Citation Nr: 1324399 Decision Date: 07/31/13 Archive Date: 08/07/13 DOCKET NO. 10-01 623 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for lymphoma, to include as due to exposure to an herbicidal agent, to also include as secondary to a service-connected disability. 2. Entitlement to service connection for a disorder manifested by stomach or abdominal pain to include as due to exposure to an herbicidal agent, to also include as secondary to a service-connected disability. ATTORNEY FOR THE BOARD S. Pflugner, Counsel INTRODUCTION The Veteran served on active duty from September 1968 to September 1970. This case comes to the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office in San Diego, California. During the pendency of this appeal, the Veteran's claim file was transferred to the Regional Office located in Indianapolis, Indiana (RO). These claims were before the Board in February 2013, at which time the Board remanded them for additional development. After this development was accomplished, the claims have been returned to the Board for further appellate review. The issue of entitlement to service connection for lymphoma, to include as due to exposure to an herbicidal agent, to also include as secondary to a service-connected disability, is REMANDED to the RO via the Appeals Management Center in Washington, DC. VA will notify the Veteran if further action is required. FINDING OF FACT The evidence of record does not include a current diagnosis of a disability manifested by stomach or abdominal pain. CONCLUSION OF LAW A disability manifested by stomach or abdominal pain was not incurred in or due to active military service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA has a duty to notify and assist veterans in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the veteran is expected to provide. 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). The notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the appellant's service and the disability; (4) degree of disability; and (5) effective date of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Prior to the initial adjudication of the Veteran's claim of entitlement to service connection for a disability manifested by stomach or abdominal pain, the RO's November 2007 letter advised the Veteran of the elements of the notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman, 19 Vet. App. at 486. Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of this claim, including the opportunity to present pertinent evidence. Thus, the Board finds that the content requirements of the notice VA is required to provide have been met. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). Additionally, the duty to assist the Veteran has also been satisfied in this case. The RO obtained the Veteran's service treatment records and his identified VA and private treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that additional evidence relevant to the service connection claim being decided herein is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran was provided a VA examination in April 2013. The examiner reviewed the Veteran's claims file and the Veteran's statements, and administered a thorough clinical evaluation. The Board finds that the examiner addressed the salient question presented by the Veteran's claim and, thus, the examination is adequate for adjudicative purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (finding that the articulated reasoning enables the Board to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this matter, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); Shinseki v. Sanders, 129 S. Ct. 1696 (2009)(reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination) (2009). Historically, the Veteran served on active duty from September 1968 to September 1970. In September 2007, the Veteran submitted a claim of entitlement to service connection for a disability manifested by stomach or abdominal pain, to include as due to exposure to an herbicidal agent, to also include as secondary to a service-connected disability. After this claim was denied in an April 2008 rating decision, he perfected an appeal to the Board. In February 2013, the Board remanded the Veteran's claim for additional development. Specifically, the Board directed the RO to provide the Veteran a VA examination in order to ascertain the presence of a disability manifested by stomach or abdominal pain and, if present, whether it was etiologically related to his military service, to include as due to exposure to an herbicidal agent, or due to or aggravated by a service-connected disability. Thereafter, the RO was to readjudicate the Veteran's claim. If the benefit sought on appeal was denied, the RO was to issue the Veteran a supplemental statement of the case and afford the Veteran an adequate opportunity to respond, after which his claim was to be remitted to the Board. In April 2013, the Veteran was provided a VA examination in order to determine the presence of a disability manifested by stomach or abdominal pain. As discussed above, the Board finds that the April 2013 VA examination was adequate. Therefore, the Board finds that the RO substantially complied with the Board's February 2013 remand directives and, thus, a remand for corrective action is not required. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the Board will address the merits of the Veteran's claim. Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred during service. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). In order to establish direct service connection for a disorder, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of a disease contracted, an injury suffered, or an event witnessed or experienced in active service; and (3) competent evidence of a nexus or connection between the disease, injury, or event in service and the current disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The salient issue with respect to the Veteran's claim of entitlement to service connection for a disability manifested by stomach or abdominal pain is whether the evidence demonstrated a current diagnosis. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that the requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves); see also Romanowsky v. Shinseki, --- Vet. App. ---, 2013 WL 3455655. An April 1994 private upper gastrointestinal imaging study was administered consequent the Veteran's complaints of chronic sharp and stabbing left periumbilical pain. Ultimately, the impression was focal irregularity at the distal antrum, "possibly" representing scarring; no evidence of gastroesophageal reflux disease or a hiatal hernia; and an unremarkable study of the chest. In April 1995, the Veteran underwent a private abdominal ultrasound based on his complaints of abdominal pain. The study ultimately showed gall stones. The impression was cholelithiasis. Later in April 1995, the Veteran underwent an upper gastrointestinal study for his complaints of abdominal pain. The impression was that the findings were "suggestive" of duodenitis. A June 1995 surgical report indicated that the Veteran's history was significant for recurrent right upper quadrant pain. This report showed that the Veteran underwent laparoscopic cholecystectomy with intra-operative cholangiogram to remove a symptomatic gall bladder. Private hospital reports showed that the Veteran returned in July 1995, with complaints of right upper quadrant pain. Ultimately, it was determined that the Veteran was experiencing an atypical type of pneumonia for which he was given antibiotics. A March 1998 letter from James T. Courtney, M.D., indicated that the Veteran was experiencing upper abdominal discomfort on an intermittent basis, with a history of peptic ulcer disease. Dr. Courtney indicated that the Veteran's symptoms seemed to replicate his pre-cholecystectomy symptoms, but laboratory findings were counter-indicative of a common bile duct stone. After discussing potential courses of treatment, the doctor opined that chronic hepatitis C was not an etiological factor for the Veteran's abdominal pain. In April 1998, the Veteran underwent an esophagogastroduodenoscopy and biopsy consequent to a history of upper abdominal discomfort and a history of peptic ulcer disease. His history was also significant for a cholecystectomy and hepatitis C. The procedure was unremarkable, leading to the conclusion that there was "no explanation" for the Veteran's discomfort. A contemporaneous computed tomography (CT) scan of the Veteran's abdomen was normal. A June 1998 private treatment report showed that the Veteran underwent a colonoscopy. The Veteran complained of mid to upper abdominal pain of an "as yet undetermined etiology." He also complained of blood in his stool. The procedure could not be completed. In July 1998, the Veteran underwent a hepatobiliary scan to address complaints of abdominal pain for possible Sphincter of Oddi dysfunction. Ultimately, the impression was that that there was no scintigraphic evidence for Sphincter of Oddi dysfunction. A July 1998 air contrast barium enema resulted in an impression of a slight redundancy of the colon, but an otherwise unremarkable study. A July 1998 letter from Dr. Courtney indicated that the Veteran reported feeling reasonably well for the previous several weeks, but that he experienced an episode of severe abdominal pain prior to that period. The doctor suggested that the Veteran "may" be experiencing a colonic volvulus, and intermittent cecal volvulus, or a sigmoid volvulus. A repeat barium enema was scheduled. A July 2001 private treatment report showed that the Veteran underwent a colonoscopy and polypectomy. The Veteran complained of abdominal bloating and discomfort with occasional blood in his stool. His past medical history was significant for his gall bladder being surgically removed and a tortuous colon. The impression was single colonic polyp, but the doctor opined that this would not explain the occasional blood in his stool. Further, the "intermittent" abdominal bloating "could" be from the tortuous colon, but "could" be from another etiology. In January 2001, the Veteran was admitted to a hospital with complaints of acute abdominal pain. The admission diagnosis was unknown (represented by a series of question marks). A computed axial tomography (CAT) scan of his abdomen revealed inflammation consistent with pancreatitis. One week later, a second CAT scan revealed that the inflammation had improved. He was discharge from the hospital with no abdominal pain. The discharge diagnoses were acute pancreatitis, lymphadenopathy, hepatitis C, and panniculitis. The Veteran's abdominal pain was not affirmatively associated with any of these diagnoses. An August 2001 private treatment report, primarily concerned with a lesion biopsy, demonstrated that the Veteran experienced chronic hepatitis, "with some abdominal complaints." No definitive diagnosis was rendered in regards to the abdominal complaints. That same month, an upper gastrointestinal study was unremarkable. A January 2002 private hospital report demonstrated that the Veteran complained of progressively worsening abdominal pain associated with acute pancreatitis. Ultimately, the assessment was acute pancreatitis of unknown etiology. According to a September 2002 private treatment report, the Veteran underwent an abdominal ultrasound. The only impression was a note that the Veteran's gall bladder had been surgical removed. A January 2003 private treatment report demonstrated that the Veteran underwent a clinical evaluation. Upon palpation, the Veteran endorsed diffuse abdominal tenderness without a mass being appreciated. The impression was, in part, a more recent development of abdominal pain with an "unclear etiology." Private treatment reports dated later in January 2003 showed that the Veteran underwent a hepatology consultation based on his long-standing hepatitis C. During a physical examination, the Veteran endorsed very mild epigastrium tenderness to palpation. No diagnosis was rendered as to a specific disability manifested stomach or abdominal pain. A contemporaneous treatment report showed that the Veteran complained of a rapid and progressive onset of abdominal pain. After reviewing the Veteran's medical history and administering a clinical examination, the impression was, in relevant part, acute pancreatitis. Later January 2003, the Veteran underwent a spiral CT scan of his chest and abdomen that resulted in findings consistent with inflammation such as pancreatitis. In February 2003, the Veteran underwent a contrast-enhanced CT study of his abdomen as a follow-up for his history of pancreatitis. His liver, spleen, adrenal glands and kidneys were grossly normal. Further, the pancreas did not display any inflammation. Later than month, a private treatment report showed that the Veteran complained of abdominal pain and bloating. The diagnoses were adenopathy, panniculitis, and abdominal pain/bloating. A February 2004 private treatment report showed that the Veteran complained of a 1-month history of abdominal pain. The Veteran stated that as least some of his abdominal pain was attributable to his pancreatitis. Ultimately, separate "diagnoses" of abdominal pain and pancreatitis were rendered. In March 2004, the Veteran complained of abdominal pain. Multiple CAT scan images of the Veteran's abdomen were obtained. Ultimately, the impression was unremarkable study of the pancreas, stable mediastinal and abdominal lymph nodes, and status post cholecystectomy with no identified intrahepatic ductal dilatation. A May 2004 private treatment report demonstrated that the Veteran endorsed a resolution to his abdominal distress. Significantly, he reported "essentially no symptoms" and that he was "feeling well." In June 2004, the Veteran complained of more abdominal pain and bloating. After a brief clinical evaluation, the "diagnosis" was abdominal pain/bloating. According to a May 2005, the Veteran underwent a CT scan of his abdomen and pelvis two days following laparoscopic porta hepatis lymph node biopsy. No specific findings were associated with and no diagnosis was rendered regarding stomach or abdominal pain. Contemporaneous radiological examination of the Veteran's abdomen revealed findings supportive of the impression of a single focal loop of mildly dilated small bowel in the central and mid abdomen and free intraperitoneal air, likely post-surgical. Private treatment reports dated in April 2003, May 2003, August 2004, October 2004, June 2005, and August 2005 included clinical evaluation of the Veteran's abdomen. On each occasion, the Veteran did not endorse the presence of stomach or abdominal pain. A February 2006, the Veteran appeared for a re-evaluation of various symptoms, including occasional episodes of abdominal pain and cramps. After a clinical evaluation, the "diagnosis" was abdominal pain. A June 2008 letter from a private doctor, Michael Kizy, M.D., indicated that the Veteran experienced recurrent issue with "unexplained stomach pains." In April 2013, the Veteran underwent a VA examination in order to ascertain the presence of a disability manifested by stomach or abdominal pain. After a thorough review of the relevant evidence of record and a clinical evaluation, the rendered a "diagnosis" of non-specific recurrent mid abdominal pain by history, but no objective clinical findings. The examiner then opined as follows: [The] Veteran's military service medical records does not reveal no chronic recurrent mid abdominal pain. Separation Examination revealed no recurrent mid abdominal pain. As well as civilian medical records immediately after [the] Veteran left the active [duty]. Nonspecific recurrent mid abdominal pain is not included in the list of medical conditions related to previous exposure to herbicide in Vietnam service. Nonspecific recurrent mid abdominal pain is not caused or aggravated by the Veteran's service connected disabilities including posttraumatic stress disorder, bilateral hearing loss, bilateral tinnitus, and hepatitis C. In a May 2013 statement, the Veteran asserted that he experienced "stomach issues" during his active duty service in the Republic of Vietnam. Further, in his September 2007 claim, the Veteran asserted that he experienced stomach or abdominal pain since 1970. Preliminarily, the Board observes that service connection for hepatitis C has already been granted. Thus, stomach or abdominal pain associated with the Veteran's service-connected hepatitis C is contemplated in the rating assigned to the Veteran's hepatitis C. Consequently, a separate disability rating will not be assigned for stomach or abdominal pain associated with hepatitis C. 38 C.F.R. § 4.14 (2012). The evidence of record demonstrated that the Veteran was treated for stomach or abdominal pain on numerous occasions since April 1994. Prior to January 2003, the evidence demonstrated that the Veteran's stomach or abdominal pain was tenuously associated with a variety of disabilities or was associated with disabilities that resolved consequent to treatment. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (holding that medical opinions couched in terms of "may" or "possible" are too speculative to establish service connection). Regardless, even if this evidence established a definitive diagnosis, the Board finds that this evidence is not sufficiently proximate to the filing of the Veteran's September 2007 claim so as to constitute evidence of a current diagnosis. Romanowsky, --- Vet. App. ---, at FN 3; see Elkins v. Gober, 229 F.3d 1369, 1377 (Fed. Cir. 2000). From January 2003 to August 2005, the Veteran's abdominal pain was as least partially attributed to episodes of acute pancreatitis. Evidence dated during this period of time demonstrated that the Veteran's pancreatitis subsequently resolved. Additionally, evidence dated during this period showed that the Veteran did not endorse stomach or abdominal pain during several clinical evaluations and specifically denied stomach or abdominal pain on one occasion. This evidence also included an opinion that the Veteran's stomach or abdominal pain was of an unclear etiology. Consequently, the Board finds that this evidence is not supportive of finding the current presence of a disability manifested by stomach or abdominal pain, or that a disability manifested by stomach or abdominal pain was present at some point during the pendency of this appeal. Id. In making this determination, the Board acknowledges the presence of the May 2005 CT findings. As discussed above, the CT findings resulted in an impression of a single focal loop of mildly dilated small bowel in the central and mid abdomen and free intraperitoneal air. These findings were obtained two days after the Veteran underwent laparoscopic porta hepatis lymph node biopsy. The rendered impression was deemed to be "likely" related to that surgery. The evidence dated after May 2005 did not demonstrate additional treatment for or diagnosis of a single focal loop of mildly dilated small bowel in the central and mid abdomen and free intraperitoneal air. Consequently, the Board finds that this evidence does not support finding the current presence of a disability manifested by stomach or abdominal pain, or that a disability manifested by stomach or abdominal pain was present at some point during the pendency of this appeal. Id. The evidence of record dated after August 2005 showed that the Veteran continued to complain of and receive treatment for stomach or abdominal pain. However, there were only two instances after August 2005 wherein a medical professional attempted to identify a disability manifested by stomach or abdominal pain. In the June 2008 letter, Dr. Kizy described the Veteran's claimed disability as "unexplained stomach pain." Further, the April 2013 VA examiner determined that the Veteran experienced non-specific recurrent mid abdominal pain by history, but that there were no objective clinical findings of an underlying disability. First, in this, and in other cases, only competent evidence may be considered to support Board findings. The Board is not free to substitute its own judgment for that of an expert. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Both Dr. Kizy and the April 2013 VA examiner rendered opinions that were negative to the Veteran's claim in that no current diagnosis of a disability manifested by stomach or abdominal pain could be rendered. The Board finds that these opinions are highly probative. Second, pain, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a "disability" for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999) vacated in part and remanded on other grounds sub nom., Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Based on the above, the Board finds that the evidence of record does not include a current diagnosis of a disability manifested by stomach or abdominal pain. McClain, 21 Vet. App. at 321; Romanowsky, --- Vet. App. ---, 2013 WL 3455655. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current 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). Absent adequate medical evidence reflecting the current presence of the claimed disability, a basis upon which to establish service connection for a disability manifested by stomach or abdominal pain has not been presented and the appeal must be denied. To the extent that the Veteran asserts that he has a disability manifested by stomach or abdominal pain, the Board finds that diagnostic opinions are more suited to the realm of medical, rather than lay expertise. Determining whether a disability manifested by stomach or abdominal pain is present is too complex for a layperson to proffer a competent opinion, especially in the presence of other disabilities. The evidence of record does not demonstrate that the Veteran possesses the ability, knowledge, or experience to provide competent diagnostic opinions. Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). Consequently, lay assertions of a diagnosis cannot constitute evidence upon which to grant the claim for service connection. Lathan v. Brown, 7 Vet. App. 359, 365 (1995). As the preponderance of the evidence is against finding a current diagnosis of a disability manifested by stomach or abdominal pain, the benefit-of-the-doubt rule does not apply. Accordingly, service connection for a prostate disorder is not warranted. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a disability manifested by stomach or abdominal pain, to include as due to exposure to an herbicidal agent, to also include as secondary to a service-connected disability, is denied. REMAND In February 2013, the Board remanded the Veteran's claim of entitlement to service connection for lymphoma for additional development. Specifically, the Board requested that the RO provide the Veteran a VA examination in order to ascertain the presence of lymphoma and whether it was incurred in or due to his active duty, to include his presumed exposure to an herbicidal agent and/or was due to or aggravated by a service-connected disability. In April 2013, the Veteran underwent a VA examination. The examiner indicated that the Veteran did not now have nor had he ever been diagnosed with a hematologic or lymphatic condition. Ultimately, the examiner opined as follows: [The] Veteran's military service medical records does not reveal no lymphoma or lymphadenopathy. Separation Examination revealed no lymphoma or lymphadenopathy. As well as civilian medical records immediately after [the] Veteran left the active [duty]. Nonspecific Lymphadenopathy is not included in the list of medical conditions related to previous exposure to herbicide in Vietnam service. Nonspecific Lymphadenopathy is not caused or aggravated by the Veteran's service connected disabilities including posttraumatic stress disorder, bilateral hearing loss, bilateral tinnitus, and hepatitis C. As discussed in the previous remand, the evidence of record included a variety of treatment reports indicating a history lymphoma and lymphadenopathy. The April 2013 VA examiner did not reconcile this evidence with the opinion that the Veteran did not now have nor had he ever been diagnosed with lymphoma and lymphadenopathy. Nieves-Rodriguez, 22 Vet. App. at 304; see Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding that medical opinions based on incomplete or inaccurate factual premise are not probative). Further, the examiner's opinion regarding the Veteran's inservice exposure to an herbicidal agent was limited to a recitation of whether presumptive service connection was available for lymphoma based on that exposure. The examiner did not provide an opinion as to whether the Veteran's lymphoma was etiologically related to his inservice exposure to an herbicidal agent. Additionally, with respect to the opinion regarding aggravation by a service-connected disability, examiner provided no underlying rationale for the conclusion reached. Id. Based on the above, the Board finds that the April 2013 VA examination was inadequate for purposes of adjudicating the Veteran's claim. Once VA undertakes the effort to provide an examination, it must provide an adequate one or, at a minimum, notify the veteran why one will not or cannot be provided. Barr, 21 Vet. App. at 311. As such, the Board finds that a remand is required in order to obtain to afford the Veteran another examination. Accordingly, the case is REMANDED for the following action: 1. The RO should schedule the Veteran for a VA examination. The claims file must be made available to the examiner in conjunction with the examination. All indicated tests and studies must be accomplished. The examiner must ascertain whether the Veteran has lymphoma or any other disability manifested by lymphadenopathy. In so doing, the examiner must reconcile any negative opinion rendered with the evidence of record that demonstrates the presence of and treatment for lymphoma/lymphadenopathy. If lymphoma (or any other disability manifested by lymphadenopathy) is present, the examiner is then requested to offer an opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's lymphoma (or any other disorder manifested by lymphadenopathy) is related to his military service, to include as due to exposure to herbicide. In so doing, the examiner should specifically comment on the Veteran's presumed exposure to herbicide. If the Veteran's current lymphoma (or any other disability manifested by lymphadenopathy) is determined to not be directly related to service, then the examiner is requested to offer an opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's lymphoma (or any other disorder manifested by lymphadenopathy) was caused or aggravated by a service-connected disability. The Veteran's service connected disabilities are posttraumatic stress disorder, bilateral hearing loss, bilateral tinnitus, and hepatitis C. Aggravation is defined as a permanent worsening beyond the natural progression of the disease or disability. The term at least 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. More likely and as likely support the contended causal relationship; less likely weighs against the claim. A complete rationale must be provided for any opinion offered. 2. The RO must notify the Veteran that it is his responsibility to report for the examination and to cooperate in the development of his claim. The consequences for failure to report for a VA examination without good cause may include denial of the relevant claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 3. Once the above actions have been completed, the RO must re-adjudicate the Veteran's claim on appeal, to include consideration of all relevant evidence of record. If any benefit remains denied, a supplemental statement of the case must be provided to the Veteran. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter 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 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). _________________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs