Citation Nr: 1339007 Decision Date: 11/26/13 Archive Date: 12/06/13 DOCKET NO. 04-12 833 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a chronic low back disorder. 2. Entitlement to service connection for an acquired psychiatric disorder, claimed as depression. REPRESENTATION Veteran represented by: Joseph R. Moore, Attorney WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran served on active duty from July 1964 to July 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Regional Office (RO) of the Department of Veterans Affairs (VA) in Newark, New Jersey. The Veteran testified at a hearing before a Decision Review Officer (DRO) at the RO in May 2004 and at a Travel Board hearing before the undersigned in January 2007. Transcripts of both hearings are of record. In May 2007, the Board remanded the issues for further development. Thereafter, in January 2010, the Board denied the claims. The Veteran appealed to the Veterans Claims Court. In March 2011, the Court Clerk granted a Joint Motion for Remand (JMR) and remanded the case for additional development in compliance with the JMR instructions. In February 2012, the Board remanded the issues consistent with the JMR. The issue of entitlement to service connection for an acquired psychiatric disorder, claimed as depression, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT A chronic low back disorder was not incurred in service, did not manifest in the first post-service year or for many years thereafter, and the current low back disorder is not otherwise related to service. CONCLUSION OF LAW A chronic low back disorder was not incurred in or aggravated by service, nor did such a disorder manifest to a compensable degree within a year of service separation. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (reasonable doubt to be resolved in veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). The provisions of 38 C.F.R. § 3.303(b) apply only to the chronic diseases enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.307, 3.309. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997); Layno v. Brown, 6 Vet. App. 465 (1994); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the veteran's claims file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Medical evidence that is speculative, general or inconclusive in nature cannot support a claim. Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). A physician's statement framed in terms such as "may" or "could" is not probative. See Warren v. Brown, 6 Vet. App. 4, 6 (1993). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on a veteran's behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran contends that a low back injury in service is the source of his current low back disorder and that low back symptomatology has been continuous from service separation to the present. The DD Form 214 indicates that he was a general supply specialist in service and that the equivalent civilian occupation was that of a stock clerk. A review of the service personnel records indicates that he was a supply specialist until separation in July 1966. Service treatment records reflect that the Veteran sought treatment for low back pain, worse in the evening, during service in January 1966. At that time, fatigue and trouble sleeping were also noted. He was given medication for his back pain. In a May 1966 Report of Medical History completed in conjunction with the separation examination, he denied a history of bone or joint deformity. The May 1966 service separation examination reflected no disorders of the spine or low back. The "PULHES" physical profile indicated a high degree of physical fitness, as it consisted of all 1's with the exception of a 2 for the eyes. See generally Hanson v. Derwinski, 1 Vet. App. 512, 514 (1991) (explaining the military medical profile system). The day following the separation examination, the Veteran was seen for aching of the back, neck, and knees. His temperature was elevated, and his throat was sore. Medication and bed rest were afforded him. He was discharged from active service in July 1966 and from the Army Reserve in June 1970. Post-service evidence reflects that in April 1968, the Veteran was admitted to a private hospital for treatment of gastrointestinal complaints. At that time, he did not report complaints regarding the low back and no such diagnosis was made. Further, he filed his first claim for VA disability benefits in 1975. At that time, he did not seek service connection for a disorder of the low back. The Board acknowledges that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology; however, here, he filed a claim for service connection, but did not mention low back symptoms. This suggests to the Board that there was no pertinent low back symptomatology at that time. While inaction regarding filing a claim is not necessarily indicative of the absence of symptomatology, where, as here, a veteran takes action regarding other claims, it becomes reasonable to expect that he is presenting all issues for which he is experiencing symptoms that they he believes are related to service. In other words, he demonstrated that he understood the procedure for filing a claim for VA disability compensation, and he followed that procedure in other instances where he believed he was entitled to those benefits. In such circumstances, it is more reasonable to expect a complete reporting than for certain symptomatology to be omitted. Thus, his inaction regarding a claim for a low back disorder, when viewed in the context of his action regarding other claims for compensation, may reasonably be interpreted as indicative of his belief that he did not sustain a chronic low back disorder in service, or the lack of low back symptomatology at the time he filed the claim, or both. The post-service evidence does not reflect low back symptomatology for many years after service discharge. Specifically, the Veteran underwent spinal surgery in 1983. This is the first documented report of low back complaints. There is evidence of record that the surgery was necessitated pursuant to a fall on ice. He subsequently denied falling on ice which puts into question his credibility on the subject. Further, medical evidence reveals that the Veteran was involved in a motor vehicle accident in April 1986. The evidence reflects, however, that only his nose was injured at that time. Thereafter, he was afforded intermittent VA outpatient treatment, including physical therapy in 2000. At that time, he gave a history of low back pain since 1983, when he had surgery. He also reported being involved in a motor vehicle accident in June 2000. In a September 2002 VA outpatient treatment note, the Veteran reported falling on ice in 1983, injuring his back and rendering himself unable to walk for six months. Later that same year, he underwent a lumbar laminectomy and fusion at a private hospital. August 2002 VA X-ray studies confirmed arthritis and disc degeneration of the lumbosacral spine. A January 2003 VA computed tomography (CT) scan confirmed spinal stenosis and disc bulging at multiple levels of the lumbosacral spine. At the April 2004 DRO hearing, the Veteran testified that his military occupational specialty was that of a supply clerk and that he worked in food services, which required heavy lifting. He indicated that he was placed on light duty from the time of his initial back complaint in service until service separation. He asserted that he sustained a low back injury after lifting a heavy load and that he reinjured his back at Ft. Drum later in 1966. The Board observes that records from Ft. Drum have been found to be unavailable. He further testified that his post-service employment as a ticketing agent for an airline and as a teller at a race track did not involve any heavy lifting or other types of activity that could potentially injure the back and that his back symptoms persisted from service to the present. In support of his claim, the Veteran submitted private medical evidence to include an April 2004 letter from Dr. MM, a private physician. Dr. MM indicated that the Veteran reported initially injuring his back during service in 1965, while trying to lift a heavy object and that due to continuing symptoms since that time, he underwent a laminectomy and spinal fusion in 1983. Dr. MM found degenerative disc disease, spinal stenosis, and disc bulging at several levels of the lumbosacral spine, resulting in chronic low back pain. He opined that the Veteran's current diagnoses of the lumbosacral spine were "secondary to the service-related injury" noted above. However, the Board places less probative value on Dr. MM's April 2004 opinion because it is conclusory and devoid of rationale. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (a medical opinion that contains only data and conclusions is accorded no weight). At the January 2007 Travel Board hearing, the Veteran testified that he injured his back in January 1966 while unloading food from a tractor trailer. He remarked that he was given medication and bed rest was prescribed. He indicated that his duties were changed after that incident to a job that did not entail lifting. He noted that his first post-service Reserve assignment was at Ft. Drum in late 1966 and that he reinjured his back at that time due to heavy lifting. He further testified that he never slipped on ice or fell in 1983 and that he was in a wheel chair at that time not because he slipped on ice but because of low back symptomatology for which he was awaiting surgery. He noted that he was operated on due to atrophy in the lower leg. He further emphasized that his position as a ticket agent did not involve lifting luggage and that subsequently, he worked as a postal clerk where he sorted mail on a stool. Thereafter, he was a teller at a race track, which also involved no lifting. He asserted that he had regular treatment for the back since service separation in 1966 and that back problems had persisted since that time. In December 2009, the Veteran underwent a VA orthopedic examination. At that time, he reported recurrent pain of the neck and upper and lower back. He stated that he initially injured his back during service, and had experienced recurrent back pain since that time. After a physical examination, the examiner diagnosed cervical spine disc herniation, lumbar radiculopathy, and lumbar spondylosis. The examiner found no evidence that the Veteran's spinal disorders were related to an in-service disease or injury. The examiner stressed that while the Veteran had two treatments for backache in 1966, there was no documented treatment from 1966 to 1983. On this basis, the examiner concluded that he could not render an opinion without resort to mere speculation. The Board assigned the December 2009 VA opinion less probative weight because the examiner asserted that an opinion regarding the etiology of the Veteran's low back disability could not be rendered without a resort to speculation. In Jones v. Shinseki, 23 Vet. App. 382 (2009), the Court held that, before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence. Id. at 390. It must also be clear that the physician has considered "all procurable and assembled data." Id. (citing Daves v. Nicholson, 21 Vet. App. 46 (2006)). Here, it is unclear whether the examiner's own limitations precluded a non-speculative answer or whether such a conclusion was beyond current medical knowledge. As such, under Jones the December 2009 VA opinion is assigned less probative value. The Veteran submitted a July 2011 written statement from a clergyman indicating that he had known the Veteran for 30 years and that he had been aware of the Veteran's back problems during that entire period. While this evidence is competent, the evidence does not show that the clergyman has any special training to determine the etiology of the Veteran's low back symptoms. Next, the Veteran submitted a December 2011 report from Dr. PC. Dr. PC reviewed the medical records but did not examine the Veteran has he works in another part of the country. Dr. PC explained that the natural history of degenerative disc disease consisted of three phases. The initial phase often involved rotational trauma such as that experienced by the Veteran in January 1966. This sort of trauma resulted in tears and fissures of the annular wall. Over the decades, the degenerative process continued, which included loss of disc height and other manifestations. Phase three consisted of further disc resorption, etc. Pain symptoms in the third phase could be acute. Thus, Dr. PC reflected that the Veteran's 1983 surgery was due to severe disability that took years to develop. According to Dr. PC, the Veteran's in-service injury, which included radiculopathy, was the first phase of the three phase process that led to his current disability. He emphasized that the Veteran's post-service employment was clerical in nature and did not involve lifting. He opined that the Veteran's present low back disability was due to the in-service injury. Dr. PC's December 2011 report is assigned less probative value because he relied on an inaccurate fact, namely that the Veteran experienced radiculopathy pursuant to his initial January 1966 back injury. The service treatment records do not indicate radiculopathy at that time. Reonal, 5 Vet. App. at 461 (medical opinion based upon an inaccurate factual premise has no probative value). In January 2013, the Veteran was afforded a VA orthopedic examination. The examiner examined the Veteran and diagnosed lumbar fusion and lumbar degenerative disc disease. The examiner outlined all of the relevant medical history in the record. He also obtained a history from the Veteran, who apparently reported that he lost his first two civilian jobs due to his back. According to the report, the Veteran indicated that his fist job entailed lifting at Delta Airlines. His second was as a letter carrier for USPS. The examiner also noted that the Veteran denied an injury in 1983 and instead just indicated that low back pain was worsening at that time. The VA examiner opined that it was not likely that the Veteran's low back disability was due to service. The examiner explained that there were only two documented episodes of back pain in the service treatment records that were associated with infections, as they were described as aches. The examiner also emphasizes that the spine was found to be normal on service separation. Further, the examination indicated that there was no evidence of a job change in service due to a back injury or disability. The examiner indicated that the notes clearly stated that the Veteran's back problems started in 1983 when he fell on ice. The Board finds that the examination was adequate for evaluation purposes. Specifically, the examiner reviewed the claims file, interviewed the Veteran, and conducted a physical examination. There is no indication that the VA examiner was not fully aware of the Veteran's past medical history. Moreover, the examiner has the requisite medical expertise to render a medical opinion regarding the etiology of the disorder and had sufficient facts and data on which to base the conclusion. Therefore, the Board finds the VA examiner's opinion to be of high probative value. Next, the Board does not find the Veteran credible regarding the facts surrounding his low back disorder. The Board does not find credible his assertions of back pain since service separation and of continuity of symptomatology, as he did not mention back pain when filing his first claim for disability benefits in 1975. Presumably, he would have taken the opportunity to file a claim for a low back disability had one existed when going through the effort of filing a claim for another alleged disability. As the evidence stands, because a chronic low back disorder was not noted on service separation and because the Veteran's PULHES profile did not reflect any disability of the back, the Board finds that a low back disorder was not incurred in service. Thus, service connection based on in-service incurrence is denied. Service connection for a low back disability is not warranted based on continuity of symptomatology, as the evidence does not reflect any problem with the back until 1983. 38 C.F.R. § 3.303(b); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). Similarly, because a low back disability was not shown until years after service separation, service connection on a presumptive basis is not warranted. Finally, the weight of competent and credible evidence finds that the current low back disorder is not otherwise related to service, and there is no medical nexus upon which to grant service connection. As stated, except for the most recent VA examinations, the medical opinions of record are not probative, and the Veteran has been found to lack credibility with respect to his low back disorder. Furthermore, although lay persons are competent to provide opinions on some medical issues, see v. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), complex spinal problems such as the Veteran's are outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claim for service connection for a chronic low back disorder, and there is no doubt to be otherwise resolved. Such a disorder was not incurred during service, or manifested to a compensable degree within a year thereafter. As a preponderance of the evidence is against service connection, the benefit of the doubt doctrine is not applicable. As such, the appeal is denied. Finally, as provided for by VCAA, VA has a 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. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). 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. 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). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2) (West 2002). In the event that a VA notice error occurs regarding the information or evidence necessary to substantiate a claim, VA bears the burden to show that the error was harmless. In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. 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. Here, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in April 2003 that fully addressed all notice elements and was sent prior to the initial RO decision in this matter. This letter informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. Additionally, further notice has been afforded the Veteran within July 2006, September 2006, June 2007, April 2009, July 2009, and September 2009 letters, which informed him of additional evidence required or obtained by VA, or submitted by him. With respect to the Dingess requirements, in July 2006, the RO provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish effective dates. With that letter, the RO effectively satisfied the remaining notice requirements with respect to the issue on appeal. The claim was subsequently readjudicated on numerous occasions to include in a February 2013 supplemental statement of the case, thus any timing defect regarding VCAA notice was cured. See Prickett v. Nicholson, 20 Vet. App. 370, 376-78 (2006) (validating the remedial measures of issuing fully compliant VCAA notification and readjudicating the claim in the form of a statement of the case to cure timing of notification defect). Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See generally 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). First, the RO has obtained the service treatment records, service personnel records, VA clinical records, private medical records, lay statements, and the Veteran's statements to include his oral testimony at two hearings. Significantly, neither the Veteran nor his attorney has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Service connection for a chronic low back disorder is denied. REMAND In December 2012, the Board remanded the issue of entitlement to service connection for an acquired psychiatric disorder, claimed as depression. The Veteran underwent an examination in January 2013; however, another remand is needed to adequately address the Veteran's claim. Specifically, the examiner did not appear to have the correct facts before him. As an example, the examiner indicated that the Veteran was placed on light duty for about 18 months prior to discharge related to a back injury; however, that injury took place about six months before separation. Thus, light duty, even if it had occurred, would not have lasted 18 months. The examiner also indicated that the Veteran was fired from the first two jobs he held after service because they entailed physical demands that he could not meet. Throughout the record, however, the Veteran insisted that his jobs did not entail any physical demands. Further, the examiner supplied no rationale for his conclusion that a psychiatric disorder was due to a low back disorder. Unsubstantiated medical conclusions are of little probative value. Therefore, another examination should be undertaken to adequately address the claim. Accordingly, the case is REMANDED for the following actions: 1. Obtain VA clinical records from the East Orange (NJ) VAMC for the period since September 2012. Any relevant treatment records contained in the Virtual VA or VBMS file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. 2. Schedule a mental health examination for a diagnosis of all extant psychiatric disorders and for an opinion regarding whether it is at least as likely as not (50 percent or greater likelihood) that any identified psychiatric disorder is related to or aggravated by service or was incurred in the first post-service year. In connection with the examination, the examiner must review all pertinent documents in the claims file. The examination report must indicate whether the claims file was reviewed. The examiner must also elicit a complete history from the Veteran and report the Veteran's stated psychiatric history in detail. Regarding all opinions and conclusions, a comprehensive rationale is necessary. Also in formulating the medical opinion, the examiner is asked to consider that the term "at least as likely as not" does not mean "within the realm of possibility." Rather, it means that the weight of the medical evidence both for and against the conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against causation. In this regard, if the examiner concludes that there is insufficient information to provide an etiologic opinion without result to mere speculation, the examiner should state whether the inability to provide an opinion was due to a need for further information (with said needed information identified) or because the limits of medical knowledge had been exhausted regarding the etiology of the disorder. 3. When the development requested has been completed, and the RO has ensured compliance with the requested action, this case should again be reviewed by the RO on the basis of the additional evidence. If the benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The 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 Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs