examiner found the GERD to most likely be related to hiatal hernia (diagnosed in the UGIS of December 2009) and upper endoscopy of May 2011, as well as poor dietary habits and alcohol consumption. The examiner further found gastritis to most likely be related to poor dietary habits and alcohol consumption. Analysis In regards to the Veteran's claim of service connection for a stomach disorder of peptic ulcer disease, the September 2011 VA examiner specifically found the Veteran to not currently have peptic ulcer disease. A threshold requirement for the granting of service connection is evidence of a current disability. In the absence of evidence of a current disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The current disability requirement for a service connection claim is satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). In the instant case, the record fails to reflect a current diagnosis of peptic ulcer disease at any time during the pendency of the appeal, though there is a pre-appeal diagnosis of that disorder in December 1985. As such, service connection for a stomach disorder of peptic ulcer disease is denied. The Veteran does meet the first criteria for service connection on a direct basis for a current stomach disorder, for GERD and gastritis. The September 2011 VA examiner diagnosed the Veteran with both disorders. However, the evidence does not establish that direct service connection is warranted based on the other direct service connection criteria, that medical evidence establish that the claimed disorder was incurred or aggravated during service. The service treatment records do not document any complaints of, or treatment for, either GERD or gastritis. Additionally post-service medical records for decades following the Veteran's October 1951 separation from service did not include any diagnoses of or treatment for either GERD or gastritis. Indeed, the September 2011 VA examiner noted that the Veteran was not diagnosed with either of those disorders until over 40 years following his discharge from service. Furthermore, the September 2011 VA examiner specifically found GERD and gastritis to have "no direct etiologic relation to military service". Indeed, the VA examiner found GERD to be more likely than not be related to the Veteran's non-service-connected hiatal hernia, poor dietary habits and alcohol consumption. The examiner further found that gastritis was more likely than not related to poor dietary habits and alcohol consumption. There are no other medical opinions of record addressing the etiology of the GERD or gastritis. Service connection is also not warranted on a secondary basis, as caused or aggravated by the Veteran's service-connected schistosomiasis. The September 2011 VA examiner specifically found GERD and gastritis to not be related to or aggravated by the service connected schistosomiasis. The VA examiner further found schistosomiasis to be inactive during examination and had become inactive more than thirty years previously, while also noting that the Veteran was not diagnosed with GERD or gastritis until within the last ten years. The September 2011 VA examiner further explained that medical literature did not support a direct etiologic relation between past schistosomiasis (currently inactive) and further development of GERD and gastritis. The only evidence of record supportive of the Veteran's claim is the Veteran's own contention that he has had GERD and gastritis since service. As a lay person, the Veteran is not competent to offer such diagnoses as he does not possess the requisite specialized knowledge. In this regard, such diagnoses require the administration and interpretation of specialized test results, to include diagnostic studies. Therefore, making such a diagnosis is a complex medical question and the Veteran is not competent to offer such a diagnosis for either GERD or gastritis. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The Board acknowledges that lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), GERD and gastritis fall 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). "Competent medical evidence" is evidence that is provided by a person qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a). As the preponderance of the 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 service connection for a stomach disorder, including peptic ulcer disease, GERD and gastritis, and to include as secondary to service-connected schistosomiasis, is denied. ORDER Service connection for a stomach disorder (including peptic ulcer disease, GERD and gastritis), including as secondary to service-connected schistosomiasis, is denied REMAND At various times since his discharge, the Veteran has asserted to have had an acquired psychiatric disorder that developed in service, that pre-existed service and was aggravated by service, and/or that developed secondary to a service-connected disability. In his most recent application, the Veteran claimed that he has an acquired psychiatric disorder that was caused or aggravated by his left testicle atrophy (which the RO found to be a disability resulting from VA medical treatment (i.e., disability under 38 U.S.C.A. § 1151) in a July 2001 rating decision). The service records, including Board Disposition Proceedings from October 1951, document that during service the Veteran had received a diagnosis of conversion reaction and that the Army had found it to have existed prior to service. Following service, a June 1976 VA medical record documented that the Veteran received a diagnosis of depressive neurosis, nearing psychotic level, with hysterical features. In a December 2003 private medical record, Dr. M. Sanz diagnosed the Veteran with major depression, recurrent, moderate. An April 2004 VA examiner diagnosed the Veteran with anxiety disorder, not otherwise specified. The November 2008 VA examiner diagnosed the Veteran with major depressive disorder as did his February 2009 private medical provider, Dr. E.T.V. Lopez. A June 2009 VA medical record documented a diagnosis of senile dementia with behavior disturbances. In April 2011, Dr. E.E. Ramos-Escoda indicated that the Veteran had actually had epileptic seizures in service. The August 2011 VA examiner similarly diagnosed the Veteran with dementia, not otherwise specified. In June 2011, the Board remanded this issue for a VA examination to determine the nature and etiology of the Veteran's claimed psychiatric disorder. The Veteran underwent a VA examination in August 2011. In August 2012, the Board remanded this matter again for an addendum opinion. An addendum opinion was provided in October 2012. Unfortunately, the Board finds that another addendum opinion is necessary for the current claim. The October 2012 VA addendum opinion provider was unclear in her findings. Although the examiner found that neither the Veteran's schistosomiasis and/or left testicular atrophy has a relationship or bearing to the Veteran's major depressive disorder onset. However, the examiner further opined that "left testicular atrophy...may hava [sic] aggravated veteran's Major Depression and serve as a perpetuating factor." Additionally, the examiner indicated that she could determine a baseline level of severity for aggravation of a nonservice connected condition by a service connected condition, but did not provide such a baseline. Once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant as to why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The RO/AMC should obtain another supplemental medical opinion to address whether the Veteran has an acquired psychiatric disorder that developed due to service, was aggravated by service or was caused or aggravated by a service-connected disability. The Board also notes that the last VA medical records associated with the claims file were from January 2013 (associated with the electronic claims file) and that the record indicates that the Veteran receives continuing treatment from VA. VA must assist a claimant in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). As this claim is being remanded, any VA medical records not already associated with the claims file should be obtained for review. 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. The RO/AMC shall request and obtain any VA medical records not already associated with the claims file, including records from January 2013 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. 2. After the requested medical records have been associated with the claims file, the RO/AMC shall obtain a medical opinion addendum for the claim for service connection for an acquired psychiatric disorder. The examiner should provide a medical opinion as to the likelihood that there is an etiological relationship between the claimed acquired psychiatric disorder and the Veteran's period of service or his service-connected disabilities of schistosomiasis and/or left testicular atrophy. The VA examiner should base his/her opinion on previous examination findings, 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 examiner 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 current acquired psychiatric disorder(s)? If so, please clarify his currently diagnosed psychiatric disorder(s). b) Did the Veteran clearly and unmistakably enter active military service with any psychiatric disorder(s)? If yes, the examiner should identify the evidence leading to this conclusion. If the Veteran currently has any psychiatric disorder(s) that pre-existed military service: 1) Did the Veteran have temporary or intermittent flare-ups in service; or was there a permanent worsening of the underlying pathology of any such condition due to or during service, resulting in the current disability? 2) Was there any increase in the severity of the psychiatric disorder(s) during service, and if so, was any such increase in severity due to the natural progression of the disability? 3) If there was an increase in severity of the psychiatric disorder(s) due to service that was beyond the natural progression of that disorder, the examiner should attempt to identify the baseline disability on entrance and the extent of increased disability due to service. c) If the Veteran has any psychiatric disorder(s) that did NOT pre-exist military service, is it at least as likely as not (50% probability or greater) that the diagnosed psychiatric disorder(s) began in or was caused by the Veteran's service? d) Is it at least as likely as not (50% probability or greater) that any psychiatric disorder(s) was caused by or aggravated beyond the natural progression of the disorder by the Veteran's service-connected disabilities of schistosomiasis and/or left testicular atrophy? If the examiner finds that any acquired psychiatric disorder(s) was aggravated by schistosomiasis and/or left testicular atrophy, he/she should determine, if possible, to what extent it was aggravated beyond the natural progression of the disorder. For purposes of this analysis, "aggravation" is defined as a permanent worsening of the nonservice-connected disability beyond that due to the natural disease process 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. The examiner is asked to explain the reason(s) for his/her answers to the questions posed above. The examiner is directed to reconcile his or her opinions with any on file that may conflict, including those previously noted in this REMAND. 3. When the development requested has been completed, the case should again be adjudicated by the RO/AMC on the basis of the additional evidence, including any evidence 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