Citation Nr: 1629728 Decision Date: 07/26/16 Archive Date: 08/04/16 DOCKET NO. 13-10 035 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Whether new and material evidence has been received to reopen service connection for a bilateral eye disability. 2. Whether new and material evidence has been received to reopen service connection for a back disability. 3. Entitlement to service connection for iritis of the eyes (a bilateral eye disability). 4. Entitlement to service connection for a back disability. 5. Entitlement to service connection for residuals of surgical removal of a spinal cord tumor, to include incomplete paraplegia of the lower extremities (claimed as confinement in a wheelchair due to surgical removal of an intramedullary spinal cord tumor). WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD L.M. Yasui, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from September 1985 to April 1989. He also served in the Army Reserves from April 1989 to October 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2011 rating decision of the Department of Veterans Affairs (VA) Atlanta Regional Office (RO) located in Decatur, Georgia. This appeal was processed using both the Virtual VA paperless claims processing system and the Veterans Benefits Management System (VBMS). Accordingly, any future review of this case should take into consideration the existence of this electronic record. In September 2015, the Veteran testified in a Videoconference Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is associated with the Veteran's file on VBMS. The Veteran was previously represented in this matter. In April 2016, the Veteran was sent a letter informing him that the previously assigned representative withdrew representation and, as a result, the Veteran was now unrepresented. The Veteran was advised that he would have 30 days to appoint a new representative, should one be desired. The Veteran was also informed that, if no new representative was appointed within 30 days of the date of the letter, VA would assume that the Veteran wished to proceed pro se, and the Board would resume its review of the appeal. To date, the Veteran has not appointed a new representative. The Veteran has waived initial RO consideration of the evidence added to the record since the issuance of the February 2013 Statement of the Case. The issues of service connection for a back disability and incomplete paraplegia of the lower extremities are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. An August 1993 rating decision denied service connection for a bilateral eye condition and a back disability on the basis that there was no evidence showing current bilateral eye iritis and no current permanent residual disability of the low back. 2. New and material evidence was received in December 1993 that revealed diagnoses of bilateral eye and back disabilities, which rendered the August 1993 rating decision pending. 3. An unappealed February 1994 rating decision denied service connection for a bilateral eye condition and low back strain on the basis that the conditions of the eyes and back treated in service were considered to be acute, transitory, and not chronic in nature. 4. The Veteran did not appeal the February 1994 rating decision after being notified of appellate rights, and no additional new and material evidence was received within one year of the decision. The most recent prior final denial is the unappealed February 1994 rating decision. 5. The evidence received since the February 1994 rating decision is neither cumulative nor redundant and addresses the grounds of the prior final denial of service connection for a bilateral eye disability and a back disability, so raises the possibility of substantiating the claims of service connection for a bilateral eye disability and a back disability. 6. The Veteran was diagnosed with iritis of the eyes during active service. 7. The Veteran has been diagnosed with iritis of the eyes since service separation. 8. The Veteran's currently diagnosed iritis of the eyes had its onset in service. CONCLUSIONS OF LAW 1. The February 1994 rating decision denying service connection for a bilateral eye condition and low back strain became final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2015). 2. New and material evidence has been received to reopen service connection for a bilateral eye disability and a back disability. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2015). 3. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for iritis of the eyes have been met. 38 U.S.C.A. §§ 1111, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The applications to reopen service connection for a bilateral eye disability and a back disability and service connection for a bilateral eye disability have been considered with respect to VA's duties to notify and assist. Given the favorable outcomes adjudicated herein (reopening of service connection for a bilateral eye disability and a back disability, and service connection for iritis of the eyes), no conceivable prejudice to the Veteran could result from this decision, and further explanation of how VA has fulfilled the duties to notify and assist is not necessary. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In attempts to reopen previously denied claims for service connection, the duty to assist does not include provision of a medical examination or opinion, unless new and material evidence has been secured. See 38 C.F.R. § 3.159 (c)(4)(iii). The issue of service connection for a back disability, which is reopened in the decision herein, is remanded below for further development. Reopening of Service Connection for Bilateral Eye and Back Disabilities Generally, a claim which has been denied in a final unappealed rating decision, or a rating decision that was appealed but was not perfected, may not thereafter be reopened and allowed. 38 U.S.C.A. § 7105(c), (d)(3); 38 C.F.R. § 20.1103. If "new and material" evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). "[N]ew evidence" means evidence not previously submitted to agency decision makers which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial. 38 C.F.R. § 3.156(a). Materiality has two components, first, that the new evidence pertains to the reason(s) for the prior final denial, and second, that the new evidence, combined with VA assistance and considering the other evidence of record, raises a reasonable possibility of substantiating the claim. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). When making a determination whether the submitted evidence meets the definition of new and material evidence, the Board should take cognizance of whether that evidence could, if the claim were reopened, reasonably result in substantiation of the claim, applying concepts derived from the duty to assist. Id., at 118. The Veteran seeks to reopen the previously denied claims of service connection for a bilateral eye disability and a back disability. The claims, initially filed in January 1993, were originally denied in an August 1993 rating decision. At that time, the issues of service connection for a bilateral eye condition and a back disability were denied on the basis that there was no evidence showing current bilateral eye iritis and no current permanent residual disability of the low back. In December 1993, within one year of the August 1993 letter notifying the Veteran of the August 1993 rating decision, additional treatment records from the Veteran's period of Army Reserves service were submitted, which revealed current diagnoses of bilateral eye iritis and scoliosis of the back. See 38 C.F.R. § 3.156(b) (2015) (new and material evidence which is received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period). Because new and material evidence was received within one year of the August 1993 letter notifying the Veteran of the August 1993 rating decision, finality of that rating decision was precluded under 38 C.F.R. § 3.156(b). Pursuant to the submission of the treatment records in December 1993, in a February 1994 rating decision, the RO readjudicated the claims of service connection for a bilateral eye condition and low back strain, and denied the claims on the basis that the conditions of the eyes and back treated in service were considered to be acute, transitory, and not chronic in nature. The Veteran did not initiate an appeal of the decision denying service connection for a bilateral eye condition and a back disability, and he also did not submit any new and material evidence with respect to this claim within the applicable one-year period. See 38 C.F.R. § 3.156(b); Jennings v. Mansfield, 509 F.3d 1362, 1368 (Fed. Cir. 2007). As such, the February 1994 decision (denying service connection for a bilateral eye disability and low back strain) became final as to the evidence then of record, and is not subject to revision on the same factual basis. 38 U.S.C.A. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. Since the February 1994 rating decision, additional evidence has been received in the form of the Veteran's statements, particularly during the September 2015 Videoconference Board hearing, VA and private treatment records, and a November 2013 opinion from Dr. C.N.B. regarding the etiology of the claimed conditions. The Veteran's statements, VA and private treatment records, and Dr. C.N.B.'s opinion are new because they have not been previously submitted. This evidence, particularly Dr. C.N.B.'s medical opinion, is also material because it pertains to the basis for the prior denial, that is, an in-service event or injury of the eyes and back, and a link (or nexus) to the current bilateral eye and back disabilities (a necessary element for direct service connection), so raises a reasonable possibility of substantiating the claims. 38 C.F.R. § 3.303. Specifically, in a September 2015 submission, Dr. C.N.B. opined that the Veteran's current bilateral eye disability and back disability are caused by syphilis, which was diagnosed in service and inadequately treated in service. In this regard, when making determinations as to whether new and material evidence has been received, the credibility of the evidence is presumed, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion. Justus v. Principi, 3 Vet. App. 510, 513 (1992); Duran v. Brown, 7 Vet. App. 216 (1995). For these reasons, the Board finds that new and material evidence has been received to reopen service connection for a bilateral eye disability and service connection for a back disability. See 38 C.F.R. § 3.156(a). The reopened issue of service connection for iritis of the eyes is adjudicated below, and the reopened issue of service connection for a back disability is addressed in the Remand section below. Service Connection - Laws and Regulations Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Iritis is not a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions based on "chronic" in-service symptoms and "continuous" post-service symptoms under 38 C.F.R. §§ 3.303(b) and 3.309(a) do not apply. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1154(a) (West 2015); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, 1 Vet. App. at 57. 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, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection for Bilateral Eye Iritis The Veteran contends that the currently diagnosed iritis of the eyes first manifested during service and that he has continued to have bilateral eye iritis since service separation. See January 1993 Claim. First, the evidence demonstrates that the Veteran has currently diagnosed iritis of the eyes. See September 2014 Private Treatment Record, Emory Eye Center. In service treatment records, dated in February 1988 and March 1988, the Veteran was diagnosed with anterior iritis of the right eye and anterior and posterior uveitis, respectively. In a March 1989 Report of Medical History, the Veteran reported that he received treatment for iritis the previous year. A January 1993 Report of Medical History, during the Veteran's period of Reserves duty, revealed that the Veteran has iritis and is currently receiving medication. Similarly, an August 1994 treatment record during the Veteran's period of Reserves duty indicated that the Veteran had recurrent episodes of iritis. As such, the Board finds that the Veteran was diagnosed with iritis of the eyes during service and since service separation. Based on the above, and resolving reasonable doubt in the Veteran's favor, the Board finds that the iritis of the eyes was incurred in active service; thus, the criteria for service connection for iritis of the eyes have been met. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. The grant of direct service connection renders moot other theories of service connection. ORDER As new and material evidence has been received, the appeal to reopen service connection for a bilateral eye disability is granted. As new and material evidence has been received, the appeal to reopen service connection for a back disability is granted. Service connection for iritis of the eyes is granted. REMAND Service Connection for a Back Disability and Incomplete Paraplegia of the Lower Extremities The Veteran contends that he has a current back disability due to the back injury sustained in service. In the alternative, the Veteran argues that the syphilis diagnosed in service resulted in the current back disability. The Veteran also contends that he is in a wheelchair because he cannot use his legs due to residuals of surgery to remove a spinal cord tumor. He further contends that the spinal cord tumor was caused by the syphilis diagnosed in service. In January 1986, the Veteran complained of back problems for the past two days. He had a positive history of back problems and reported that the back pain occurred while lifting and moving heavy equipment. Approximately one week later, in January 1986, the Veteran continued to complain of mid-back pain. At that time, he was assessed with lumbosacral strain secondary to increased lordosis and mechanical low back pain. Intrascapular muscle strain was also indicated. A March 1988 service treatment record reveals that the Veteran was admitted to the Army Medical Center from March 10, 1988 to March 23, 1988 after complaints of an eye infection that was not improving with medication. At that time, the Veteran denied exposure, symptoms, or treatment of syphilis, but he admitted to three days of intermittent chest pain described as sharp midsternal pain decreasing with respirations prior to his eye pain, redness, and photophobia. In light of some positive test results, the Veteran was suspected to have a diagnosis of secondary or latent syphilis in combination with uveitis (service connection for iritis is adjudicated and granted in the decision above). It was elected, in consultation with the Infectious Disease Service, to treat the Veteran for a 14-day course of Penicillin. In a January 1993 Report of Medical History during the Veteran's Reserves service, the Veteran complained of occasional back pain. In June 2003, during Reserves duty, multiple views of the thoracic spine revealed mild to moderate dextroscoliosis and degenerative changes throughout the thoracic spine. In a November 2013 submission, Dr. C.N.B. offered opinions as to the etiology of the Veteran's claimed back condition and incomplete paraplegia. While Dr. C.N.B. opined that the back disorder and incomplete paraplegia are due to the inadequately treated syphilis in service (argued by Dr. C.N.B. as evidenced by the recurrence of bilateral eye iritis in service and since service), the Board finds that Dr. C.N.B.'s opinions are inadequate. In the lengthy explanation of his conclusions, while Dr. C.N.B. briefly mentioned a finding of "x-ray scoliosis convex at L2," Dr. C.N.B. does not include a discussion of the scoliosis and the etiologies of the current back disabilities and incomplete paraplegia in relation to the scoliosis. Indeed, in an April 2003 private treatment record, the treating physician indicated that the Veteran was transferred to his care with a diagnosis of incomplete paraplegia secondary to a spinal cord tumor, which was diagnosed in December of 2002. The private treating physician immediately noted that the Veteran has had longstanding scoliosis, as well as lower extremity weakness, and over the past two years, the Veteran has noticed increasing weakness of the right lower leg. In this regard, scoliosis may be considered congenital. Service connection is available for congenital diseases, but not defects, that are aggravated in service. Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009); Monroe v. Brown, 4 Vet. App. 513, 515 (1993). In cases where the appellant seeks service connection for a congenital condition, the Board must indicate whether the condition is a disease or defect and discuss the presumption of soundness. Quirin, 22 Vet. App. at 394-97. It follows that, in such cases where a congenital condition is at issue, a VA medical opinion may be needed to determine whether the condition is a disease or defect, whether the presumption of soundness has been rebutted, and if so whether there was aggravation during service. Id. at 395. Also, the presumption of soundness does not apply to congenital defects because such defects "are not diseases or injuries" within the meaning of 38 U.S.C.A. §§ 1110 and 1111. See 38 C.F.R. § 3.303(c); see also Quirin at 394 (holding that the presumption of soundness does not apply to congenital defects); Winn v. Brown, 8 Vet. App. 510, 516 (1996) (holding that a non-disease or non-injury entity such as a congenital defect is "not the type of disease or injury-related defect to which the presumption of soundness can apply"). For purposes of determining whether a disorder is a congenital defect or a familial disease, VA interprets the term "disease" in 38 U.S.C. §§ 1110, 1131, and the term "defects" in 38 C.F.R. § 3.303(c), as being mutually exclusive. "Disease" is broadly defined as any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. See VAOPGCPREC 82-90 (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 385 (26th Ed. 1974)). On the other hand, the term "defect," viewed in the context of 38 C.F.R. § 3.303(c), is defined as a structural or inherent abnormality or conditions which are more or less stationary in nature. As noted in VAOPGCPREC 82-90, a Federal court, in drawing a distinction between "disease" and "defect," indicated that disease referred to a condition considered capable of improving or deteriorating, whereas defect referred to a condition not considered capable of improving or deteriorating. See Durham v. United States, 214 F.2d 862, 875 (D.C. Cir. 1954); see also United States v. Shorter, 343 A.2d 569, 572 (D.C. 1975). If it is determined during service that a veteran suffers from a congenital disease, as opposed to a defect, VA cannot simply assume that, because of its congenital nature, the disease must have preexisted service. That is, the presumption of soundness still applies to congenital diseases that are not noted at entry. Quirin at 396-97. VA must then show by clear and unmistakable evidence that the congenital disease preexisted service and was not aggravated thereby in order to rebut the presumption of soundness. Monroe v. Brown, 4 Vet. App. 513, 515 (1993). VA may not rely on a regulation as a substitute for the requirement that it rely on independent medical evidence. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). VA's Office of General Counsel has also interpreted that the existence of a congenital hereditary disease under 38 C.F.R. § 3.303(c) does not always rebut the presumption of soundness, and that service connection may be granted for congenital hereditary diseases which either first manifest themselves during service or which preexist service and progressed at an abnormally high rate during service. See VAOPGCPREC 67-90. A preexisting injury or disease that is "noted" at service entrance will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. 38 C.F.R. § 3.306. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. Id. Given the above, a remand is warranted for a VA examination and medical opinion to assist in determining the etiology of any back disability and the incomplete paraplegia of the lower extremities. Accordingly, the issues of service connection for a back disability and incomplete paraplegia of the lower extremities are REMANDED for the following actions: 1. Schedule the appropriate VA examination to assist in determining the nature, extent, and etiology of any back disorder, to include scoliosis, and the residuals of the surgical removal of a spinal cord tumor, including incomplete paraplegia of the lower extremities. All relevant documents should be made available to and reviewed by the VA examiner in rendering the opinions. The VA examiner should conduct a thorough examination, including any relevant tests and studies, and provide a diagnosis for any pathology found. Based on the examination and review of the appropriate records, the VA examiner should offer the following opinions: a) Does the Veteran have a current back disability, including, but not limited to, scoliosis? If the Veteran does not have a current diagnosis of a back disability, to include, but not limited to, scoliosis, the VA examiner should so state. b) If the Veteran has a currently diagnosed back disability (other than scoliosis), is it at least as likely as not (a 50 percent or greater degree of probability) that the disability began during service or is etiologically related to active service? In rendering the opinion requested in paragraph b), the VA examiner should note, consider, and address, the service treatment records from January 1986 that reflect treatment for a back injury, the March 1988 diagnosis of secondary syphilis, and the January 1993 Report of Medical History during the Veteran's Reserves service, which revealed the Veteran's complaint of occasional back pain. c) If the Veteran is diagnosed with scoliosis, is the scoliosis congenital or acquired? d) If the Veteran's scoliosis is acquired, is it at least as likely as not (a 50 percent or greater degree of probability) that the acquired scoliosis had onset in service or is otherwise etiologically related to service? e) If the Veteran's scoliosis is congenital, is the congenital scoliosis more accurately characterized as a congenital "disease" or a congenital "defect"? f) If the scoliosis is a congenital defect, is it at least as likely as not (a 50 percent or greater degree of probability) that such condition was subject to, or aggravated by, a superimposed disease or injury during service which resulted in additional disability? g) If the scoliosis is a congenital disease, did it clearly and unmistakably preexist service? If it is the VA examiner's opinion that the congenital scoliosis (as a disease) clearly and unmistakably preexisted service, was the preexisting congenital scoliosis clearly and unmistakably not aggravated (not permanently worsened beyond the natural progression) during active service? In rendering the opinions requested in paragraph g), the VA examiner should use the explicit standard - clearly and unmistakably - to determine whether the congenital scoliosis, as a disease, preexisted service and was not aggravated by service. Note: The term aggravated means a lasting increase in severity of the underlying disability that is not due to the natural progress of the disease. An exacerbation of symptoms during service does not constitute aggravation. Moreover, if the disability becomes worse during service and then improves due to in-service treatment to the point that it was no more disabling than it was at entrance into service, there is no aggravation. h) If the VA examiner concludes that it is not clear and unmistakable that the Veteran's congenital scoliosis preexisted service in September 1985, OR it is not clear and unmistakable that the preexisting congenital scoliosis was not permanently worsened by service beyond the natural progression, the VA examiner should then provide the following opinion: Is it at likely as not (a 50 percent or greater degree of probability) that any current congenital scoliosis is directly related to service, that is, did congenial scoliosis begin during service? Also, in rendering the opinions requested in paragraphs d), f), g), and h), the VA examiner should note, consider, and address the service treatment records from January 1986 that reflect treatment for a back injury, the March 1988 diagnosis of secondary syphilis, and the January 1993 Report of Medical History during the Veteran's Reserves service, which revealed the Veteran's complaint of occasional back pain. i) Is it at likely as not (a 50 percent or greater degree of probability) that the residuals of the surgical removal of a spinal cord tumor, including incomplete paraplegia of the lower extremities, are directly related to service, including the March 1988 diagnosis of syphilis? Specifically, the VA examiner should address whether it is at least as likely as not that the spinal cord tumor (which was removed in April 2003 and resulted in incomplete paraplegia of the bilateral lower extremities) was caused by, or is related to, the syphilis diagnosed in service in March 1988. The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather 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 causation as it is to find against it. A rationale should be given for all opinions and conclusions rendered. The opinions should address the particulars of this Veteran's medical history and the relevant medical science as applicable to these claims. 2. After completion of the above and compliance with the requested actions has been ensured, the appeals of service connection for a back disability and residuals of the surgical removal of a spinal cord tumor, including incomplete paraplegia of the lower extremities, should be readjudicated in light of all the evidence of record. If the determinations remain adverse to the Veteran, he and his representative, if any, should be furnished with a Supplemental Statement of the Case. An appropriate period of time should then be allowed for a response 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 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). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs