Citation Nr: 1315757 Decision Date: 05/14/13 Archive Date: 05/15/13 DOCKET NO. 09-42 313A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Whether new and material evidence has been submitted sufficient to reopen a claim for service connection for an acquired psychiatric disorder, to include a depressive disorder. 2. Entitlement to service connection for an acquired psychiatric disorder, to include a depressive disorder. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for a back disability. 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for tinnitus. 7. Entitlement to service connection for sinusitis. 8. Entitlement to service connection for sleep apnea. REPRESENTATION Appellant represented by: Kenneth LaVan, Esq., and Dianne Olson, Esq. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Juliano, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1978 to July 1982, and from July 1982 to December 1983. These matters come before the Board of Veterans' Appeals (Board) on appeal from July 2008 and March 2010 rating decisions of the Department of Veterans Affairs (VA) regional office (RO) located in Atlanta, Georgia. In January 2013, the Veteran testified before the undersigned Veterans Law Judge at a videoconference Board hearing at the RO located in Atlanta, Georgia. A transcript of the proceeding has been associated with the claims file. The Board notes that in light of the medical evidence of record and the Court's holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board has recharacterized the Veteran's application to reopen his claim for service connection for schizophrenia as for service connection for an acquired psychiatric disorder, to include a depressive disorder. With regard to the Veteran's application to reopen his claim of entitlement to service connection for acquired psychiatric disorder, to include a depressive disorder, despite any determination reached by the RO to reopen a claim, the Board must find new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. See Barnett v. Brown, 83 F. 3d 1380 (Fed. Cir. 1996). As will be discussed in detail below, the Board has determined that new and material evidence has been received, and, therefore, the claim is reopened. The issues of entitlement to service connection for hypertension, a back disability, hearing loss, tinnitus, sinusitis, and sleep apnea are addressed in the remand section below and are REMANDED to the RO. VA will notify the appellant if further action is required. FINDINGS OF FACT 1. A July 1997 Board decision denied service connection for an acquired psychiatric disorder; the Veteran did not appeal, and the decision became final. 2. Evidence received since the July 1997 Board decision is not cumulative and redundant, and raises a reasonable possibility of substantiating the claim for service connection for an acquired psychiatric disorder, to include a depressive disorder. 3. There is an approximate balance of positive and negative evidence as to whether the Veteran has an acquired psychiatric disorder, to include a depressive disorder, that is related to his active service. CONCLUSIONS OF LAW 1. The unappealed July 1997 Board decision that denied the Veteran's claim of service connection for an acquired psychiatric disorder is final. See 38 U.S.C.A. §§ 7104(b), 7266 (West 1991); 38 C.F.R. § 20.1100 (1997). 2. Since the unappealed July 1997 Board decision, new and material evidence sufficient to reopen the Veteran's claim of service connection for an acquired psychiatric disorder has been received. See 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). 3. Resolving doubt in favor of the Veteran, service connection for an acquired psychiatric disorder, to include a depressive disorder, is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) With regard to the Veteran's application to reopen the previously denied claim of entitlement to service connection for an acquired psychiatric disorder, to include a depressive disorder, the Board has reopened and granted, as explained below. As such, the Board finds that any error under the VCAA with regard to the Veteran's claim is moot. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Analysis A. Application to Reopen New evidence means evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2012). When determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed. See Justus v. Principi, 3 Vet. App. 510 (1992). The preliminary issue for resolution before the Board is whether new and material evidence has been submitted sufficient to reopen the Veteran's previously denied claim of entitlement to service connection for an acquired psychiatric disorder , to include a depressive disorder. After a review of the evidence of record, the Board finds that new and material evidence has been received. By way of background, a June 1992 rating decision denied the Veteran's claim for service connection for schizophrenia, which the Veteran appealed to the Board. A July 1997 Board decision denied the Veteran's claim as not well grounded on the basis that there was no competent evidence to etiologically link any current psychiatric disorder to service. The Veteran did not appeal to the Court, and the Board decision became final. In March 2007, the Veteran filed a request to reopen his claim. At the time of the July 1997 Board decision, the evidence of record included one August 1983 service treatment record indicating that he had a previous psychiatric hospitalization for three days in service due to a situational reaction with paranoid features, as well as an April 1993 MHC record reflecting diagnosed dysthymic disorder, adjustment disorder, and polysubstance abuse by history. Since the final July 1997 Board decision, new evidence associated with the claims file includes, but is not limited to, several VA treatment records dated from 1991 to 2013, including records of an April 1992 psychiatric hospitalization for anxiety, as well as more recent VA treatment records reflecting a diagnosed mood disorder NOS, polysubstance abuse, depression, and schizophrenia. See, e.g., VA Treatment Records, March 2010, March 2011, August 2011, February 2013. New evidence also includes an April 2012 VA examination report that reflects that the VA examiner opined that he could not diagnose schizophrenia or PTSD due, among other things, to the questionable effort by the Veteran. In addition, the record contains a newly submitted July 2012 letter from Dr. E.B. of the VA medical center, in which she recorded a diagnosis of a chronic depressive disorder NOS and opined that it was caused by his active service and that she did not believe him to be malingering. The Board finds that the newly submitted July 2012 letter from Dr. E.B. of the VA medical center, in which she opines that the Veteran has a current, chronic psychiatric disorder that is related to service, constitutes new and material evidence. It relates to a fact necessary to substantiate the claim, that of nexus. Presuming its credibility in this context, the Board finds it sufficient to reopen the claim. B. Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting 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) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2012). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran served on active duty for two periods, first from July 1978 to July 1982, and second from July 1982 to December 1983. He claims that he has an acquired psychiatric disorder, to include a depressive disorder, that began due to incidents in his first period of service, and lasted throughout the remainder of his second period. He cites an in-service psychiatric hospitalization for three days, and a subsequent psychiatric evaluation in service in August 1983. He further asserts that that recruits or privates for whom he was in charge on a rifle range were supposed to shoot and kill him, that he was demoted in service from corporal due to defending his life against these recruits or privates, and that he was otherwise mistreated by his superiors. See Board Hearing Transcript at 2-3, 5-8. He has also asserted that he was discharged from service as a result of his psychiatric condition. See Transcript at 3. An August 1983 service treatment record notes a history of a three-day hospitalization in the psychiatric ward at the Naval Regional Medical Center in Charlestown, South Carolina due to suspicious behavior in believing that others were against him, and that he had been diagnosed with a situational reaction with paranoid features. The August 1983 record goes on to reflect that the Veteran had been referred by his commanding officer for psychiatric evaluation at that time to determine his fitness to continue working on a rifle range because he appeared guarded and apprehensive about working with privates and he was fearful that he may have the same symptomatology that necessitated his past hospitalization. Notably, at the Board hearing, the Veteran maintained that the privates or recruits on the rifle range truly "were supposed to kill me" and "I was actually fighting for my life," see transcript at 7. Mental status examination, however, was within normal limits, and there was no sign of psychosis or any affective disorder. It was further recommended that he be transferred to a less stressful assignment, and in the event that he was not able to adjust to his new work assignment, he be administratively separated. The Board acknowledges that the inpatient service treatment records from the three-day psychiatric hospitalization are not of record (as addressed in the remand below). Post-service, April 1992 VA treatment records reflect that the Veteran had a psychiatric hospitalization for anxiety. A July 1992 VA treatment record reflects diagnosed generalized anxiety disorder. More recent VA treatment records reflect that the Veteran has been followed for various psychiatric diagnoses, including but not limited to an adjustment disorder, dysthymic disorder, mood disorder NOS, polysubstance abuse, lifetime, depression, and schizophrenia. See, e.g., April 1993, November 2007, March 2010, March 2011, August 2011, May 2012 (Dr. E.B.), February 2013. The Veteran was provided with a VA examination in April 2012. The VA examiner noted the Veteran's psychiatric history in service as shown in the August 1983 service treatment record, as well as his post-service history of treatment at the VA medical center, including for a diagnosed depressive disorder (and also noting recent treatment by a Dr. E.B.). The examiner, however, only recorded a diagnosis of substance abuse, in remission, and opined that he was unable to diagnose PTSD or schizophrenia because the Veteran gave questionable effort during the examination, and because substance abuse symptoms can mimic those of a psychotic disorder such as schizophrenia. Subsequently, the Veteran submitted a July 2012 letter from his treating physician at the VA medical center, Dr. E.B. In her letter, Dr. E.B. noted that she had reviewed the Veteran's electronic records as well as the above August 1983 service treatment record. She noted that his diagnosis was a chronic depressive disorder, not otherwise specified, and that she opined that his condition was caused by his active service. More specifically, she opined that the in-service incident that caused his psychiatric hospitalization led to a chronic mood disturbance and unhealthy coping behaviors over the decades that followed. Dr. E.B. went on to explain that, in her opinion, the Veteran was not malingering and that another VA psychiatrist who had evaluated the Veteran, a Dr. J., also independently arrived at the same conclusion. As shown above, there is evidence of psychiatric treatment and hospitalization in service, post-service treatment for a depressive disorder, and two conflicting, competent medical opinions as to whether the Veteran has a current psychiatric disorder, to include a depressive disorder, that is related to service. In this particular case, the Board has no reason to favor one of these opinions over the other. They are both rendered on the basis of examination of the Veteran and review of pertinent records. Both offer the underlying reasons for the conclusions stated. As the Board ultimately finds the Veteran credible in his assertions, the Board concludes that the evidence is in relative equipoise; therefore, the Board will resolve all doubt in favor of the Veteran and grant entitlement to service connection for an acquired psychiatric disorder, to include a depressive disorder. In sum, having resolved all doubt in the Veteran's favor, service connection for an acquired psychiatric disorder, to include a depressive disorder, is warranted. 38 U.S.C.A. § 5107(b). ORDER New and material evidence sufficient to reopen a claim of entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, has been received, and application to reopen the claim is granted. Service connection for an acquired psychiatric disorder, to include schizophrenia, is granted. REMAND A. Hypertension The Veteran claims that he has had hypertension since his first period of service. See Board hearing Transcript at 22. The medical evidence of record includes VA treatment records dated since 1991, which reflect that he has been followed for diagnosed hypertension since 2001. See VA Treatment Record, July 2001 (electronic). The medical evidence of record also includes a printout from the VA medical center of the Veteran's vitals from July 1999 to July 2007, which include readings of 176/88 in July 1999, 191/91 in March 2001, 172/106 in May 2001, 167/109, 164/104, and 164/104 in April 2006. See also VA Treatment Records, May 2001 (VVA; 193/108, 185/106, 172/106 ). As noted above, one August 1983 service treatment record submitted by the Veteran in support of his psychiatric service connection claim is the only service treatment record associated with the claims file, and that none of his personnel records are in evidence except for his DD Form 214 from his second period of service. In that regard, the Board acknowledges that in June 1992, the RO received microfiche service records for the Veteran, but they only contained a few coversheets and no actual records. The RO sent requests in September and November 1996 to National Personnel Records Center (NPRC) for copies of the Veteran's service treatment records, in response to which negative replies were received in November 1996 and January 1997. A careful review of the file, however, shows that the request covered only the Veteran's second period of service. Then in April 2008, the RO sent a request to VA's Records Management Center (RMC) for all of the Veteran's service treatment records; a negative response was received in June 2008. Also, the RO sent a notice to the Veteran in May 2008 regarding the unavailability of his service treatment records. While the Board acknowledges the above efforts made by the RO outlined above, nevertheless, the Board notes that it there is no record of the RO ever requesting copies of the Veteran's service treatment records for his first period of service from the normal keeper of those records, the NPRC, or copies of his service personnel records. Nor does the record show that the RO requested inpatient treatment records from the Naval Regional Medical Center in Charlestown, South Carolina, which would be kept separate and apart from his service treatment records. The Board finds that it is plausible that any such hospitalization records would include blood pressure readings. Therefore, the Board finds that a remand is necessary so that these vital records may be associated with the claims file. 38 U.S.C.A. § 5103A (West 2002). Also, a December 2009 VA treatment record reflects that the Veteran applied for disability benefits with the Social Security Administration (SSA). It is unclear to which condition his claim may relate. Therefore, the Board finds that a remand is also necessary so that copies of any outstanding SSA records may be associated with the claims file, as they may contain information relevant to VA claims. Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992). B. Back Disability The Veteran claims that he has a back disability that is related to service. Specifically, he asserts that he injured his back in service lifting a box of tar, which caused a current arthritic condition. See Board Hearing Transcript at 17. He also testified that a VA physician, Dr. P., told him that his present arthritic condition was related to carrying an 85 pound backpack in service. See id. In addition, he testified that his current back condition could be related to sleeping on the ground in service or to a cold weather injury incurred in his first period of service. See id. He also asserts that he has experienced back problems since service. See Transcript at 19; cf. VA Treatment Record, February 2009 (regarding a 2007 injury). The Veteran's VA treatment records reflect that he has a history of back pain dating back to 2003. See, e.g., records dated in November 2003, September 2005. Recent VA treatment records show that he continues to be followed for chronic low back pain. See, e.g., records dated in May 2011. A March 2007 VA x-ray report shows an impression of degenerative joint disease (DJD). As service treatment records for the first period of service may be available and relevant to his claim, remand is required. C. Hearing Loss and Tinnitus The Veteran claims that he has hearing loss and tinnitus as a result of service. Specifically, he asserts that he experienced acoustic trauma as a result of his duties as a rifleman and his duties as an instructor on a rifle range. See Board Hearing Transcript at 3-4, 7, 12. He testified at the Board hearing that as a rifle range instructor five days a week, eight to ten hours per day, he did not wear hearing protection half of the time because he had to take it off every time somebody asked him a question. He asserts that at the time of his separation examination, he was told that he had hearing loss, and that he first noticed a ringing or humming in his ears within a year after discharge from service. See Transcript at 12, 14. As an initial matter, the Board acknowledges that the Veteran's DD Form 214 from his second period of service reflects that his military occupational specialty had been a rifleman for five years (the form from his first period of service is not in the claims file). Based thereon, the Board finds that noise exposure is conceded in this case. The Veteran was provided with a VA examination relating to his claim in April 2012. Pure tone thresholds exceeded 40 decibels bilaterally in at least one of the frequencies 500, 1000, 2000, 3000, or 4000, thereby meeting the VA criteria for a hearing loss disability, and the examiner recorded diagnoses of hearing loss and tinnitus. See 38 C.F.R. § 3.385 (2012). The VA examiner opined, however, that he could not provide an etiological opinion without resorting to mere speculation, reasoning in part that the Veteran's hearing loss and tinnitus were likely/possibly attributable to aging, occupational, and recreational noise exposure. The Board notes that the Veteran clarified at the Board hearing that his post-service employment as a corrections officer was in a juvenile detention center without any significant noise, and his employment in a PVC plant likewise was in a place that did not have any significant noise because he was only a packer and loader unless he went out onto the floor where it was mandatory to wear hearing protection. See Transcript at 15-16. He further denied recreational noise exposure after service. It is unclear from the examination report upon what history the examiner based his opinion of significant post-service noise exposure. Therefore, the Board finds that a remand is necessary so that another VA medical opinion may be obtained to take into consideration the conceded in-service acoustic trauma in this case despite the lack of service treatment records, as well as the Veteran's recent Board hearing testimony regarding his post-service noise exposure. In addition, the Board notes that the April 2012 VA examiner cited a March 5, 2007 VA treatment record containing audiometric data, which is not in the paper or electronic claims file. Therefore, the Board also finds that a remand is necessary so that any March 5, 2007 VA treatment record containing audiometric or audiological information may be associated with the claims file. D. Sinusitis The Veteran claims that he has sinusitis that is related to service, and that he is currently being treated for it. He testified at the Board hearing that his symptoms were the worst when he was stationed at Parris Island, and that maybe it was a particular flower there that caused his condition (but that he was not certain of the etiology, but that he knew his symptoms were the worst there). See Hearing Transcript at 24. He also testified that his condition may be related to flea bites in service. See Transcript at 23. The Board acknowledges that the July 2008 rating decision denied the Veteran's claim on the basis that, among other things, there was no current diagnosis of sinusitis. At the same time, however, the Board acknowledges that the Veteran testified at the Board hearing that he is currently being treated for sinusitis or allergies, and that his recent VA treatment records show that he has active prescriptions for certain allergy medications. See records dated in January 2010. As noted above, the Veteran testified at the Board hearing that he was being treated for a current sinusitis condition. Apart from medication lists, these records have not, however, been associated with the claims file, despite several volumes of VA treatment records already in the claims file. Therefore, the Board finds that a remand is necessary to provide the Veteran with an opportunity to more specifically identify where he has recently received treatment for a current sinusitis condition so that any records so identified may be obtained. VA is required to seek a medical opinion if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but contains competent lay or medical evidence of a current disability, establishes that the veteran suffered an event, injury or disease in service, and indicates that the current disability may be associated with the in-service event, injury or disease. 38 C.F.R. § 3.159(c)(4) (2012). Here, the current medical evidence establishes that the Veteran receives treatment for allergies, though the extent of that treatment is unknown. Additional service treatment records may confirm treatment in service, as the Veteran has credibly testified as to having symptoms during service. The question therefore remains whether the evidence indicates that there may be an association. Such an indication will be found when there is "medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation." McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Because the Veteran has indicated experiencing these symptoms since service, on remand, an examination and opinion must be obtained. E. Sleep Apnea The Veteran claims that he has sleep apnea that is related to service. Specifically, he asserts that ever since he passed out during a heat stroke or heat exhaustion physical test run during boot camp, he has had trouble breathing during his sleep. See Board Hearing Transcript at 19. He testified that for years, he told his wife to wake him up if he stopped breathing, and that he did not know what sleep apnea was until he took a particular class (although he did not specify when the class took place). See Transcript at 21. As noted above, none of the Veteran's service treatment records are available except for the August 1983 treatment record. A July 2010 VA treatment record reflects diagnosed severe sleep apnea. At the time of the March 2010 rating decision that denied the Veteran's claim, however, there was no record of diagnosed sleep apnea. The Veteran has not been provided with a VA examination relating to his claim. In light of the Veteran's recent diagnosis of sleep apnea, and the fact that he is competent to testify that he has experienced trouble breathing during his sleep since service, the Board finds that the "low threshold" requirement for providing the Veteran with a VA examination has been met and, therefore, the claim must be remanded to provide him with a VA examination relating to his claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. Request, directly from the SSA, complete copies of any determination on a claim for disability benefits from that agency as well as the records, including medical records, considered in adjudicating the claim. All attempts to fulfill this development should be documented in the claims file. 2. Request from NPRC the Veteran's service treatment records from his first period of service (July 1978 to July 1982). Also request from NPRC the Veteran's service personnel records for the length of his service (July 1978 to December 1983). Lastly, obtain inpatient mental health treatment records from the Naval Regional Medical Center in Charlestown, South Carolina. If any of these records are found to be unavailable, this should be specifically noted in the claims file. 3. Obtain any outstanding VA treatment records dated March 5, 2007, or otherwise dated in March 2007 reflecting audiological data or treatment. If these records are found to be unavailable, this should be specifically noted in the claims file. 4. Ask the Veteran to identify the approximate dates and location of treatment for his claimed sinusitis, and obtain any records so identified. If these records are found to be unavailable, this should be specifically noted in the claims file. 5. Ask the Veteran to identify the VA medical center where he was treated for his back condition by Dr. P., who indicated it may be related to carrying a heavy backpack in service, and the approximate dates of treatment, and obtain any outstanding records so identified. If these records are found to be unavailable, this should be specifically noted in the claims file. 6. After all of the above development in paragraphs (1) to (5) has been completed, forward the claims file to an audiologist to review the claims file, including a copy of this remand. The audiologist is asked to opine as to whether it is at least as likely as not (meaning likelihood of at least 50%) that any hearing loss or tinnitus had its onset in service, or is otherwise related to service. The audiologist is advised that in-service noise exposure due to extended periods of time on the rifle range is established. Review of the entire file is required; however, attention is invited to the Veteran's credible hearing testimony regarding his exposures both in service and after. A clear explanation for any opinion expressed is required. The examiner is reminded that the term "at least as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 7. After all of the above development in paragraphs (1) to (5) has been completed, schedule the Veteran for a VA examination with an appropriate examiner to determine the current nature and the etiology of his claimed sinusitis or other allergy condition. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The complete claims folder must be provided to the examiner for review in conjunction with the examination. The examiner is asked to opine as to whether it is at least as likely as not (meaning likelihood of at least 50%) that any sinusitis condition had its onset in service, or is otherwise related to service. Review of the entire file is required; however, attention is invited to the Veteran's credible hearing testimony regarding the symptoms he experienced in service, and his theories regarding the cause (allergic reaction to flowers and possible flea bites). A clear explanation for any opinion expressed is required. The examiner is reminded that the term "at least as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 8. After all of the above development in paragraphs (1) to (5) has been completed, schedule the Veteran for a VA examination with an appropriate examiner to determine the current nature and the etiology of his claimed sleep apnea. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The complete claims folder must be provided to the examiner for review in conjunction with the examination. The examiner is asked to opine as to whether it is at least as likely as not (meaning likelihood of at least 50%) that any current sleep apnea condition had its onset in service, or is otherwise related to service. A clear explanation for any opinion expressed is required. The examiner is reminded that the term "at least as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 9. Then, readjudicate the Veteran's claims. If his claims remain denied, he should be provided with a Supplemental Statement of the Case (SSOC). After the Veteran and his representative have been given the applicable time to submit additional argument, the claims should be returned to the Board for further review. The appellant 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 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). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs