Citation Nr: 1616825 Decision Date: 04/27/16 Archive Date: 05/04/16 DOCKET NO. 09-18 719 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for respiratory problems, to include asthma and bronchitis, as a qualifying chronic disability under 38 C.F.R. § 3.317. 2. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected Lyme disease with arthritis and arthralgias of multiple joints and spine. 3. Entitlement to service connection for restless leg syndrome. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty in the U.S. Air Force from September 1989 to July 1995, plus had 8 years and 10 days of prior unverified active service. He served in support of Operation Desert Shield/Storm from August 1990 to February 1991, and served in the Desert Shield/Storm area of responsibility from July 1991 to September 1991. These matters initially came to the Board of Veterans' Appeals (Board) on appeal from a January 2009 rating decision that denied service connection for asthma, for obstructive sleep apnea, and for restless leg syndrome. The Veteran timely appealed. In August 2009, the Veteran testified during an informal hearing conference before RO personnel. In March 2013 and in May 2014, the Board remanded the matters for additional development. The Board is satisfied there was substantial compliance with its remand orders for the claims decided below. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that the U.S. Court of Appeals for Veterans Claims has held that the Board must broadly construe claims, and consider other diagnoses for service connection when the medical record so reflects. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Accordingly, because the Veteran claimed service connection for asthma and had been diagnosed with bronchitis, the issue on the title page reflects the expanded issue on appeal as a result of the Clemons decision. The issue of service connection for restless leg syndrome is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran had active service in the Southwest Asia Theater of operations during the Persian Gulf War. 2. The Veteran does not have an undiagnosed illness, characterized by respiratory problems; and currently diagnosed asthma was not present during active service, and is not otherwise related to a disease or injury during active service-to include exposure to burning oil fields. 3. Obstructive sleep apnea was not present during active service, and is not otherwise related to a disease or injury during active service; and is not due to or aggravated by his service-connected Lyme disease with arthritis and arthralgias of multiple joints and spine. CONCLUSIONS OF LAW 1. A disability manifested by respiratory problems, to include as a disability due to undiagnosed illness, was not incurred or aggravated in service; and asthma was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2015). 2. Obstructive sleep apnea was not incurred or aggravated in service, and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist 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 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). VA should notify the Veteran of: (1) the evidence that is needed to substantiate the claim(s); (2) the evidence, if any, to be obtained by VA; and (3) the evidence, if any, to be provided by the claimant. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (codified at 38 C.F.R. Part 3). Through June 2008 and December 2008 letters, the RO notified the Veteran of elements of service connection and the evidence needed to establish each element. These documents served to provide notice of the information and evidence needed to substantiate the claims. VA's letters notified the Veteran of what evidence he was responsible for obtaining, and what evidence VA would undertake to obtain. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA informed him that it would make reasonable efforts to help him get evidence necessary to support his claims, particularly, medical records, if he gave VA enough information about such records so that VA could request them from the person or agency that had them. In each letter, the RO specifically notified the Veteran of the process by which disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Defects as to the timeliness of the statutory and regulatory notice are rendered moot because each the Veteran's claims decided on appeal has been fully developed and re-adjudicated by an agency of original jurisdiction after notice was provided. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). There is no indication that any additional action is needed to comply with the duty to assist the Veteran. The RO or VA's Appeals Management Center (AMC) has obtained copies of the service treatment records and outpatient treatment records, and has arranged for VA examinations in connection with the claims decided on appeal, reports of which are of record and appear adequate. The opinions expressed therein are predicated on a substantial review of the record and consideration of the Veteran's complaints and symptoms. The Veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. Given these facts, it appears that all available records have been obtained. There is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C.A. § 5103A(a)(2). II. Analysis Service connection is awarded for disability that is the result of a disease or injury in active service. 38 U.S.C.A. §§ 1110, 1131. Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). 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 distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). 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. Id. The Federal Circuit has held that section 3.303(b) applies only to those chronic conditions specifically listed in 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, and disorders noted at the time of examination, acceptance, and enrollment; or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2014). The Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). Specific to Persian Gulf War service, service connection may be granted for objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms-to include respiratory signs or symptoms, and signs or symptoms involving muscle or joint pain. The chronic disability must have become manifest either during active military, naval, or air service in the Southwest Asia Theater of operations (SWA) during the Persian Gulf War, or to a degree of 10 percent or more disabling not later than December 31, 2016, and must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317; see 76 Fed. Reg. 81,834 (Dec. 29, 2011) (interim final rule extending statutory period). Compensation shall not be paid under this section, however, if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in SWA during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in SWA during the Persian Gulf War, and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). A Persian Gulf Veteran is a Veteran who served on active military, naval, or air service in SWA during the Persian Gulf War. 38 U.S.C.A. § 1117(e); 38 C.F.R. § 3.317(d). In this case, the Veteran's DD Form 214 shows service in SWA, and confirms receipt of the Southwest Asia Service Medal. This medal generally indicates service in the area and time period referenced under 38 C.F.R. § 3.317. The term "chronic disability" was changed to "qualifying chronic disability," and the definition of "qualifying chronic disability" was expanded to include (a) undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C.A. § 1117 (West 2014); 38 C.F.R. § 3.317 (2015). A. Respiratory Disability The Veteran contends that service connection for respiratory problems is warranted on the basis of his service in SWA during the Persian Gulf War. Signs or symptoms involving the respiratory system (upper or lower) are objective signs of undiagnosed illness. On a report of medical history completed by the Veteran at the time of a separation examination in May 1992, he did not report asthma or shortness of breath or other respiratory problems. He did report pain or pressure in chest. Subsequent Air Force Reserves records, dated in September 1996, show that the Veteran did not report asthma or shortness of breath or other respiratory problems at the time of a periodic examination. At the time he indicated not knowing whether he ever had or now had pain or pressure in chest. VA records, dated in July 2001, show that the Veteran denied any respiratory problems. Examination revealed unlabored respirations, equal bilateral chest expansion, and no adventitious sounds. Records show that, in May 2008, the Veteran was treated in the emergency department for bronchitis. Chest X-rays at the time showed no acute changes; and no evidence of consolidation, infiltrates, pleural effusion, or pneumothorax. Subsequently records show that the Veteran was hospitalized in the intensive care unit of a private facility in June 2008 for an asthma attack. He reported being told that it was possible that exposure to oil smoke while in Desert Storm could have triggered asthma. VA records show that the Veteran was prescribed inhalers in September 2008, and that his bronchitis had resolved. Pulmonary consultation in October 2008 revealed assessments of possible asthma and possible allergic rhinitis. The VA physician noted that the Veteran was a lifelong non-smoker. The Veteran described loading and unloading aircraft in Desert Storm, and that he was in air-conditioned quarters and saw black clouds of smoke when oil fields were burned. Based on this evidence, the VA physician opined in October 2008 that it is unlikely the Veteran developed asthma from such an indirect exposure. Private records, dated in November 2008, show symptoms of difficulty breathing. Following the Board's March 2013 remand, the Veteran underwent a VA examination in April 2013 for purposes of determining the nature and etiology of his respiratory problems. The Veteran described the onset of symptoms of an acute respiratory illness in 2008; and that when his symptoms did not resolve, he underwent an inpatient evaluation and was diagnosed with asthma. Records show that, in mid-2012, evaluations continued due to persistent episodes of hypoexemia; and there continued to be several different possible diagnoses/etiology for the Veteran's respiratory condition, in addition to his known asthma. Computed tomography of the chest in March 2013 was indicative of eosinophilic pulmonary syndrome. The April 2013 examiner remarked that the Veteran's respiratory condition (other than asthma) had yet to be formally diagnosed. Because there was no confirmed etiology or diagnosis, the April 2013 examiner could not comment on what was causing the Veteran's current respiratory symptoms (other than asthma). Regarding asthma, the April 2013 examiner noted the history of diagnosis in 2008, many years after discharge from active service; and the absence of medical records prior to then that would suggest chronic respiratory symptoms. The April 2013 examiner suggested that the Veteran's asthma did not have its clinical onset during active service; and that there is no research that formally establishes a causal relationship between exposures during active service in SWA and the subsequent development of asthma. However, on the examination report, the April 2013 examiner "checked the box" for an opinion stating that the claimed condition was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. In this regard, the Board finds the opinion and the rationale provided by the examiner are in conflict; hence, the opinion has minimal probative value. Following the Board's May 2014 remand, the Veteran underwent a VA examination in January 2015 for purposes of determining the nature and etiology of his respiratory problems. Records show that pulmonary function testing in August 2014 was normal. Following examination, the January 2015 examiner opined that the Veteran's respiratory condition was less likely than not (less than 50 percent probability) incurred in or caused by any incident of active service, to include in-service exposure to burning oil fields and service in SWA. In support of the opinion, the January 2015 examiner reasoned that the Veteran's exposure was minimal at worst; and there was no documentation of any respiratory problems or complaints until 17 years later. In a January 2015 addendum, the VA examiner noted the Veteran's diagnosis of asthma and his medical history; and opined that the Veteran has asthma that, on occasion, has been associated with eosinophilia. The VA examiner opined that the Veteran does not have an undiagnosed illness that causes respiratory symptoms. In this regard, the VA examiner noted that the Veteran had gastroesophageal reflux disease and a hiatal hernia; and that failure to treat these commonly aggravated his asthma. The VA examiner indicated that the Veteran also used nonsteroidal antiinflammatory agents that are known to aggravate asthma, and the Veteran has been cautioned to avoid them. Here, the Board finds that the January 2015 examiner attributed the Veteran's respiratory problems to a known clinical diagnosis. Thus, a disability manifested by respiratory problems cannot be considered an undiagnosed illness or a qualifying chronic disability for entitlement to service connection based on the Veteran's service in the Persian Gulf. As for service connection on a direct basis, the report of the January 2015 VA examination weighs against a finding that the Veteran's respiratory disability was incurred in or caused by any incident of active service, to include in-service exposure to burning oil fields and service in SWA. The Board finds the January 2015 opinion is factually accurate, fully articulated, and contains sound reasoning. Therefore, the opinion is afforded significant probative value. As noted above, the Veteran's in-service exposure was minimal at worst, and there was no documentation of any respiratory problems until many years post-service. While the Veteran contends that his respiratory disability was caused by exposure to burning oil fields and service in SWA, he is not shown to have the medical expertise to offer an opinion on such a complex medical question. He is not shown to be competent to render an opinion as to the nature of his underlying respiratory disability, or to identify that such a disability is related to service in SWA. In essence, the Board finds that the issue presented in the case is not one in which the Veteran's lay contentions can serve to support an award of service connection. For the reasons and bases set forth above, the Board concludes that the preponderance of the evidence is against granting service connection for a respiratory disability, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Obstructive Sleep Apnea In this case, the record reflects that the Veteran was first diagnosed with obstructive sleep apnea in July 2008-i.e., several years after his military discharge from service. Although the disability has persisted, he is nevertheless not entitled to direct service connection for obstructive sleep apnea because there is no competent evidence linking the disability to any disease or injury in active service. Service treatment records do not reflect any findings or complaints of sleep problems or sleep apnea. On a "Report of Medical History" completed by the Veteran in May 1992, the Veteran reported frequent trouble sleeping. The examiner noted that the Veteran's work lately had been very stressful. No sleep disorder was found in active service. A nocturnal polysomnography report, dated in August 2008, reveals a diagnosis of mild obstructive sleep apnea syndrome. VA records, dated in September 2008, show that the Veteran was using a CPAP machine; and he had great improvement in daytime somnolence. In July 2009, the Veteran's daughter reported that the Veteran had snored in his sleep for a long time. Following the Board's May 2014 remand, the Veteran underwent a VA examination in January 2015 for purposes of determining the nature and etiology of his sleep apnea. Following a review of the Veteran's medical history and examination, the examiner opined that the Veteran's sleep apnea was less likely than not (less than 50 percent probability) incurred in or caused by the in-service injury, event, or illness. In support of the opinion, the examiner reasoned that the Veteran's sleep apnea was first diagnosed in 2008; and that there was no evidence of this problem in his treatment records dating back to 1980. The Board is within its province to make a determination as to whether the evidence supports a finding of service incurrence. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). As indicated above, the first credible showing of pertinent disability is many years after service with no competent evidence that it is in any way related to active service. While the Veteran is competent to report symptoms, he is not competent to provide an etiology opinion linking obstructive sleep apnea to active service, as this is beyond the capacity of a lay person to observe. Here, the Veteran also asserts that his obstructive sleep apnea is secondary to his service-connected Lyme disease with arthritis and arthralgias of multiple joints and spine. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. See 38 C.F.R. § 3.310(a), (b), as amended effective October 10, 2006. The report of an April 2013 VA mental disorders examination reflects that the Veteran reported sleep difficulty; and he addressed a number of physical problems related to arthritis, breathing difficulty, and leg movement at night that appears to explain the majority of his sleep disturbance. Although the Veteran had endorsed pain resulting from arthritis that interfered with his sleep, the VA examiner indicated that primary insomnia is not diagnosed when sleep disturbance is the result of a medical condition. In January 2015, another VA examiner opined that the Veteran's sleep apnea was less likely than not (less than 50 percent probability) proximately due to or the result of a service-connected disability. In support of the opinion, the examiner reasoned that sleep apnea was caused by neither arthralgias nor arthritis; and that the sleep apnea was not proximately due to or the result of service-connected disability. In reviewing the evidence of record, the Board finds that the Veteran originally was diagnosed with mild obstructive sleep apnea in 2008. Since then, the evidence primarily reflects that his obstructive sleep apnea had improved through the regular use of a CPAP machine. In this regard, no demonstrated increase in severity of symptoms of obstructive sleep apnea has been conceded to warrant secondary service connection via aggravation. The Board finds the January 2015 examination report to be persuasive in finding that the current obstructive sleep apnea is less likely related to active service, or due to the service-connected Lyme disease with arthritis and arthralgias of multiple joints and spine. Here, the VA examiner reviewed the medical history and provided a rationale which considered whether there was any relationship between obstructive sleep apnea, and arthralgias and arthritis. The evidence does not show that obstructive sleep apnea was present in service. The Board finds the opinion in the January 2015 examination report is factually accurate, fully articulated, and contains sound reasoning. Therefore, the opinion is afforded significant probative value. Nieves-Rodriguez, 22 Vet. App. at 304. Moreover, given the evidence of record demonstrating improvement in symptoms with regular use of a CPAP machine, the Board finds that aggravation or a permanent increase of severity of symptoms of obstructive sleep apnea due to Lyme disease with arthritis and arthralgias of multiple joints and spine, is indeed lacking. While the Veteran contends that his obstructive sleep apnea was caused by or had worsened due to his Lyme disease with arthritis and arthralgias of multiple joints and spine, he is not shown to have the medical expertise to offer an opinion on such a complex medical question. He is not shown to be competent to render an opinion as to the nature of his underlying obstructive sleep apnea, or to identify that such a disability is related to service or due to or aggravated by his service-connected Lyme disease with arthritis and arthralgias of multiple joints and spine. In essence, the Board finds that the issue presented in the case is not one in which the Veteran's lay contentions can serve to support an award of service connection. In short, for the reasons and bases set forth above, the Board concludes that the preponderance of the evidence is against granting service connection for obstructive sleep apnea, to include as secondary to Lyme disease with arthritis and arthralgias of multiple joints and spine. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a disability manifested by respiratory problems, to include asthma and bronchitis, is denied. Service connection for obstructive sleep apnea, to include as secondary to Lyme disease with arthritis and arthralgias of multiple joints and spine, is denied. REMAND Records Recent VA treatment records are pertinent to the Veteran's claim and should be obtained. See Bell v. Derwinski, 2 Vet. App. 611 (1992) (constructive notice of VA generated documents). Restless Leg Syndrome Nocturnal polysomnography reports, dated in July 2008 and in August 2008, include assessments of moderate periodic limb movement disorder. VA records show an assessment of restless legs in September 2008. In October 2008, the Veteran reported classical symptoms of obstructive sleep apnea, with many arousals attributed to restless legs. A VA physician indicated that, in approximately 50 percent of cases, the restless legs may disappear (and not require therapy). Records show that the Veteran took medications for restless leg syndrome in 2008 and in 2009. In April 2013, a VA examiner suggested that consultation with a pulmonary specialist was required to determine which symptoms were attributable to overlapping sleep conditions; and to determine whether the Veteran actually had a formal sleep disorder(s). In the absence of proof of present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). See also Degmetich v. Brown, 104 F.3d 1328 (1997) (also interpreting 38 U.S.C. § 1131 as requiring the existence of a present disability for VA compensation purposes). However, the Board recognizes the Court's decision in Romanowsky v. Shinseki, 26 Vet. App. 303 (2013), which held that a claimant satisfies the current disability threshold when a disability exists at the time his claim was filed, even if the disability resolves prior to VA's adjudication of the claim. In this case, although a diagnosis of restless leg syndrome was not rendered during VA examinations in 2014 and in 2015, the Board observes that VA treatment records during the pendency of the appeal include assessments of restless leg syndrome in 2008 and in 2009. Given that these assessments of record satisfy the current disability threshold as existing at the time the Veteran's claim was filed, the Board requires a clarifying medical opinion to ascertain whether the Veteran's previously diagnosed restless leg syndrome is related to his active service or to a service-connected disability. 38 C.F.R. § 3.159(c)(4) (2015). Accordingly, the case is REMANDED for the following action: 1. Obtain the Veteran's outstanding VA treatment records, dated from March 2015; and associate them with the Veteran's claims file. 2. Afford the Veteran a VA examination to determine the etiology of any current restless leg syndrome found to be present, and the etiology of restless leg syndrome diagnosed in 2008 and 2009. While examiners did not diagnose restless leg syndrome on VA examinations in 2014 and in 2015, restless leg syndrome was diagnosed during the pendency of the claim and thus an opinion as to etiology should be provided. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves). The examiner should opine as to: (a) Whether restless leg syndrome at least as likely as not (50 percent probability or more) either had its onset in active service or is otherwise related to active service, to include in-service exposure to burning oil fields and service in SWA. Please provide a complete explanation for the opinion. (b) Whether it is at least as likely as not (50 percent probability or more) that the service-connected Lyme disease with arthritis and arthralgias of multiple joints and spine, and/or medications taken for treatment, caused restless leg syndrome. Please provide a complete explanation for the opinion. (c) Whether it is at least as likely as not (50 percent probability or more) that the service-connected Lyme disease with arthritis and arthralgias of multiple joints and spine, and/or medications taken for treatment, aggravated (i.e., permanently worsened) the Veteran's restless leg syndrome beyond the natural progress of the disease. Please provide a complete explanation for the opinion. If aggravation is found, the examiner should address the following medical issues: (1) the baseline manifestations of the Veteran's restless leg syndrome found prior to aggravation; and (2) the increased manifestations which, in the examiner's opinion, are proximately due to a service-connected disability. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. If the examiner determines that an opinion cannot be made without resort to mere speculation, then it should be clear in the examiner's remarks whether it cannot be determined from current medical knowledge that a specific in-service injury or disease can possibly cause the claimed disorder, or whether the actual cause is due to multiple potential causes. In other words, simply stating that an opinion cannot be made without resort to mere speculation is not acceptable without a detailed explanation as to why this is so. See Jones v. Shinseki, 23 Vet. App. 382 (2010). All opinions and conclusions expressed must be supported by a complete rationale in a report. The Veteran's claims file, to include a complete copy of this REMAND, must be available to the examiner designated to examine the Veteran, and the examination report should note review of the file. 3. After ensuring that the requested actions are completed, re-adjudicate the claim on appeal. If the benefits sought are not fully granted, furnish a supplemental statement of the case (SSOC) and then return the claims file to the Board, if otherwise in order. No action is required of the Veteran and his representative until they are notified by the RO or VA's Appeals Management Center (AMC); however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2015). The Veteran has the right to submit additional evidence and argument on the matter that 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 2014). ______________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs