Citation Nr: 18143264 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 12-19 402 DATE: October 18, 2018 ORDER Entitlement to service connection for a respiratory disability variously diagnosed as chronic obstructive pulmonary disease (COPD) and reactive airway disease (RAD), to include as due to undiagnosed illness, is denied. REMANDED The issue of entitlement to service connection for hiatal hernia is remanded. FINDING OF FACT A chronic respiratory disability did not result from undiagnosed illness that was shown during active service; the evidence is against a finding that a chronic respiratory disability is related to active service or events therein. CONCLUSION OF LAW The criteria for entitlement to SC for obstructive/restrictive airway disease denied have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Entitlement to SC for obstructive/restrictive airway disease denied Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a claimant must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service”-the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Service connection may also be established for a chronic disability manifested by certain signs or symptoms which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021, and which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1); 81 FR No. 200, pp. 71382-71384 (October 17, 2016). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): an undiagnosed illness; the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) Chronic fatigue syndrome; (2) Fibromyalgia; (3) Functional gastrointestinal disorders; or (4) Any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a). The term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a). A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a). A disability referred to in this section shall be considered service connected for purposes of all laws of the United States. 38 C.F.R. § 3.317(a). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) Fatigue (2) Signs or symptoms involving skin (3) Headache (4) Muscle pain (5) Joint pain (6) Neurologic signs and symptoms (7) Neuropsychological signs or symptoms (8) Signs or symptoms involving the respiratory system (upper or lower) (9) Sleep disturbances (10) Gastrointestinal signs or symptoms (11) Cardiovascular signs or symptoms (12) Abnormal weight loss (13) Menstrual disorders. 38 C.F.R. § 3.317(b). Compensation shall not be paid under this section if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations 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 the Southwest Asia theater of operations 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). The term “Persian Gulf Veteran” means a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b). The Veteran seeks service connection for a respiratory disability. Signs and symptoms involving the respiratory system are included in 38 C.F.R. § 3.317(b). The report of a VA general medical examination in October 1992 reflects various complaints and diagnoses, but does not include any referable to the Veteran’s respiratory system. A Persian Gulf Registry exam history dated in November 1993 indicates that chest X-ray findings indicated a prominent gastric air bubble. The Veteran reported occasional shortness of breath. Physical examination indicated clear lungs. X-rays were unremarkable without infiltrate, effusion, or consolidation. Records dated in January 1998 from Walter Reed Medical Center (WRMC) Gulf War Health Center reflect that the Veteran was seen for a history of persistent physical symptoms with onset after service in the Gulf War. An intake note indicates undifferentiated somatic complaints, to include dyspnea and pleurisy. Symptoms included chest pain, dizziness, and fatigue. Admission diagnoses included obstructive airway disease. The Veteran underwent a comprehensive evaluation through WRMC’s Specialized Care Program, a multidisciplinary intensive outpatient program for the treatment of persistent, disabling Gulf War-related symptoms. Following completion of that program, the discharge diagnoses did not include any referable to his respiratory system. A June 2000 VA mental health outpatient record notes the Veteran’s report of Gulf War syndrome and related medical problems, to include shortness of breath. An April 2007 record from a private gastroenterologist indicates the Veteran’s report of dyspnea. Physical examination revealed normal breath sounds, without rubs, wheezes, rale, or rhonchi. Chest excursion as normal, without intercostal retraction or accessory muscle use. A private treatment note from Care MD, dated in February 2009, reflects that the Veteran presented with complaints of symptoms from the Gulf War. On review of systems, the Veteran denied shortness of breath. On examination, his lungs were clear. In a March 2009 letter, D.F., DO, Care MD, stated that the Veteran had disorders that were as likely as not due to service in the Gulf War. He specified various disorders, but did not include any referable to the Veteran’s respiratory system. A June 2009 statement from the Veteran’s wife indicates that the Veteran felt winded and short of breath with normal activities. A June 2009 statement from the Veteran’s mother indicates that he had a multitude of medical problems. On VA examination in October 2009, the Veteran denied a history of asthma, bronchitis, and pneumonia. He indicated onset of symptoms during the Gulf War, reporting shortness of breath, wheezing, and cough. The examiner noted that a diagnosis of mild obstructive airway disease had been rendered. The Veteran endorsed daily coughing, shortness of breath, and decreased exercise tolerance. He reported that he had gained 25 pounds in the previous year. Pulmonary function tests revealed borderline obstruction and FEV1/FVC normal (lowest limit). Chest X-ray showed normal heart size and lungs. The diagnoses included mild obstructive airway and restrictive airway disease per PFT findings. The examiner stated that there were no undiagnosed Gulf War conditions. In a July 2010 statement, the Veteran indicated that while in Southwest Asia, he was exposed to the fumes from burn pits and smoke from burning oil. He indicated that on his return, he experienced consistent issues breathing and was unable to finish runs or perform any type of prolonged physical activity. On VA examination in August 2010, the Veteran reported occasional wheezing at night, and dyspnea with mild exertion. Pulmonary examination revealed prolonged expiration bilaterally. The examiner stated that pulmonary function tests showed no evidence of obstruction. However, borderline restriction and normal diffusion capacity of the lungs were found. The diagnosis was mild restrictive airways dysfunction. The examiner opined that this condition was more likely than not secondary to the body habitus, noting that the Veteran’s body mass index (BMI) was 31. She explained this was the only risk factor for this restrictive disorder, and it was scientifically documented that obesity would cause a mild restrictive disorder on standard pulmonary function tests. She further opined that this condition was less likely as not related to any specific exposure event experienced during service in Southwest Asia. A letter dated in November 2010 by Dr. F reflects that he reviewed pulmonary function tests dated in 1997, 2009, and 2010, along with a physician’s comment that the changes in the studies were a result of the Veteran being overweight. Dr. F disagreed with that conclusion that a BMI of 31 and/or obesity caused reactive airway disease. He recommended a full pulmonary consultation on whether the disease was partially responsible for the pulmonary changes. In a May 2012 letter, Dr. F stated that it was as likely as not that the Veteran’s respiratory problems were directly related to his exposures to toxins when serving in the military during the Gulf War. He noted that he had seen the Veteran for multiple visits with respiratory problems such as shortness of breath, wheezing, and chronic lung changes over the previous seven years. In June 2012, the Veteran reported that he was not over weight in service when he began to experience symptoms of obstructive airway disease. He suggested that he had a qualifying chronic disability manifested by obstructive/restrictive airway disease, which merited VA disability compensation. In July 2012, Dr. F stated that the Veteran been under his care for many years. He noted that the Veteran suffered from post-gulf war syndrome which had caused a combination of problems including irritable bowel syndrome, fibromyalgia and chronic fatigue syndrome. He stated that all of the Veteran’s problems started very acutely initially but had come chronic issues over time. In 2015, VA received a “Formal Health Record” from a private medical provider at Care MD listing the Veteran’s medical problems, which included asthma, with onset date of November 2013, other disease of trachea and bronchus with onset date of November 2010, and unspecified esophagitis with onset date of June 2010. In 2015, the Veteran submitted statements from service buddies and his mother. TS reported that she served with the Veteran and knew that he had breathing problems, and that he took medication for his problems. DL reported that he served with the Veteran in Saudi Arabia, Iraq, and Kuwait; and that they were exposed to environmental hazards described as dust storms and burn pits, and given “experimental inoculations” for anthrax and malaria. DL reported knowledge of the Veteran’s breathing problems with physical exertion activities. During his May 2015 hearing, the Veteran testified that he experienced breathing problems while in the Gulf. He stated that he developed a horrible cough and chronic bronchitis. He stated that he received extensive testing and was diagnosed with obstructive airway disease. On VA examination in October 2016, the examiner reviewed the Veteran’s history and included a detailed recitation of the evidence of record. She indicated that there was a history of borderline obstructive lung disease and a history of borderline restrictive lung disease, but no current evidence of such, or of RAD, COPD, interstitial lung disease, or other intrinsic lung condition of clinical significance. She also noted that there was a stable pulmonary nodule secondary to prior infection, without active infection or clinical significance. With respect to current symptoms, the Veteran endorsed shortness of breath at rest, with tightness in his chest several times per week. He also endorsed shortness of breath with exertion such as walking up stairs and walking for more than one block. He indicated that he experienced wheezing only at peak exercise. Following examination, the examiner concluded that it was less likely than not that any respiratory disorder was first manifested in service. She reasoned that the Veteran had no history of a respiratory condition diagnosed or identified in service. Regarding Veteran's subjective symptoms of shortness of breath, the examiner noted that although the Veteran currently reported that episodes of shortness of breath with exertion started in service, service treatment records reflected that two months prior to discharge from service, the Veteran denied shortness of breath on his medical history questionnaire. She noted that, as there were many “yes” answers on this questionnaire, it was not likely that the lack of positive response was due to concern about reporting medical issues. She pointed out that her review of the service treatment records revealed no history of wheezing, chronic cough or a lung condition, and that the only report of shortness of breath was during an episode of upper respiratory infection in 1991, during which shortness of breath would be expected. She indicated that she had considered the Veteran’s history as well as the buddy statements noting some difficulty with physical exercise. She pointed out, however, that the Veteran had reduced/limited physical activity due to a comorbid ankle condition, and stated that shortness of breath with the previous level of exercise was not unexpected if fitness/conditioning was reduced due to the ankle. She specified that as physical activity was reduced and physical fitness declined, shortness of breath could be expected with physical activities that previously did not cause shortness of breath. She indicated that reduction in exercise capacity occurred rapidly with reduction in aerobic exercise. She stated that, overall, there was no evidence that this represented an intrinsic lung condition, and that there is no support for onset of a respiratory disorder in service. She noted that the Veteran had a relatively recent diagnosis of pulmonary nodule, which she believed was secondary to previous infection. She indicated that there was no evidence that this started in service, as initial radiographs post service did not identify this condition, which supported a finding of recent onset years post service. She specified that the Veteran had no history of infection in service that would be expected to cause this condition, and medical literature did not support pulmonary nodules in association with environmental disorders The examiner also opined that it was less likely than not the Veteran had a respiratory disorder that was etiologically related to service, including environmental exposures during service in Southwest Asia. She reasoned that the Veteran's current diagnoses included history of borderline obstructive lung disease and history of borderline restrictive lung disease, with no current evidence of obstructive lung disease, restrictive lung disease, reactive airways disease, COPD, interstitial lung disease, or other intrinsic lung condition of clinical significance. With respect to the identified pulmonary nodule, she stated that this was a diagnosable medical condition with known etiology. She specified that she had reviewed the Veteran's extensive records, his reports, buddy statements, letters from medical providers, previous examinations, previous and current pulmonary function test results, and pulmonary evaluations. She noted that the Veteran had subjective complaints of shortness of breath that began with exertion and gradually progressed to include occasional symptoms at rest. She acknowledged that these reported subjective symptoms had triggered various medical diagnoses over the years, noting that previous testing was borderline for both obstructive disease and restrictive disease. She noted that diagnoses of asthma and reactive airways disease had also been given to the Veteran due to the lack of abnormality on pulmonary function tests. She stated that borderline values were not diagnostic of these conditions. She pointed out that review of previous examinations showed no objective evidence of active wheezing on physical exams. She concluded that, overall, there had not been objective support for a respiratory disability or condition. She noted that evaluation at WRAMC in January 1998 indicated a diagnosis of obstructive airway disease on admission, however, she pointed out that after phase II exam testing was completed, there was no respiratory disorder identified on discharge. She indicated that her review of various medical provider evaluations over the years confirmed various diagnoses based on subjective symptoms. She noted that most recently, pulmonary evaluation by VA noted that, based on reported symptoms, the Veteran was initially felt to have constrictive bronchiolitis, which had been associated with Gulf War exposure; however, she pointed out that pulmonary function tests and CT scan did not confirm this diagnosis, and the pulmonologist in the most recent diagnosis did not include constrictive bronchiolitis, noting only the pulmonary nodule which was stable and followed by multiple CT with no additional respiratory condition diagnosed. She noted that a previous VA examiner noted borderline restriction likely due to weight. She stated that increased abdominal girth secondary to obesity was well-documented in medical literature as a cause of restriction on pulmonary function tests and agreed with the previous examiner that there was no evidence of intrinsic lung disease to include restrictive lung disease. She stated that current testing did not identify restrictive lung disease. She added that the Veteran had been on multiple medications but reported that none were particularly helpful for his pulmonary symptoms. She stated that, overall, the Veteran had reported subjective symptoms of shortness of breath without objective evidence of diagnosable lung condition. She indicated that the Veteran's symptoms were completely consistent with deconditioning regardless of whether he was of normal weight or overweight. She stated that the Veteran's current overweight condition and disproportionate increased abdominal girth would be expected to cause shortness of breath. The examiner additionally concluded that it was less likely than not the Veteran's respiratory symptoms were a qualifying chronic disability resulting from an undiagnosed illness or part of medically unexplained chronic multisymptom illness. She reasoned that multiple medical diagnoses had been ascribed to the Veteran’s subjective symptoms of shortness of breath primarily with exertion. She stated that current evaluation included normal physical lung exam, normal pulmonary function tests, and normal imaging, other than the stable benign pulmonary nodules which did not cause clinical symptoms. She indicated that, although the Veteran reported subjective symptoms, there was no evidence of a disability associated with the subjective symptoms beyond that which was expected for the Veteran's current level of physical deconditioning and obesity with increased abdominal girth. She concluded that the Veteran’s symptoms could be explained due to those factors without evidence of pulmonary illness. Finally, the examiner concluded that it was less likely than not that the Veteran had a respiratory disorder that was either proximately due to or aggravated by a service connected disability. She reasoned that the Veteran's stable pulmonary nodule was a residual due to previous infection sometime after service. She noted that there was no pathophysiologic mechanism by which the pulmonary nodule could be caused by or aggravated by any of the Veteran’s service-connected disabilities, She stated that the Veteran's subjective shortness of breath with exercise is not associated in the medical literature with any of his service-connected conditions, and that there was no plausible pathophysiologic mechanism by which his service-connected conditions would be expected to contribute to or aggravate these subjective symptoms. Upon careful review of the record, the Board has concluded that service connection is not warranted for the claimed respiratory disability. In this regard, the Board acknowledges that the Veteran has a history of respiratory complaints, to which various diagnoses have been ascribed. However, the October 2016 VA examiner concluded that the Veteran’s subjective respiratory symptoms are related to his body habitus, obesity, and deconditioning, and that there was no respiratory disease. In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). A symptom or a finding, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a “disability” for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). The Court has consistently held that, under the law, a “determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service.” Watson v. Brown, 4 Vet. App. 309 (1993). This principle has been repeatedly reaffirmed by the Federal Circuit, which has stated that “a veteran seeking disability benefits must establish... the existence of a disability [and] a connection between the veteran’s service and the disability.” Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). To the extent that the Veteran asserts that his claimed respiratory disorder is related to service, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and that his assertions in that regard are entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). He is competent to report incidents and symptoms in service and symptoms since then. He is not, however, competent to render an opinion as to diagnosis because he does not have the requisite medical knowledge or training, and because such matters are beyond the ability of a lay person to observe. See Rucker v. Brown, 10 Vet. App. 67, 71 (1997); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). On the other hand, the VA clinician who examined the Veteran in 2016 concluded that there was no diagnosed respiratory disease, and that the Veteran’s subjective symptoms were related to body habitus and obesity, as well as general deconditioning. She carefully recited the relevant evidence, demonstrating that she had reviewed the Veteran’s history, statements, and assertions. She stated that, overall, the Veteran had reported subjective symptoms of shortness of breath without objective evidence of diagnosable lung condition. She indicated that the Veteran’s symptoms were completely consistent with deconditioning regardless of whether he was of normal weight or overweight. She stated that the Veteran’s current overweight condition and disproportionate increased abdominal girth would be expected to cause shortness of breath. The examiner additionally concluded that it was less likely than not the Veteran’s respiratory symptoms were a qualifying chronic disability resulting from an undiagnosed illness or part of medically unexplained chronic multisymptom illness. She acknowledged that multiple medical diagnoses had been ascribed to the Veteran’s subjective symptoms, but pointed out that current evaluation included normal physical lung exam, normal pulmonary function tests, and normal imaging, other than the stable benign pulmonary nodule which did not cause clinical symptoms. She indicated that, although the Veteran reported subjective symptoms, there was no evidence of a disability associated with the subjective symptoms beyond that which was expected for the Veteran’s current level of physical deconditioning and obesity with increased abdominal girth. She concluded that the Veteran’s symptoms could be explained due to those factors without evidence of pulmonary illness. In assigning high probative value to this examiner’s opinions, the Board notes that she reviewed the record, obtained a history from the Veteran, and conducted a complete examination. There is no indication that the examiner was not fully aware of the Veteran’s past medical history or that she misstated any relevant fact. Indeed, this examiner provided an exhaustive recitation of the record and fully supported her conclusions with specific citation to the record. The Board thus finds the examiner’s opinions to be of greater probative value than the Veteran’s assertions to the contrary. For the reasons expressed above, the Board finds that a preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a respiratory disability, and the claim must be denied. Because the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND The issue of entitlement to service connection for hiatal hernia is remanded. The Veteran’s gastrointestinal diagnoses include hiatal hernia. In April 2016, the Board remanded the issue of entitlement to service connection for a gastroesophageal disorder, to include gastroesophageal reflux disease (GERD) and hiatal hernia, for an examination to determine the etiology of any diagnosed gastroesophageal disorder. On VA examination in August 2016, the examiner concluded that hiatal hernia was not proximately due to or aggravated by service-connected disability. She reasoned that hiatal hernia was a specific physical and physiologic change with no pathophysiologic mechanism for the other service-connected disabilities to cause or aggravate this condition. Following this examination, service connection was awarded for GERD. Notably, the report of a June 2011 VA examination includes a statement by the examiner that GERD is often associated with hiatal hernia. This raises the question of whether the Veteran’s hiatal hernia is due to or aggravated by the now service-connected GERD. An opinion must be obtained regarding this question. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed hiatal hernia. The claims file must be made available to the examiner. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. Following review of the record and examination of the Veteran, the examiner should provide an opinion with respect to whether it is at least as likely as not (50 percent or more probability) that hiatal hernia was caused or aggravated (worsened beyond normal progression) by the Veteran’s service-connected GERD. 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 is unable to offer any of the requested opinions, a rationale for the conclusion that an opinion cannot be provided without resort to speculation should be provided, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. The complete rationale for any conclusion reached should be provided. C. TRUEBA Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Barone, Counsel