Citation Nr: 1327670 Decision Date: 08/29/13 Archive Date: 09/05/13 DOCKET NO. 10-32 253 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a low back disorder. 2. Entitlement to service connection for hepatitis C. REPRESENTATION Veteran represented by: Florida Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. Nigam, Counsel INTRODUCTION The Veteran served on active duty from August 1975 to August 1978. This case comes before the Board of Veterans' Appeals (hereinafter "Board") on appeal from a September 2008 rating decision of the Department of Veterans Affairs (hereinafter "VA") Regional Office (hereinafter "RO") in St. Petersburg, Florida. The Veteran testified at a videoconference hearing at the St. Petersburg RO before the undersigned Veterans Law Judge (hereinafter "VLJ") in July 2012. A transcript has been associated with the file. At the July 2012 hearing, the undersigned VLJ and representative for the Veteran outlined the issues on appeal, engaged in a colloquy as to the substantiation of the claim, and identified any outstanding evidence that needed to be obtained. Overall, the hearing was legally sufficient and the duty to assist has been met. No prejudice in the conduct of the hearing is shown or have been alleged. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The issue of whether new and material evidence has been received to reopen the claim of service connection for posttraumatic stress disorder has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (hereinafter "AOJ"). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The appeal is REMANDED to the RO via the Appeals Management Center (hereinafter "AMC"), in Washington, DC. VA will notify the Veteran if further action is required. REMAND In this appeal, the Veteran seeks service connection for hepatitis C on the basis that he believes he was exposed to the hepatitis C virus due to his active duty service as a medic which exposed him to blood products and other bodily fluids; and/or as a result of inoculations received via jet injector while in service. He also seeks service connection for a low back disorder, which he believes is related to his service as a medic, which involved lifting patients into and out of ambulances and off of gurneys. Applicable law provides that service connection will be granted if it is shown that a veteran has a disorder resulting from an injury suffered or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty, in the active military, naval or air service. In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection generally requires evidence satisfying three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999). Certain chronic diseases, such as arthritis, which are listed in 38 C.F.R. § 3.309(a), may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). 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. Id. However, if chronicity in service is not established or where the diagnosis of chronicity may be legitimately questioned, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). A claimant "can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in § 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). Specifically with respect to hepatitis C, in a VA "Fast Letter" issued in June 2004 (Fast Letter 04-13, June 29, 2004), VA noted that a rating decision (in an unrelated case) had been issued that was apparently based a statement incorrectly ascribed to a VA physician to the effect that persons who were inoculated with a jet injector were at risk of having hepatitis C. The fast letter then identified "key points" that included the fact that hepatitis C is spread primarily by contact with blood and blood products, with the highest prevalence of hepatitis C infection among those with repeated, direct percutaneous (through the skin) exposure to blood (i.e., intravenous drug users, recipients of blood transfusions before screening of the blood supply began in 1992, and hemophiliacs treated with clotting factor before 1987). Another "key point" was the fact that hepatitis C can potentially be transmitted with the reuse of needles for tattoos, body piercing, and acupuncture. The fast letter indicates, in its Conclusion section that the large majority of hepatitis C infections can be accounted for by known modes of transmission, primarily transfusion of blood products before 1992, and injection drug use. It also noted that transmission of hepatitis C virus with air gun injections was "biologically plausible," notwithstanding the lack of any scientific evidence so documenting. It noted that it was "essential" that the report upon which the determination of service connection is made includes a full discussion of all modes of transmission, and a rationale as to why the examiner believes the air gun was the source of the veteran's hepatitis C. As provided by 38 C.F.R. § 19.5 (2012), the Board, in its consideration of appeals, "is bound by applicable statutes, regulations of the VA, and precedent opinions of the General Counsel of the VA. The Board is not bound by Department manuals, circulars, or similar administrative issues." See also 38 U.S.C. § 7104(c). Although further delay is regrettable, the Board finds that further development is required prior to adjudicating the Veteran's claims for service connection. See 38 C.F.R. § 19.9 (2012). A. Outstanding Treatment Records A September 2003 VA mental health psychiatry general progress note reveals the Veteran had been recently released from a 90-day sentence in the "Cobb County Detention" center, and indicated that he had given permission for the release of records from the jail. These records appear to have been obtained by VA, as the VA psychiatrist referred to them in the report. These records seem to have largely involved treatment for the Veteran's various psychiatric disorders. However, the VA psychiatrist also indicated that these jail records apparently showed the Veteran had hepatitis C contracted from intravenous drug use, yet the Veteran denied intravenous drug use and reported that he contracted hepatitis C while working as a paramedic. As these records are pertinent to the Veteran's appeal but have not been associated with the claims file, the Board finds that an attempt should be made to secure them, and any outstanding VA treatment records on remand. Also, in July 2012 the Veteran testified that he had private treatment in connection to a Workmen's Compensation claim filed in 1978; however he has failed to supply a VA Form 21-4142, Authorization and Consent to Release of Information to the Department of Veterans Affairs, or to identify a particular physician from whom to obtain any outstanding treatment records. As these records may be pertinent to the Veteran's appeal but have not been associated with the claims file, the Board finds that an attempt should also be made to secure them on remand. B. VA Examination In McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006), the United States Court of Veterans Claims (hereinafter "Court") made clear that VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. Low Back Disorder The service treatment records dated in April and August 1976 show complaints of lower back pain after injury to the back from falling while unloading an ambulance. He was given an impression of low back strain and muscle spasm. Straight leg raising was described as normal. An August 1977 service treatment record reflects complaints of acute chronic low back pain, for which the Veteran was prescribed physical therapy. A June 1978 Report of Medical History for the purpose of separation from service indicates the Veteran complained of occasional episodes of recurrent back pain, which the examining physician noted were "non-contributory." However, an accompanying Report of Medical Examination reflects normal findings for the spine. A private treatment record from "Dr. Dave," dated in July 1997, appears to generally indicate complaint of a "sprain." An October 1998 treatment record, also from Dr. Dave, shows a single complaint of lower back pain. VA treatment records reflect findings of treatment for back pain following a slip and fall in May 2006. X-ray studies performed at the time indicated L5 to S1 chronic degenerative disc disease, no acute fracture or dislocation, and minimal degenerative changes with tiny anterior osteophytes at L4 and L5. SSA internal medicine evaluation, requested by the Division of Disability Determination, dated in July 2007, indicates a history of chronic low back pain since the 1970's, and recent complaints of intermittent aching pain in the lower back that occasionally became throbbing with physical activities. In August 2008 the Veteran underwent VA spine examination. Here, the Veteran reported injury to the spine while lifting patients in the course of his duties as a medic. The examiner observed various service treatment records showed treatment for low back pain, with diagnoses of low back strain and low back muscle spasm. The examiner noted that the June 1978 examination revealed findings of a normal spine. However, the Veteran complained of low back pain since separation from service in 1978, and that his symptoms had worsened with age. He noted that he was next treated for his low back problem around 1980; however records of treatment were not available for review during the examination. The examiner noted that the only post-service treatment records available were those from VA, which showed treatment for low back pain following a fall injury in the same month. The examiner observed that X-ray studies from that time revealed no fracture, but L5 to S1 chronic degenerative disc disease. The examiner indicated that a February 2005 VA treatment record did not mention any back condition. Also, the Veteran denied any post-service job-related injuries, motor vehicle accident injuries or surgery to the lumbar spine. The Veteran was diagnosed with degenerative joint disease of the lumbar spine, and with sciatica symptoms in both lower extremities. The examiner opined that, the diagnosed degenerative disc disease of L5 to S1, degenerative joint disease of the lumbar spine and sciatica symptoms in both lower extremities were less likely as not caused by the Veteran's service. The examiner explained that the Veteran was discharged from service 30 years prior, the service treatment records were silent for degenerative disc disease of L5 to S1, degenerative joint disease of the lumbar spine and sciatica symptoms in both lower extremities; there was no documentation of treatment for degenerative disc disease of L5 to S1, degenerative joint disease of the lumbar spine and sciatica symptoms in both lower extremities within one year of separation from service; a February 2005 VA treatment record did not indicate any back condition; and the Veteran sustained at least one other injury to the back in 2006 since his separation from service. On his VA Form 9, Appeal to Board of Veterans' Appeals, received in July 2010, the Veteran acknowledged that degenerative disc disease of the lumbar spine was not present in service, and was a condition that had developed over time due to his initial service-related problems. The Veteran noted that he had received treatment numerous times in service for low back pain, and that he began undergoing VA treatment in 2006 for back problems. However, he indicated that he received treatment prior to 2006 for his back, and argued that his current disorder and his in-service low back problems were related. In July 2012, the Veteran testified that he injured his back after lifting many heavy patients while in service. The Veteran denied being put on a profile, or being assigned light duty or bed rest for this injury. He indicated that he first was underwent treatment for his low back post-service in 1978 when he went to work for "Virginia Power Electric Company" and he re-strained his back while lifting something heavy. He also acknowledged that he reinjured his back in 2006 after slipping while taking a step. The Board finds that the August 2008 VA spine examination was inadequate in various respects. First, it failed to consider that the Veteran was diagnosed with degenerative disc disease at the time of the fall in 2006 and explain why that diagnosis was not indicative of a chronic disability. Second, the examiner failed to explain the likely etiology of the osteoarthritis, which appears to have occurred in the interim between the Veteran's separation from service and when he was treated in 2006. Third, this opinion does not address the Veteran's lay testimony that he experienced chronic low back pain since his separation from service. As arthritis is a disability listed under 38 C.F.R. § 3.309(a), the holding in Walker applies, and lay statements may serve as competent evidence of a chronic disability. Finally, this opinion does not contain a rationale for the conclusions reached and cannot be afforded any probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300-01 (2008) (holding that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). The examiner merely explained that the clinical record did not indicate any back condition post-service, and noted that the Veteran sustained at least one other injury to the back in 2006, but did not provide rationale that discussed why the in-service treatment and post-service treatment to the low back were not related. Thus, the Board finds that remand is necessary to provide the Veteran with a new examination and clarifying medical opinion. Given the above, there is insufficient competent medical evidence on file for VA to make a decision on the claim for entitlement to service connection for hepatitis C and the McLendon elements are met. Thus, a VA examination with clarifying medical opinion is warranted. Specific instructions to the examiner are detailed below. Hepatitis C The service personnel records confirm that the Veteran's military occupational specialty (hereinafter "MOS") was as a medic, that he provided combat support while stationed at the "15th Combat Support Hospital," and that he performed duties as an ambulance driver and as an "aidman" while on active duty. These records also show that the Veteran served as an ambulance orderly in Korea, from November 1976 to February 1977, while stationed with the 560th Medical Company. The service treatment records reflect that on Report of Medical History for the purpose of enlistment, dated in July 1975, the Veteran indicated that he had a history of "jaundice or hepatitis." He went on to explain that at the age of 12 he was hospitalized for 14 days with hepatitis, without residuals. A May 1977 service dental clinic health questionnaire indicates the Veteran reported a history of jaundice in 1969 or 1970. On Report of Medical History for the purpose of separation, dated in June 1978, the Veteran again provided a history of "jaundice or hepatitis." The examining physician noted the Veteran had contagious hepatitis and lost part of his liver in 1968. Both the accompanying Report of Medical Examination for the purpose of enlistment, and the accompanying Report of Medical Examination for the purpose of separation, were without findings of any diagnoses or defects related to the liver. Post-service treatment records indicate findings of hepatitis as early as January 1997, approximately 19 years after the Veteran's separation from service. In October 1998 the Veteran provided a past medical history of treatment for hepatitis A. Starting in 2001, approximately 23 years after his separation from service, he was diagnosed with hepatitis C. Specifically, a private laboratory report, dated in January 2001 shows results of non-reactive hepatitis A IGM antibody; no detected hepatitis B surface antigen; non-reactive hepatitis B core IGM antibodies; and reactive hepatitis C antibody. Subsequent records indicate liver function test results representative of modest elevations. Notably, a VA mental health intensive care screening note, dated in September 2003, reflects the Veteran's description of his past drug abuse, including smoking marijuana at age 13; taking speed in 1966 or 1967 and stopping in 1973 or 1974; and snorting cocaine from 1974 to 1975 and from 1985 to 1986. He also reported that he starting snorting crystal methamphetamines in 2001. A September 2003 VA discharge summary manual entry shows the Veteran reported serving as a paramedic in the Army during non-war time, but that he witnessed shootings, stabbings and suicides while on active duty. He also provided a history positive for substance abuse, including cocaine, opiates, marijuana and crystal methamphetamine; however he denied intravenous drug abuse. An October 2003 VA treatment record shows the Veteran reported a history of drug and alcohol use starting in his early teens. An October 2004 VA gastroenterology consult reflects an impression of hepatitis C by history. The examining physician's assistant noted the Veteran had risk factors of intravenous drug use throughout the 1960's; a blood transfusion prior to 1992, including gamma globulin at the age of 16; a history of multiple sexual partners; and a history of military exposure in Vietnam from 1975 to 1978 while serving as a trauma technician and paramedic, including being stuck with a needle 4 to 5 times and having lots of blood exposure. The Veteran also noted that he underwent airgun vaccination in the service. An April 2005 ultrasound of the liver, gall bladder, pancreas and spleen reveals findings of moderately dense appearance of the liver without evidence of focal lesions noted, and no evidence of gallstones or dilated biliary tree. A November 2005 VA consult for infectious disease reveals reports of testing hepatitis C positive since 2002, and risk factors of working as a medic in the Army and after the Army. The Veteran also admitted to pre-service intravenous drug use, pre-service intranasal cocaine use, and having approximately 25 female sexual partners throughout his lifetime. A May 2006 VA pathology report from a liver biopsy shows findings of chronic hepatitis (clinical hepatitis C), with mild periportal inflammation, focal lobular necrosis, and minimal portal fibrosis. An SSA record, dated in May 2007, reveals the Veteran reported many years of field service with the Dale City Fire Department, and as a U.S. Army paramedic and "GSA" paramedic. The Veteran noted that he contracted hepatitis C through blood exchange of patients, in automobile accidents and in trauma situations, after not being properly protected. An internal medicine evaluation requested by the Division of Disability Determination, dated in July 2007, indicates a history of hepatitis C diagnosed since 2001, and a history of marijuana use from the age of 27. He was diagnosed with hepatitis C. A June 2009 VA ultrasound for epigastric pain indicates an impression of a normal appearing gall bladder and biliary tree, and mild hepatic enlargement with a mildly heterogeneous echotexture and no focal abnormality present. More recently, in June 2010, the Veteran underwent a VA liver, gall bladder, and pancreas examination. Here, the examiner noted a date of onset of hepatitis C in 2001, as diagnosed by a positive hepatitis C lab test. The examiner noted that the hepatitis C had improved since its onset, and that there was no current treatment for it. The examiner observed there was a history of chronic liver disease risk factors including blood exposure during service and intravenous drug use before service. The examiner also noted a pre-service history of hepatitis A since 1963. The examiner provided a history of the Veteran's treatment for hepatitis C, including a November 2005 VA infectious disease consult in which the examiner noted the Veteran was known to be hepatitis C positive since 2002; however, such treatment did not include follow up with obtaining a genotype due to long wait times at the laboratory that processed his test. The Veteran reported that he was a retired Army medic, and that post-service he had worked as a GSA medic. The Veteran described being stuck by needles approximately 4 times, as well as being exposed to significant amounts of blood while in service. He also admitted to intravenous drug use and intranasal cocaine use in the 1960's. Finally, the Veteran admitted to having approximately 25 female sexual partners throughout his lifetime. The examiner noted that on pathology report in May 2006, the Veteran was given a needle biopsy of the liver that revealed chronic hepatitis (clinical hepatitis C). The examiner noted that on ultrasound in June 2009, the Veteran was diagnosed with an impression of normal appearing gallbladder and biliary tree, and with mild hepatic enlargement with a mildly heterogeneous echotexture, without focal abnormality present. The Veteran was ultimately diagnosed with hepatitis C that was mostly likely due to pre-service intravenous drug use. The second most likely risk factor was blood exposure during service as a medic, and the third most likely risk factor was undergoing air gun vaccinations during service. In July 2010, the Veteran filed a VA Form 9, Appeal to Board of Veterans' Appeals, in which he reported that he was constantly exposed to bodily fluids and daily contaminants, and that he was stuck with needles that were exposed to other people's blood products on multiple occasions. The Veteran also explained that during his enlistment examination he advised the examining physician that he had contracted hepatitis A as a child while in school, and denied ever having part of his liver removed. The Veteran noted that he had not been diagnosed with hepatitis C at any time prior to service, and concluded that his hepatitis C was not the result of any pre-service drug use. In July 2012 the Veteran testified that he was diagnosed with hepatitis A at the age of 12, which resolved, and denied that any segment of his liver was removed at any time in his life. He reported that he tried intravenous drugs prior to his enlistment in the Army, but indicated that he used new needles when he injected the drugs and that he only used intravenous drugs on 3 or 4 occasions. He denied using intravenous drugs at any other time in his life. The Veteran also testified that while stationed in Korea he drove an ambulance as an emergency medical provider for a nearby airfield out of a small emergency room. He indicated that it was at the airfield, and at the DeWitt Army Hospital that he was exposed to hepatitis C because he did not wear gloves and was constantly exposed to bodily fluids and blood products. The Veteran noted that the June 2010 VA examiner was not fully aware of the extent of which he was exposed to the risk factors noted on examination. The Board finds the June 2010 VA examiner's opinion to be lacking in various respects. First, the examiner failed to provide an adequate description of the clinical record, which reveals reports of several liver disease risk factors not mentioned in the examination report. As consideration of these risk factors is paramount in determining the etiology of the Veteran's hepatitis C, the Board finds that a thorough social and clinical history must be obtained and discussed for a hepatitis C examination to be deemed adequate for VA rating purposes. Second, the examiner failed to adequately discuss the service treatment records, which showed a pre-service history of hepatitis at the age of 12 without residuals, and that the Veteran reportedly had contagious hepatitis and lost part of his liver in 1968. As noted, the Veteran has clarified that he had a diagnosis of hepatitis A when he was 12, but did not have a diagnosis of hepatitis C. However, the May 1977 service dental clinic health questionnaire indicates the Veteran reported a history of jaundice in 1969 or 1970, and the June 1978 Report of Medical History for the purpose of separation includes a notation that the Veteran had contagious hepatitis and lost part of his liver in 1968. The Board finds that clarification is needed as to the significance of this evidence. Third, this opinion does not contain a rationale for the conclusions reached and cannot be afforded any probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300-01 (2008) (holding that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). The examiner's conclusory opinion that the Veteran's intravenous drug use prior to service and not his exposure to blood products as a medic during service is the cause of his hepatitis C is not adequately explained. Thus, the Board finds that remand is necessary to provide the Veteran with a new examination and clarifying medical opinion. A medical opinion based on an incorrect factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). The Court has cautioned against relying only upon epidemiological research and statistical information to deny a Veteran's claim for service connection; rather an informed medical opinion which pertains to the Veteran's situation in particular is required. See by analogy, Polovick v. Shinseki, 23 Vet. App. 48 (2009). Given the above, there is insufficient competent medical evidence on file for VA to make a decision on the claim for entitlement to service connection for hepatitis C and the fourth McLendon element is met. Thus, a VA examination with clarifying medical opinion is warranted. Specific instructions to the examiner are detailed below. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC must take appropriate steps to request that the Veteran identify all healthcare providers that have treated him for his hepatitis C and low back, and provide sufficient information, and if necessary, authorization to enable it to obtain any additional evidence pertinent to the claim on appeal that is not currently of record. The RO/AMC should specifically seek to obtain treatment records from the Cobb County Detention Center, and any records related to a Workmen's Compensation claim filed in 1978. After securing any necessary release forms, with full address information, the RO/AMC should request that all records of medical treatment not currently associated with the claims file should be requested. All records obtained pursuant to these requests must be included in the Veteran's claims file. If the search for such records has negative results, documentation to that effect should be included in the claims file. 2. After the above development has been accomplished to the extent possible, the RO/AMC must schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of his current low back disorder. In conjunction with the examination, the examiner must review the entire claims file, including a complete copy of this remand, Virtual VA and any lay assertions presented. All indicated tests and studies are to be performed, and comprehensive social, educational, and occupational histories are to be obtained. The examiner is requested to provide an opinion addressing whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that a current low back disability, to include degenerative disc disease, is related to the Veteran's reported in-service back injury or other event of his service, including serving as a medic and lifting patients into and out of ambulances. In doing so, the opinion of the August 2008 VA examination should be discussed. The examiner should be notified that the term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. For purposes of the opinion, the examiner should accept as fact that the Veteran is competent to report that he injured his back during service and experienced low back pain since service. A report of the examination should be prepared and associated with the Veteran's VA claims file. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 3. After the above development has been accomplished to the extent possible, the RO/AMC must schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of his current hepatitis C. In conjunction with the examination, the examiner must review the entire claims file, including a complete copy of this remand, Virtual VA and any lay assertions presented. All indicated tests and studies are to be performed, and comprehensive social, educational, and occupational histories are to be obtained. The examiner is requested to identify the types of hepatitis the Veteran has been diagnosed with, and to provide brief explanation as to what distinguishes each type according to symptomatology and effect on the body. The examiner is then requested to consider and list all possible risk factors that may be relevant to the Veteran's current hepatitis C. For the purpose of this examination, the examiner should note that the service treatment records outlining the Veteran's pre-service hepatitis history as well as the pre-service, in-service, and post-service risk factors for hepatitis C. In a prepared report the examiner should: (1) list the types of hepatitis with which the Veteran has been diagnosed; (2) list the Veteran's in-service risk factors for hepatitis C and any pre-service and/or post-service risk factors for hepatitis C and rank in order of most important to least important as they relate to the Veteran's current hepatitis C; and (2) provide an opinion addressing whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the current disability manifested by hepatitis C is due to a risk factor or other event of the Veteran's service, including serving as a medic and being exposed to blood products and other bodily fluids; and/or as a result of inoculations received via jet injector. In doing so, the opinion of the June 2010 VA examination should be discussed. The examiner should be notified that the term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. For purposes of the opinion, the examiner should accept as fact that the Veteran is competent to report that was exposed to blood products and other bodily fluids while serving as a medic on active duty, and to report that he received inoculations via a jet injector during service. A report of the examination should be prepared and associated with the Veteran's VA claims file. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. After completion of the above and any additional development deemed necessary, the RO/AMC should review the issues on appeal. All applicable laws and regulations should be considered. If any benefit sought remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).