Citation Nr: 1330858 Decision Date: 09/25/13 Archive Date: 09/30/13 DOCKET NO. 08-39 776 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus. 2. Entitlement to service connection for a neurological disorder of the upper extremities, to include as secondary to service-connected diabetes mellitus. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for tinnitus. 5. Entitlement to service connection for a brain tumor, to include as due to herbicide exposure. 6. Entitlement to service connection for irritable bowel syndrome, to include as secondary to service-connected posttraumatic stress disorder (PTSD). 7. Entitlement to an initial evaluation in excess of 30 percent for PTSD. 8. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Rebecca Feinberg, Counsel INTRODUCTION The Veteran served on active duty from January 1966 to January 1968. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from April 2008, December 2008, August 2009, and January 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. The April 2008 rating decision denied service connection for bilateral hearing loss, tinnitus, and irritable bowel syndrome, but granted service connection for PTSD and assigned a 10 percent disability evaluation effective from October 9, 2007. The December 2008 rating decision denied service connection for hypertension, and the August 2009 rating decision denied service connection for a brain tumor. The January 2010 rating decision also denied service connection for peripheral neuropathy of the upper extremities. During the pendency of the appeal, the RO issued a statement of the case in November 2008 in which the disability evaluation for PTSD was increased to 30 percent effective from October 9, 2007. However, applicable law mandates that when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). The Board has also recharcterized the claim for service connection for peripheral neuropathy of the upper extremities to include all neurological disorders in order to allow for consideration of other potential diagnoses. Clemons v. Shinseki, 23 Vet. App. 1 (2009). A hearing was held on January 11, 2011, in Wichita, Kansas, before the undersigned Veterans Law Judge. A transcript of the hearing is in the claims file. A review of the Veteran's virtual VA claims files shows that they include some relevant evidence not also contained in the paper claims file. However, this evidence was considered by the RO prior to the issuance of the November 2012 supplemental statement of the case and by the Board prior to rendering this decision. The Board previously remanded the case in March 2011. As will be discussed in more detail below, there has been compliance with those remand directives regarding the claims denied herein. Stegall v. West, 11 Vet. App. 268 (1998). The issues of entitlement to service connection for hypertension, bilateral hearing loss, and tinnitus and entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A neurological disorder of the upper extremities did not manifest during service or for many years thereafter and has not been shown to be related to his military service, herbicide exposure, or service-connected diabetes mellitus. 2. A brain tumor did not manifest during service or for many years thereafter and has not been shown to be related to service, including herbicide exposure. 3. The Veteran currently has irritable bowel syndrome that is related to his service-connected PTSD. 4. The Veteran's PTSD is productive of occupational and social impairment with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The disability is also not manifested by total occupational and social impairment. CONCLUSIONS OF LAW 1. A neurological disorder of the upper extremities was not incurred in active service, may not be presumed to have been so incurred, is not due to herbicide exposure in service, and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 1154 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013). 2. A brain tumor was not incurred in active service, may not be presumed to have been so incurred, and is not due to herbicide exposure in service. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 1154 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 3. Resolving all reasonable doubt in favor of the Veteran, irritable bowel syndrome is proximately due to or the result of his service-connected diabetes mellitus. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2013). 4. The criteria for an initial 50 percent evaluation for PTSD, but no higher, have been met. 38 U.S.C.A. § 1155 (West 2002 2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim 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) (2013). With regard to the Veteran's claim of entitlement to service connection for IBS, this claim is granted in full herein, and no discussion of the duties to notify or assist with regard to this claim is necessary. Proper notice from VA must inform the claimant 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 claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice should be provided prior to an initial unfavorable RO decision on a claim. 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 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. 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). The Veteran was provided all required VCAA notice in a letter dated in November 2007 regarding his PTSD and peripheral neuropathy claims. These claims were thereafter initially adjudicated in April 2008 and December 2008. He was also provided all required VCAA notice in a letter dated in July 2009 regarding his brain tumor claim, which was initially adjudicated in August 2009. Similarly, in August 2009, the RO provided all required notice regarding peripheral neuropathy on a secondary basis, which was initially adjudicated in January 2010. The Board also notes that the Veteran's claim of entitlement to a higher rating for PTSD arises from the Veteran's disagreement with the rating assigned in connection with the grant of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007); VAOPGCPREC 8-2003 (2003). The Court has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as a disability rating) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105 (West 2002). Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). Consequently, further discussion of the VCAA's notification requirements with regard to this claim is unnecessary. The VCAA also requires VA to make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claims for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The record reflects that all pertinent available service treatment records (STRs) and all available post-service medical evidence identified by the Veteran relative to the claims decided herein have been obtained, to include records from the Social Security Administration. The Veteran's written and oral statements are also of record. Neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate the claims. The Board is also unaware of any such evidence. In addition, the Veteran was afforded appropriate VA examinations with medical opinions in connection with his claims of entitlement to service connection for a neurological disorder and a brain tumor. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). He was also provided numerous examinations evaluating the severity of his PTSD, which addressed the necessary rating criteria. The Board finds that the examinations were adequate, in that they were conducted by a medical professional who reviewed the claims file, solicited history from the Veteran, and performed a thorough examination. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board also finds that the RO has complied with the Board's March 2011 remand directives. Specifically, the Veteran's VA outpatient treatment records were obtained and associated with the claims file, and his Social Security Administrations records were also secured. In addition, he was afforded VA examinations that contained opinions regarding his brain tumor that were compliant with the remand directives. As such, with regard to the disabilities decided herein, no further development is necessary. Stegall v. West, 11 Vet. App. 268, 271 (1998). Moreover, as previously noted, the Veteran was afforded an opportunity to present testimony at hearings before the RO and the Board during the course of this appeal. In Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010), the Court held that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with 38 C.F.R. § 3.103(c)(2). These duties consist of (1) fully explaining the issues pertinent to the claim(s) on appeal; and (2) suggesting the submission of evidence that may have been overlooked. See also 38 C.F.R. § 3.103(c)(2). In this case, the undersigned Veterans Law Judge set forth the issues to be discussed and sought to identify pertinent evidence not currently associated with the claims folder. The hearing focused on the elements necessary to substantiate the claims and the Veteran, through his testimony and questioning by his representative, demonstrated his actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that VA complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). In summary, the Board finds that VA has complied with its duty to assist the Veteran. Based on the foregoing, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. Bernard v. Brown, 4 Vet. App. 384 (1993). II. Service Connection The Veteran's DD Form 214 shows that his specialty in service was light weapons infantry. He received sharpshooter (pistol) and expert (machinegun, rifle) badges and the Combat Infantryman Badge. His service in combat is therefore verified. As such, to the extent that he contends that any of his claimed disabilities were incurred in combat service, the provisions of 38 U.S.C.A. § 1154(b) are applicable. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including tumors of the brain, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As tumors of the brain are considered to be chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). In addition, VA laws and regulations provide that, if a Veteran was exposed to Agent Orange during service, certain listed diseases are presumptively service-connected. 38 U.S.C.A. § 1116(a)(1); 38 C.F.R. § 3.309(e) (2013). This includes early-onset peripheral neuropathy. The evidence of record shows that the Veteran served in Vietnam during the Vietnam era. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2013); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. A. Peripheral Neuropathy of the Upper Extremities The Veteran's service treatment records are negative for any complaints, treatment, or diagnosis of a neurological disorder. When he was examined in November 1967 prior to his discharge from service, his upper extremities were normal, and the Veteran denied any history of neuritis. In October 2007, the Veteran underwent a VA Agent Orange protocol examination. He reported having paresthesias that affected the bilateral tips of his fingers. During a February 2008 VA examination for diabetes mellitus, it was noted that the Veteran had paresthesias that involved cramping of the bilateral hands that was related to his diabetes. He indicated that the symptoms began in 2006. However, a neurologic examination of the upper extremities was normal. A July 2008 VA outpatient treatment record shows that the Veteran complained of numbness and cramping of both hands for the past two years. It was noted that that his cramping lasted for a few minutes and subsided with massaging. Following an evaluation, the assessment was made that following disorders had to be ruled out: early amyotrophic lateral sclerosis, bilateral carpal tunnel syndrome, and sensory peripheral polyneuropathy. A July 2008 VA report of an EMG revealed ulnar neuropathy at the elbow on both sides. An August 2008 VA outpatient record also shows that there was evidence of mild underlying peripheral neuropathy. An October 2008 VA record indicates that the Veteran's muscle cramping gradually subsided with Dilantin. There had been no recurrent muscle cramping for the past two months. The assessment was bilateral ulnar neuropathy and muscle cramping. In July 2010, the Veteran underwent a VA examination at which time he described cramping, itching, and tingling in his hands that had an onset in the same year as his diagnosis of diabetes mellitus. He had been put on Dilantin, but was unaware of any seizures. He also indicated that he had been told that he had possible peripheral neuropathy. Reflex, sensory, and motor tests were conducted, and nerve conduction studies were performed. Following an evaluation, the impression was that the left upper extremity showed evidence of a mild to moderate degree of ulnar nerve entrapment across the elbow, but there was no evidence of neuropathy in the left arm. The impression was a mild right ulnar nerve entrapment in the region of the elbow and a mild right median nerve entrapment in the region of the wrist. There was no other clear evidence of focal neuropathy, plexopathy, or radiculopathy. The examiner noted that the Veteran had retired due to age, eligibility, and medical problems, which included both physical and psychiatric problems. The pertinent diagnosis was mild to moderate ulnar nerve entrapment at the elbows bilaterally, which was unrelated to his type II diabetes mellitus. Instead, the noted etiology was his occupation and years of wear and tear. The examiner explained that this was a very common finding in years of operative equipment and driving a large truck, such as the Veteran did for 34 years. In January 2011, the Veteran testified before the undersigned Veterans Law Judge that he first noticed symptoms in his upper extremities around the time he was diagnosed as having diabetes mellitus. In March 2012, the Veteran underwent another VA examination at which time he described symptoms that began four to five years ago. He indicated that he had numbness and tingling in his hands and fingers. Upon examination, strength, reflex, light touch, position sense, and vibration sense testing was also normal. The Veteran did not have upper extremity diabetic peripheral neuropathy, and the examiner indicated that the findings of mild to moderate carpal tunnel syndrome bilaterally and severe cubital tunnel syndrome (ulnar neuropathy) are not related to, caused by, or aggravated by his diabetes mellitus. Instead, the examiner believed that it was due to occupational years of wear and tear, as well as aging, which was a very common finding in years of operating equipment and driving large trucks. He noted that risk factors included smoking, educational level, and work experience. In contrast, gender, body mass index, alcohol consumption, elbow trauma, diabetes, and hypertension were not risk factors. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection for a neurological disorder of the upper extremities is not warranted. First, the Board finds that the evidence supports diagnoses of ulnar neuropathy at the elbows and ulnar and median nerve entrapment, but not peripheral neuropathy. There is one record dated in August 2008 that indicates that there is evidence of mild underlying peripheral neuropathy. However, subsequent medical evidence that includes full neurological testing specifically indicated that peripheral neuropathy is not present. The Board finds that the VA examination reports, based on the comprehensive testing, are more probative than the August 2008 VA outpatient record on the matter of diagnosis. Furthermore, while a layperson is often competent to provide opinions on the medical matters of diagnosis and etiology, Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007), the Board finds that the opinions of medical professionals are more probative than those of the Veteran. Specifically, the opinions provided in the July 2010 and March 2012 VA examination reports are from medical professionals with specialized education, training, and experience. The Veteran has not been shown to have such expertise. The opinions provided by the VA examiners demonstrated that specialized testing was conducted to determine the appropriate diagnosis. The examiners also provided rationales for the conclusions reached that were based upon accurate recitations of the facts contained in the claims file. The rationales both indicated that the Veteran's post-service work experience with machinery and trucks caused his ulnar neuropathy. The reports show definitively that diabetic peripheral neuropathy is not present and indicate that the ulnar neuropathy and carpal tunnel syndrome that are present are not related to, caused by, or aggravated by the Veteran's service-connected diabetes mellitus. The opinions are comprehensive and supported by rationales consistent with the record. There is no other lay or medical evidence that suggests that any currently diagnosed neurological disorder is otherwise related to the Veteran's service. In addition, there is no lay or medical evidence suggesting that the Veteran has ever been shown to have early-onset peripheral neuropathy. In this regard, there is no evidence showing that peripheral neuropathy manifest to a degree of 10 percent or more within one year after the date of last exposure to herbicides. Indeed, the Veteran has not contended, nor has the evidence shown, that his disorder or symptoms thereof manifested in during service or within one year thereafter. Rather, there was a decades-long evidentiary gap between his military service and his first complaints. He has actually reported that the first symptoms began in 2006. Moreover, as discussed above, the more probative evidence indicates that the Veteran does not even have a diagnosis of peripheral neuropathy. As such, presumptive service connection on the basis of his service in Vietnam during the Vietnam era is not warranted. 38 C.F.R. §§ 3.307, 3.309. Lastly, the Board notes that there is no other event, disease, or injury in service to which the Veteran's current neurological disorder could be related. Indeed, as previously discussed, his service treatment records are entirely negative for any pertinent findings, and there is no evidence of any disability until many decades after his military service. Based on the foregoing, the Board concludes that the preponderance of the evidence is against a finding that the Veteran has a current neurological disorder that is related to his military service, including his herbicide exposure therein, or that is secondary to his service-connected diabetes mellitus. Accordingly, service connection is not warranted for a neurological disorder. B. Brain Tumor The Veteran's service treatment records are negative for any complaints, treatment, or diagnosis of a brain tumor. When he was examined in November 1967 prior to his discharge, the Veteran's head was normal. He also denied having a history of frequent or severe headaches at that time. In October 2007, the Veteran underwent a VA Agent Orange protocol examination during which he denied a history of chronic or recurrent headaches. A March 2009 scan of the brain revealed a mass present in the lateral ventricle on the right side. A May 2009 VA outpatient record shows that the Veteran had a nonenhancing lesion in the right lateral ventricle consistent with a subepedymal growth. It was not believed to be a malignancy. A June 2009 VA treatment record shows that the Veteran's headaches had improved, and a scan showed no change in the size of his tumor compared to one in March. The neurosurgeon believed that it was a benign tumor and had probably been present for a while. The Veteran told the physician of his exposure to Agent Orange and the death of his child from birth defects. In the examiner's opinion, the current tumor probably had some relationship thereto, but he could not determine how much. In October 2009, the Veteran testified before the RO that his doctor told him that his brain tumor may be related to Agent Orange exposure. He had headaches that he believed were related to this tumor for two years. In January 2011, the Veteran testified before the undersigned that he was first diagnosed with a brain tumor in 2009 after complaining of headaches. In March 2012, the Veteran underwent another VA examination during which the diagnosis of a benign glioma or blial brain tumor (consistent with subependymoma) from 2009 was noted. The examiner opined that the brain tumor was less likely as not caused by or a result of herbicide exposure. It was noted that the low grade glioma was not a presumptive condition correlated to Agent Orange exposure. The examiner also referenced medical literature indicating that the etiological factors responsible for the development of ependymoma were not known. Many were sporadic and idiopathic. Based on a review of the record, the Board finds that service connection for a brain tumor must be denied. The Veteran has not contended, nor does the evidence show, that the brain tumor manifested in service or for many decades thereafter. There is also no evidence of any disease, injury, or event to which a current disorder could be related other than herbicide exposure. Thus, the Board concludes that the Veteran is not entitled to service connection on a direct basis. In this same vein, the Board finds that a chronic tumor was not "noted" in service. Furthermore, the Veteran has not contended that it or the symptomatology that he associates with his brain tumor began during service or continued since then. Rather, the Veteran has stated that his headaches began approximately two years prior to the diagnosis of his brain tumor in 2009. Therefore, service connection on a chronic basis under the provisions of 38 C.F.R. § 3.303(b) is not warranted. Moreover, there are three opinions of record that address whether the tumor is related to service, particularly exposure to herbicides. These opinions are those of the Veteran, the physician that treated him in June 2009, and the VA examiner who rendered the March 2012 opinion. First, the Board finds that the Veteran's opinion, while it might be competent, is less probative than the opinions provided by medical professionals. As noted above, laypersons are often competent to provide opinions on medical matters such as etiology. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the opinions provided by medical professionals, who have specific training and expertise, are more probative than the Veteran's lay assertions. Therefore, the Veteran's opinion is less probative than either opinion provided by the VA medical professionals. Between the opinions provided in June 2009 and March 2012, the Board finds that the March 2012 opinion is more probative. The opinion provided in June 2009 is qualified and somewhat speculative, as the physician indicated that the tumor was "probably" related, but he admitted that he did not know to what extent. The Board notes that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. See e.g. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (finding doctor's opinion that "it is possible: and "it is within the realm of medical possibility" too speculative to establish medical nexus); Goss v. Brown, 9 Vet. App. 109, 114 (1996) (using the word "could not rule out" was too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (medical opinion framed in terms of "may or may not" is speculative and insufficient to support an award of service connection for the cause of death); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (physician's statement that the veteran "may have been having some symptoms of his multiple sclerosis for many years prior to the date of diagnosis" was insufficient to award service connection); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (a generic statement about the possibility of a link between chest trauma and restrictive lung disease was "too general and inconclusive" to support an award of service connection). Applicable regulations also provide that a finding of service connection may not be based on a resort to speculation or a remote possibility. See 38 C.F.R. § 3.102 (2013). Conversely, the March 2012 VA examiner stated definitively that the tumor, or ependymoma, was not related to Agent Orange exposure and provided a rationale for his opinion. The Board notes that the March 2012 VA examiner indicated as part of the rationale that the tumor was not a disability presumptively related to Agent Orange exposure. The Board finds that this rationale is, on its own, an inadequate basis. A veteran may establish service connection for a disability as related to exposure to herbicides, even if the disability is not presumptive. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). However, the VA examiner provided an additional rationale for his conclusion that includes specific reference to medical literature showing that the etiology of tumors such as the Veteran's is unknown, as many are sporadic and idiopathic. This rationale alone is sufficient to support the conclusion provided by the VA examiner, even separate from the other rationale. This opinion is also the only definitive one of record provided by a medical professional with a rationale. For all of these reasons, the Board finds that the opinion provided in March 2012 by the VA examiner is the most probative contained in the claims file on the question of whether the Veteran's brain tumor is related to exposure to herbicides during his military service. There is no lay or medical evidence suggesting that the Veteran's brain tumor is otherwise related to service. Accordingly, the Board finds that a preponderance of the evidence is against the claim for service connection for a brain tumor. C. Irritable Bowel Syndrome (IBS) In October 2007, the Veteran underwent VA Agent Orange protocol examination, and the Veteran's wife reported that he had frequent diarrhea. Private medical records dated in November 2007 and December 2007 documented a diagnosis of IBS. The Veteran complained of symptomatology for a number of years. In a May 2008 written statement, the Veteran asserted that panic attacks associated with PTSD caused his IBS. An August 2008 private treatment record of testing shows diagnoses of chronic gastritis and ulcers. In September 2008, the Veteran testified before the RO that his IBS was related to his PTSD and the stress he had since service. A January 2009 VA outpatient record documents an assessment of IBS for which the physician notes there is no relationship to military service. The Veteran was advised to eat a low fat diet, watch his stress levels, and continue medication for stomach acid. It was noted that weight loss would also help. The Veteran indicated during his September 2010 VA psychiatric examination that, when he got upset due to his PTSD, he experienced diarrhea. In January 2011, the Veteran testified that he first had problems with his symptoms in Vietnam. He also indicated that it continued when he returned home. In March 2012, the Veteran underwent VA examination at which time it was noted that a diagnosis of moderately severe diverticulosis was noted to have rendered in 2008. The Veteran complained of diarrhea for a few years and indicated that he had episodes up to eight times per week. He noted that it was not related to what he ate and that, at times, he was fine for a few weeks. The Veteran's claims file was reviewed, and the examiner concluded that the Veteran did not have IBS. He had moderately severe diverticulosis found on sigmoidoscopy in August 2008, which was not secondary to his PTSD or Agent Orange exposure. Risk factors included a westernized lifestyle that included low dietary fiber, lack of exercise, and obesity as predispositions. In a May 2012 addendum opinion, a VA examiner indicated that clinical manifestations of diverticulosis included cramping, bloating, flatulence, and irregular defecation. These same symptoms were also present in IBS. However, the Veteran had moderate to severe diverticulosis of the left colon and a symptom of diarrhea at night, which is a symptom atypical of IBS. Therefore, the weight of the evidence shows his clinical signs are most likely related to his diverticulosis rather than IBS related to PTSD. A May 2012 outpatient record shows that the Veteran did not have diarrhea at night. Instead, if he got up to urinate at night, he had some flatus and sometimes loose stools while sitting on the toilet to urinate. Following an examination, the assessment was chronic diarrhea that was most likely due to IBS related to PTSD. The physician disagreed with the VA examination that determined that the Veteran did not have IBS. In so doing, the physician noted that diverticulosis was not associated with diarrhea and did not preclude IBS, which was a functional diagnosis. It was noted that the Veteran did not wake up at night due to diarrhea and that the sometimes loose stools he experienced when waking up to urinate were not contradictory to his IBS. The assessment also included diverticulosis, which the physician believed was not the cause of the Veteran's diarrhea. In a May 2013 written statement, the Veteran's VA physician opined that the Veteran had long-standing chronic diarrhea since he returned from Vietnam. Again, the physician took issue with the VA examiner's opinion in regards to nighttime diarrhea and her misquoting information from a website. The quote that was left out indicated that it was unclear whether symptoms, such as cramping, bloating, flatulence, and irregular defecation, were attributable to underlying diverticulosis or to coexistent IBS. The Veteran's physician believed that the Veteran's symptoms were due to IBS that was secondary to his PTSD. Based on the evidence of record, the Board finds that service connection for IBS, as secondary to the service-connected PTSD, should be granted. There are several opinions of record concerning the etiology and diagnosis. The Board finds that, on both matters, the opinions provided by the Veteran's physician in May 2012 and May 2013, which are supportive of his claim, are at least as probative as the opinions provided by a VA examiner in March 2012 and May 2012 that weigh against his claim. The May 2012 and May 2013 opinions are competent, reasoned, definitive, and contain an accurate recitation of the evidence of record. Therefore, the Board concludes that the evidence in favor of the Veteran's claim is at least as probative as the evidence against his claim. As such, the benefit-of-the-doubt rule is applicable, and the claim for service connection for IBS is granted. III. Increased Rating for PTSD The Veteran is in receipt of a 30 percent rating for PTSD pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. This Diagnostic Code addresses PTSD. However, all psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under the general rating formula, a 30 percent rating requires a showing of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such an unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. A total schedular rating of 100 percent is warranted when the disorder results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443. Furthermore, the rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). When the symptoms attributable to a service-connected disability cannot be separated from those attributable to a non-service-connected disability, all symptomatology should be considered in determining the appropriate rating, and that has been done here. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (when it is not possible to separate the effects of the service-connected and non-service-connected disabilities, the benefit of the doubt doctrine described in 38 C.F.R. § 3.102 dictates that such signs and symptoms be attributed to the service-connected disability or disabilities). The GAF (Global Assessment of Functioning) scale reflects psychological, social, and occupational functioning of a hypothetical continuum of mental health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). A GAF score of 41-50 denotes serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51-60 denotes moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61-70 indicates mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. See Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, DC, American Psychiatric Association, 1994. In this case, a November 2007 VA outpatient record shows that the Veteran was cooperative and appropriately dressed. His eye contact was good, and there were no unusual movements or mannerisms, although his posturing was somewhat tense. His speech was also spontaneous and relevant, and his mood was slightly depressed, although his affect was congruent. The Veteran's form of thought showed his responses to be relevant and coherent. There was no evidence of obsessions, compulsions, suicidal thoughts, delusions, or hallucinations. His memory was grossly intact, and his insight and judgment were fair. A GAF score of 60 was assigned. In February 2008, the Veteran underwent a VA examination at which time he reported experiencing intrusive thoughts, nightmares, fighting in his sleep, cold sweats, prominent guilt, and self-blame. He also reported having an exaggerated startle response and being unable to tolerate anything involving a surprise. His coworkers found it humorous to startle him or make loud noises behind him. As a result, he had punched them on occasion out of surprise. His symptoms were daily and constant, and he described them as severe. He denied current suicidality. The Veteran reported an incident about a year ago when he lost control during an argument with his son with whom he had difficulty being close. They had an altercation resulting in police intervention. He felt badly about this incident and indicated that it was his only legal difficulty. The Veteran has been married since July 1965 and reported much strain on his marital relationship as a result of his PTSD. They had four children, two of which were still living with them. He occasionally played pool, and he and his wife used to attend church until an incident that killed their daughter. He previously enjoyed hunting ducks and geese, but had only been one time that season and two times the previous season. In the past, the Veteran had been quite active. He currently received outpatient care and denied any history of inpatient care. Since his separation from service, the Veteran had only two places of employment and had been currently employed for many years. He was able to work alone for the most part and avoid other people. On examination, the Veteran was appropriately dressed and cooperative. He reported having difficulty with his thought processes, a continual stream of intrusive thoughts, and severe guilt related to traumas in Vietnam. His communication was generally understandable. The Veteran denied auditory or visual hallucinations, and no overt delusions were apparent. He endorsed experiencing occasional suicidal thoughts, although he had no intent to act on the thoughts. He also denied any homicidal ideas, thoughts, plans, or intentions. It was noted that he could accomplish basic activities of daily living without requiring assistance. The Veteran was oriented and demonstrated an appropriate understanding of the purpose of the examination. He reported having short-term memory difficulties, centered around problems in attention, concentration, focusing, and comprehension. He acknowledged that some of this may be related to his hearing loss, and his long-term memory appeared to be intact. The Veteran denied ritualistic behavior, and his speech was normal. He also denied panic attacks, but reported a full range of depressive symptoms and evidenced clinically significant anxiety. He reported some impulse-control difficulty and sleep difficulty. The diagnoses were PTSD, chronic, severe, and major depressive disorder, recurrent, moderate. It was noted that they had a common etiology and clearly were caused by the traumas incurred during service. The GAF score was 58. While the Veteran was employed full time, it was noted that this was due to his being able to work alone for a majority of the day. His overall symptoms were in the severe range. In a May 2008 written statement, the Veteran asserted that he had panic attacks. A Social Security Administration (SSA) determination shows that the Veteran was found to have become disabled on June 1, 2008. The primary diagnosis was neuropathy of both hands, and the secondary diagnosis was PTSD. The remainder of the Veteran's SSA records are largely duplicative of records already associated with his claims file. To the extent that they are different, they show symptomatology that is consistent with that shown in the VA and private evidence of record. In a June 2008 written statement, a coworker of the Veteran indicated that he had witnessed the Veteran's focus and concentration while operating equipment deteriorate. He decided to retire before his excellent work record was tarnished. In September 2008, the Veteran testified before the RO and described becoming physical towards his wife during a previous fight. He had also broken things during arguments. However, these things had happened in the past. During the last year, he thought of ending his marriage during fights, but knew it was not the answer and had not said this to his wife. He quit his job recently due to stress, anxiety, and depression. Because of his medication, he was not able to concentrate and almost injured other workers. In the last year, his relationships with his children had gotten better, and he had a good relationship with his youngest son. The altercation with his older son happened in August 2006. He could count his real good friends on one hand. A November 2008 VA record shows that the Veteran demonstrated symptoms of a restricted range of affect and avoidance behavior, along with symptoms previously reported. On examination, his clothing and grooming were appropriate, and he was cooperative and oriented. His behavior activity and speech were within normal limits. The Veteran's mood was dysphoric and serious, but his affect was full range. His thought processes and content were intact and adequate. He acknowledged occasional suicidal thoughts with some specificity of plan, but any denied intention, and there was no history of attempts. He also denied homicidal thoughts. The Veteran's insight, judgment, and impulse control were adequate or good. The GAF score was 55/65. A June 2009 VA outpatient report shows that the Veteran demonstrated increased symptoms of PTSD most likely secondary to ongoing therapeutic interventions. He had no suicidal ideations. In an October 2009 written statement, the Veteran's wife described his short-term memory loss and irritability. During a March 2010 VA outpatient appointment, the Veteran reported that he had a very good talk with his son for the first time in ages. The Veteran was pleasant and cooperative. He had a slightly irritable mood and congruent affect. He was sleeping well and had no suicidal ideations. The GAF score was 69. In September 2010, the Veteran underwent another VA examination. He indicated that he was quick to argue with people, including family. On a typical day, he had coffee with some longtime friends and then went home and read the paper. He napped during the day, and he had no motivation to do anything and sometimes forgot to feed the dogs. He did not have many good moods. The Veteran indicated that he had problems with concentration when he was working, and his energy was low. He loved his dogs, but procrastinated taking them to the veterinarian. He was interested in his grandchildren and watching their sporting events. He avoided certain movies and startled easily, and he described general anxiety and worry. The Veteran worked for the same company from 1974 until he retired two and half years ago. He retired after making mistakes when he was put on medication for anxiety. With regard to his marriage, the Veteran stated that his wife put up with him and took care of the household, finances, and getting him to his appointments. He blamed their marital difficulties on his PTSD. He got along with his younger son, but less so with his older son. He had no siblings, but got along with his wife's sibling about half the time. He described some friends, two of which were close. He did not participate in many of the activities that he used to do. On examination, there was no impairment of thought process or communication, and there were no delusions or hallucinations. The Veteran was dressed appropriately. His affect was a little irritable in general, but he was very cooperative. He was circumstantial at times, but could easily be redirected. He had occasional suicidal thoughts, but no intent or plan, and he had no homicidal ideation. The thoughts of his grandchildren kept him going, and he generally took care of himself. The Veteran was oriented, although he had short-term memory problems. There was no obsessive thinking or ritualistic behavior. His speech was normal, and impaired impulse control was not noted. There were no panic attacks separate from PTSD triggers. The diagnoses were PTSD, chronic, severe; depressive disorder due to PTSD; and anxiety disorder, not otherwise specified, due to PTSD. The GAF score was 57. A November 2010 VA outpatient record shows that the Veteran reported a recent return of suicidal ideation, although he denied any intention. He recently had more trouble with his older son. The GAF score was 50. In January 2011, the Veteran testified before the undersigned. He described experiencing hypervigilance and suicidal thoughts. He indicated that he retired due to his PTSD and health. In this regard, he noted that was making bad decisions at work. When he was working, he struggled to meet expectations, so he sometimes worked through his break to make it up. He also had problems with memory. In addition, the Veteran described panic attacks when he was being tested for his memory and could not remember a story he had just read. He enjoyed spending time with his grandchildren, but he and his wife rarely spent time with other couples. He stated that he lost his temper easily, particularly with his older son. He also described loud disagreements with his wife and his former boss. The Veteran lacked motivation to do much of anything besides read the newspaper and nap. A February 2011 VA outpatient record shows that the Veteran recently had an argument with his older son. He was mildly anxious and dysphoric with some irritability. His affect was congruent, and there was no suicidal or homicidal ideation. His speech was normal, and his thoughts were well-organized. Cognition was grossly intact. The diagnoses were PTSD, anxiety, and depressive disorder, and the GAF score was 56. After reviewing the record, the Board finds that the criteria for a 50 percent rating have been met. The Veteran has certainly demonstrated reduced reliability and productivity, and he has described some panic attacks and difficulty with understanding directions. He also reported impairment of memory that affected his job and his family relationships. He had very little if any motivation to complete tasks and often put them off as long as possible. While he had some friends and supportive coworkers, he reported some problems in his marriage and other family relationships. His GAF score, which was 50 at its lowest during the appeal period, is also commensurate with the 50 percent rating now assigned by the Board. However, the Board also finds that the criteria for a rating in excess of 50 percent for PTSD have not met. While they had marital problems, the Veteran maintained a relationship with his wife, to whom he has been married for more than forty years. He also reported a good relationship with one of his sons, some of his in-laws, and all of his grandchildren. He continued to report problems with his older son. However, the Veteran indicated that he had coffee on a typical day with friends. Moreover, he occasionally, although much less often, engaged in recreational pursuits that included hunting and shooting pool. The Veteran stated that he retired from his job in 2009 due, in part, to being unable to concentrate and worrying that he would hurt someone. He also had physical problems that interfered with his ability to work, as evidenced by his Social Security Administration disability determination, which listed neuropathy of the upper extremities as his primary disability. He noted that he was able to work so long because he had been left alone. The Veteran was able to maintain some effective relationships and did not demonstrate deficiencies in most areas. Specifically, his judgment and thinking were always normal, and he maintained many family relationships. Most of the time, the Veteran's mood was congruent. While he reported occasional suicidal thoughts with no plan or intent, there is no evidence of obsessional rituals, abnormal speech, near-continuous panic or depression, disorientation, or neglect of personal appearance or hygiene. There was some history of problems with impulse control, but they had also improved and appeared to be only recently related to one of his sons. There was also no evidence of total occupational or social impairment, gross impairment in thought processes or communication, delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, disorientation, or memory loss for such facts as the names of close relatives, his occupation, or his name. As such, the criteria for a 70 or 100 percent rating have not been met, either on the basis of occupational and social impairment or the specific symptomatology associated with those ratings. Neither the medical or lay evidence suggests the presence of the symptomatology needed to satisfy the criteria for these higher ratings. To the extent that the Veteran seeks a rating in excess of 50 percent, the evidence preponderates against the claim, and it must be denied. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's PTSD is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id.; see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1) ) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Indeed, the 50 percent evaluation contemplates the overall effect of all of his symptomatology on his occupational and social functioning. As discussed above, there are higher ratings available under the diagnostic code, but the Veteran's disability is not productive of such manifestations. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected PTSD under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008) The Board concludes that the evidence supports a disability rating of 50 percent for PTSD. However, the preponderance of the evidence is against assignment of a rating higher than 50 percent for PTSD, and, to that extent, the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for a neurological disorder of the upper extremities, to include as secondary to service-connected diabetes mellitus, is denied. Service connection for a brain tumor, to include as due to herbicide exposure, is denied. Service connection for irritable bowel syndrome as secondary to PTSD is granted, subject to the laws and regulations governing the payment of VA benefits. A 50 percent initial rating for PTSD is granted, subject to the laws and regulations governing the payment of VA benefits. REMAND With regard to the claim of entitlement to service connection for hypertension, the Veteran contends that it is secondary to his service-connected type II diabetes mellitus. In February 2008, the Veteran underwent a VA examination for diabetes mellitus. Following an evaluation, the examiner opined that hypertension was not a complication of diabetes and was not worsened or increased by the diabetes. However, the examiner provided no rationale for this conclusion. Therefore, an additional medical opinion is needed in this case. With regard to the claims of entitlement to service connection for bilateral hearing loss and tinnitus, the Veteran has stated that he underwent hearing conservation testing during his years working around machinery. The VA examiner that provided the February 2008 VA opinion indicated that the Veteran had shown him the audiograms from his occupation's hearing conservation program. However, this evidence is not associated with the claims file. On remand, the Veteran should be informed that this evidence is not associated with the claims file and asked for the evidence or a release so that VA could request the evidence. The claim of entitlement to a TDIU is being remanded as it is inextricably intertwined with the other issues. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should request that the Veteran provide the evidence from his former occupation's hearing conservation program or, in the alternative, provide a release so that VA can request those records on his behalf. 2. The RO/AMC should provide the Veteran's claims file to a VA examiner to obtain an opinion with regard to his claim of entitlement to service connection for hypertension, to include as secondary to diabetes mellitus. The examiner is asked to review the record and provide an opinion as to whether the Veteran's hypertension is at least as likely as not related to his military service. He or she should also state whether it is at least as likely as not that the Veteran's service-connected diabetes mellitus caused or aggravated his hypertension. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) The examiner should provide a rationale for any conclusion reached. 3. After completing these actions, the RO/AMC should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. 4. Thereafter, the RO/AMC should consider all of the evidence of record, and readjudicate the issues on appeal. If any benefit sought is not granted, the RO/AMC should issue a Supplemental Statement of the Case and allow the Veteran and his representative an opportunity to respond. 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). ______________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs