Citation Nr: 18145052 Decision Date: 10/26/18 Archive Date: 10/25/18 DOCKET NO. 16-15 644A DATE: October 26, 2018 ORDER New and material evidence having been received, the appeal to reopen a claim for a low back disability is granted. Entitlement to service connection for a low back disability, to include degenerative joint disease of the lumbar spine (previously claimed as residuals of a fall including low back condition), is denied. As new and material evidence has not been received to reopen a claim for right knee disability, the claim for entitlement to service connection for a right knee disability is not reopened. New and material evidence having been received, the appeal to reopen a claim for a left knee disability, to include degenerative joint disease, is granted. Entitlement to service connection for a left knee disability, to include degenerative joint disease, is denied. REMANDED Entitlement to service connection for an acquired psychiatric disability is remanded. FINDINGS OF FACT 1. A January 2004 rating decision denied entitlement to service connection for residuals of a fall including low back condition; the Veteran did not timely appeal that decision, and new and material evidence was not submitted as to that issue within the one-year appeal period. 2. Evidence received since the January 2004 rating decision is new and relates to an unestablished element necessary to substantiate the Veteran’s claim for a low back disability. 3. The preponderance of the evidence is against finding that the Veteran’s low back disability, to include degenerative joint disease of the lumbar spine, is due to a disease, event or injury in service. 4. An August 2004 rating decision denied entitlement to service connection for a right knee disability; the Veteran did not timely appeal that decision, and new and material evidence was not submitted as to that issue within the one-year appeal period. 5. New evidence has not been received relating to the Veteran’s claim for right knee disability. 6. An August 2004 rating decision denied entitlement to service connection for residuals of a fall including left knee condition; the Veteran did not timely appeal that decision, and new and material evidence was not submitted as to that issue within the one-year appeal period. 7. Evidence received since the August 2004 rating decision is new and relates to an unestablished element necessary to substantiate the Veteran’s claim for a left knee disability. 8. The preponderance of the evidence is against finding that the Veteran’s left knee disability, to include degenerative joint disease, is due to a disease, event or injury in service. CONCLUSIONS OF LAW 1. The January 2004 rating decision which denied service connection for residuals of a fall including low back condition is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 3.156, 20.200, 20.202, 20.302, 20.1103 (2017). 2. New and material evidence having been received, the claim for entitlement to service connection for a low back disability is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. §§ 3.156 (a); 3.303 (2017). 3. The criteria for entitlement to service connection for a back disability, to include degenerative joint disease of the lumbar spine (previously claimed as residuals of a fall including low back condition) have not been met. 38 U.S.C. §§ 1110, 5107 (b) (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (a) (2017). 4. The August 2004 rating decision which denied service connection for a right knee disability is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 3.156, 20.200, 20.202, 20.302, 20.1103 (2017). 5. New evidence has not been received regarding the Veteran’s right knee disability; accordingly, the claim is not reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (a) (2017). 6. The August 2004 rating decision which denied service connection for residuals of a fall including left knee condition is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 3.156, 20.200, 20.202, 20.302, 20.1103 (2017). 7. Evidence received since the August 2004 rating decision is new and relates to an unestablished element necessary to substantiate the Veteran’s claim for a left knee disability. 38 U.S.C. § 5108 (2012); 38 C.F.R. §§ 3.156 (a); 3.303 (2017). 8. The criteria for entitlement to service connection for a left knee disability, to include degenerative joint disease, have not been met. 38 U.S.C. §§ 1110, 5107 (b) (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the Army from November 1967 to December 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a September 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Little Rock, Arkansas. Jurisdiction currently resides with the RO in Jackson, Mississippi. The Veteran initially submitted a claim for entitlement to service connection for depression. Although the Veteran sought service connection only for depression, a psychiatric claim “cannot be a claim limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed.” Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In essence, a veteran does not file a claim to receive benefits for a particular psychiatric diagnosis that is named on a claims form, but instead makes a general claim for compensation for the difficulties posed by the mental disability. Id. Accordingly, the Board has reframed the issue on appeal. New and Material Evidence – Legal Criteria In general, rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.1103 (2017). An exception to this rule is provided in 38 U.S.C. § 5108, which states that if new and material evidence is presented or secured with respect to a claim that has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is existing evidence not previously submitted to VA. Material evidence is existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). In Elkins v. West, 12 Vet. App. 209 (1999), the United States Court of Appeals for Veterans Claims (Court) held that the Board must first determine whether the appellant has presented new and material evidence under 38 C.F.R. § 3.156 (a) to have a finally denied claim reopened under 38 U.S.C. § 5108. Then, if new and material evidence has been submitted, the Board may proceed to evaluate the merits of the claim, but only after ensuring that VA’s duty to assist has been fulfilled. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The Court has also held that the law should be interpreted as enabling reopening of a claim, rather than precluding it. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The focus is not exclusively on whether evidence remedies the principal reason for denial in the last prior final decision, but on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement. Id. at 118. Thus, evidence is new and material if, when considered with the evidence of record, it would at least trigger VA’s duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Id. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation during service of a preexisting injury or disease. 38 U.S.C. §§ 1110, 1131. To establish service connection for a disability on a direct-incurrence basis, a veteran 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also 38 C.F.R. § 3.303. A disability which is proximately due to or the result of a service-connected disease or injury shall be service-connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will also be service-connected. 38 C.F.R. § 3.310 (b). Service connection for chronic diseases, including arthritis, listed at 38 C.F.R. § 3.309 (a) may be established on a presumptive basis if the chronic disease was shown as chronic in service; manifested to a compensable degree within a presumptive period after separation from service; or was noted in service with continuity of symptomatology since service. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303 (b), 3.307, 3.309 (a). Continuity of symptomatology may be established if a claimant can demonstrate: (1) that a condition existed during service; (2) post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997). Analysis The Veteran filed a claim for entitlement to disability compensation and pension in July 2003, in which he listed a fall and a knee injury under the section for disability compensation, and most of his skeletal system under the pension section. The RO informed the Veteran that it would interpret his claim to include the disabilities listed under the pension section as part of his claim for disability compensation. A January 2004 rating decision denied service connection for residuals of a fall, including residuals associated with a low back condition and residuals associated with a left knee disability. The January 2004 rating decision did not address a right knee disability. In April 2004, the Veteran submitted correspondence indicating that he would like to reopen his claim, and thereafter, provided additional VA medical records in August 2004, reflecting treatment for degenerative joint disease, mental health conditions, and low back pain. The RO issued a rating decision in August 2004 denying service connection for a right knee disability, and reopening and denying service connection for a left knee disability. The August 2004 rating decision did not discuss the Veteran’s low back disability. The Veteran did not file a notice of disagreement or submit any additional evidence within one year of the August 2004 rating decision; therefore, the August 2004 decision became final. The Veteran filed an informal claim in September 2012, in which he requested compensation for a back condition, knee condition, and depression. In September 2013, the RO issued a rating decision denying service connection for left knee degenerative joint disease, lumbar spine degenerative joint disease, and depression, and declining to reopen the claim for a right knee disability for want of new and material evidence. The Veteran filed a notice of disagreement in May 2014, the RO issued a statement of the case in April 2016, and the Board received a timely Form 9 that same month. This is the decision currently on appeal. The Board notes that there is an exception to finality for pending claims when new and material evidence is submitted prior to the expiration of the appeal period. 38 C.F.R. § 3.156 (b). The Veteran’s August 2004 evidence was submitted within the appeal period, and reflected treatment for a lower back condition; however, the RO did not readjudicate the Veteran’s lower back claim. If such evidence were determined to be new and material to the lower back claim, and the RO did not readjudicate, the claim would remain pending, and new and material evidence would not now be required to reopen the claim. However, the August 2004 evidence, though new, is not material to the lower back claim as it does not relate to an established fact necessary to substantiate the claim, namely a nexus between the disability and active service. 38 C.F.R. § 3.156 (a). The evidence contains summaries by physicians of the Veteran’s allegations that his low back condition is related to service, which are duplicative and cumulative of the Veteran’s allegations already of record. Id. Under the circumstances, the January 2004 decision is final, and new and material evidence is required to reopen the claim. Evidence received since the prior final denials includes VA examinations relating to the Veteran’s low back disability and left knee disability. For such evidence to be new and material, it would have to relate to the existence of a causal relationship between the Veteran’s current disability and an in-service injury, event or disease. See 38 C.F.R. § 3.156 (a). The Board finds that the VA examinations are new, in that they were not of record at the time of the prior final denials. See id. They are also material in that they relate to an unestablished fact necessary to substantiate the claim, namely, the question of a medical nexus between the Veteran’s current disabilities and active service. Id. Because new and material evidence has been submitted, and the duty to assist is satisfied, the Board may adjudicate the Veteran’s claims for a low back disability and a left knee disability. See Vargas-Gonzalez, 12 Vet. App. at 328. The Veteran has not submitted any new and material evidence for his right knee disability. Service treatment records do not reflect any complaints, treatment, symptoms, or diagnoses of right knee disability. Neither the Veteran nor his representative has submitted additional evidence or argument indicating the existence of a right knee disability, or a connection between such a disability and active duty service. As such, the Veteran’s claim for service connection for a right knee disability is not reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). Service Connection – Low Back Disability The Veteran seeks service connection for a low back disability. The Veteran was diagnosed with degenerative joint disease of the lumbar spine in August 2013. Therefore, there is evidence of a current disability. The Veteran’s service treatment records indicate that he complained of a recurrent back ache lasting three weeks in May 1969. The record noted that the injury resulted from overwork. There is no further indication of complaints, treatment, symptoms, or diagnoses of a back strain or lumbar spine degenerative joint disease. The Veteran’s separation examination did not document any back disabilities, and the Veteran provided the following written statement with the examination: “to the best of my knowledge[,] I have no idea of anything being the matter with me.” The Veteran was provided a VA examination in August 2013. The examiner reviewed the claims file and service treatment records, and evaluated the Veteran. He diagnosed degenerative joint disease of the lumbar spine, and opined that it was less likely than not incurred in or caused by active service. He reasoned that the Veteran was seen and treated for a back ache in May 1969, but there was no follow up treatment during the Veteran’s period of service. The separation examination documented a normal spine and musculoskeletal system, and the examiner cited the Veteran’s written statement denying any perceived health problems After considering the evidence of record, the Board finds that the preponderance of the evidence is against the Veteran’s claim for service connection for a lower back disability. The Board has considered service connection on a presumptive basis under 38 C.F.R. §§ 3.307, 3.309. Degenerative joint disease is not a disability that is capable of lay diagnosis, and there is no medical evidence that the Veteran’s symptoms of degenerative joint disease of the lumbar spine manifested to a degree of 10 percent or more disabling within one year of service. Savage, 10 Vet. App. at 495-96. Therefore, presumptive service connection is not for application. The August 2013 VA examiner opined that it was less likely than not that the Veteran’s degenerative joint disease of the lumbar spine was related to active service, including the May 1969 back ache. He noted that the Veteran did not seek any further treatment for such a condition, and that the separation examination was negative for a back condition. He quoted the Veteran’s statement denying any perceived health problems at separation from service. Because the examiner’s opinion is based on an accurate medical history, and provides clear conclusions with supporting data, the Board affords it high probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has considered the Veteran’s lay statements. A Veteran is competent to report symptoms capable of lay observation, such as pain. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Veteran has not been shown to have the expertise required to render an etiology opinion connecting his degenerative joint disease of the lumbar spine with active duty service, as such a determination requires complex medical knowledge including interaction between bodily symptoms and interpretation of complicated diagnostic testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As such, the Board affords higher credibility to the probative medical evidence of record. In sum, the preponderance of the evidence is against the claim for service connection for a lower back disability, to include degenerative joint disease of the lumbar spine. The benefit of the doubt does not apply, and the claim is denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). Service Connection – Left Knee Disability The Veteran seeks entitlement to service connection for a left knee disability. The Veteran was diagnosed with degenerative joint disease of the left knee in August 2013. The Veteran’s service treatment records indicate that he was treated for a left knee injury in November 1970. The Veteran sustained the knee injury after getting out of a tank. The impression listed was a periosteal injury. The Veteran returned two days later for a follow-up evaluation, and the treating physician indicated a probable second-degree sprain. The records do not indicate any further complaints, treatment, symptoms, or diagnoses of a left knee disability. The Veteran’s separation examination found normal lower extremities, and the Veteran provided the following written statement with the examination: “to the best of my knowledge[,] I have no idea of anything being the matter with me.” The Veteran was afforded a VA examination in August 2013. The examiner reviewed the claims file and service treatment records, and evaluated the Veteran. He diagnosed degenerative joint disease of the left knee, and opined that it was less likely than not that the Veteran’s disability was incurred in or caused by active service. The examiner reasoned that the Veteran was treated for a knee injury during service, but returned to duty, and the records did not show any additional treatment for a knee condition. The separation examination was negative for a knee condition, and the examiner cited the Veteran’s written statement denying any perceived health problems. The Board finds that the preponderance of the evidence is against the Veteran’s claim for service connection for a left knee disability. The Board has considered service connection on a presumptive basis under 38 C.F.R. §§ 3.307, 3.309. Degenerative joint disease is not a disability that is capable of lay diagnosis, and there is no medical evidence that the Veteran’s symptoms of degenerative joint disease of the left knee manifested to a degree of 10 percent or more disabling within one year of service. Savage, 10 Vet. App. at 495-96. Therefore, presumptive service connection is not for application. The August 2013 VA examiner opined that it was less likely than not that the Veteran’s degenerative joint disease of the left knee was related to active service, including the November 1970 knee sprain. He noted that the Veteran did not seek any further treatment for such a condition, and that the separation examination was negative for a knee condition. He quoted the Veteran’s statement denying any perceived health problems at separation from service. Because the examiner’s opinion is based on an accurate medical history, and provides clear conclusions with supporting data, the Board affords it high probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has considered the Veteran’s lay statements. A Veteran is competent to report symptoms capable of lay observation, such as pain. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Veteran has not been shown to have the expertise required to render an etiology opinion connecting his degenerative joint disease of the left knee with active duty service, as such a determination requires complex medical knowledge including interaction between bodily symptoms and interpretation of complicated diagnostic testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As such, the Board affords higher credibility to the probative medical evidence of record. In sum, the preponderance of the evidence is against the claim for service connection for a left knee disability, to include degenerative joint disease of the left knee. The benefit of the doubt does not apply, and the claim is denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). REASONS FOR REMAND The Veteran’s claim for entitlement to service connection for an acquired psychiatric disability is remanded for further development. VA must provide a medical examination when evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 U.S.C § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 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 (38 C.F.R. part 4) 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. 38 C.F.R. § 3.310 (b). The Veteran’s service treatment records do not evince any complaints, treatment, symptoms, or diagnoses of any acquired psychiatric disability. The Veteran’s separation examination revealed normal psychiatric findings, and the Veteran provided a written statement denying any perceived health conditions. The Board notes that the Veteran has not been provided with a VA medical examination for an acquired psychiatric disability. However, the Veteran submitted an opinion from a private psychologist, Dr. H. H.-G, dated June 2015. Dr. H. H.-G reviewed the claims file, interviewed the Veteran, and diagnosed unspecified depressive disorder. She indicated symptoms productive of functional impairment equivalent to occupational and social impairment with deficiencies in most areas. Dr. H. H.-G stated that the severity of the Veteran’s symptom complex related back to the original date of the Veteran’s claim in September 2012. She noted that the Veteran experiences tinnitus (for which he has been separately service-connected) and opined that the Veteran’s tinnitus continues to manifest as depressive disorder, and further opined that the Veteran’s tinnitus aggravated the depressive disorder. Dr. H. H.-G included medical research articles discussing, among other things, the high co-incidence of tinnitus and depression in individuals, and suggesting that depressive symptoms will manifest as a reaction to tinnitus. She concluded that the Veteran’s unspecified depressive disorder more likely than not began in military service, and continued uninterrupted to the present, and is aggravated by the Veteran’s service-connected tinnitus. A medical opinion is adequate where it is based upon consideration of the Veteran’s prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board’s “‘evaluation of the claimed disability will be a fully informed one.’” See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). An opinion is inadequate where it does not consider relevant evidence of record, does not provide a rationale, or is conclusory. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board is not obligated to accept any examiner’s opinion; the fact that there are opinions of record does not require the Board to decide a claim. Hayes v. Brown, 5 Vet. App. 60, 69 (1993). The Board notes the existence of fundamental inconsistencies in Dr. H. H.-G.’s opinion. For example, she opined that the Veteran’s tinnitus more likely than not aggravated the Veteran’s mood disorder, but also wrote that the Veteran’s tinnitus “continues to manifest as a depressive disorder.” Such an opinion is facially inconsistent, as it suggests both that tinnitus is a direct manifestation of depressive disorder, but also a separate condition that aggravated the Veteran’s depressive disorder. Nieves-Rodriguez, 22 Vet. App. at 304. The studies referenced by Dr. H. H.-G. state that depressive symptoms could contribute significantly to tinnitus, depressive symptoms may manifest as a reaction to tinnitus, there is often a high co-incidence of tinnitus and depressive symptoms, and that co-occurrence of depression and tinnitus is not purely reactive as a reflection of a learned distress response. The studies do not state that tinnitus could etiologically cause depression, or that tinnitus itself is a manifestation of depressive disorder. The fact that there is a notable discrepancy between Dr. H. H.-G.’s rationale and provided evidence suggests the need for additional examination and opinion. See id. The Board also notes that Dr. H. H.-G. opined that the Veteran’s disabilities began in service and continued uninterrupted to the present; however, she did not consider relevant information in the Veteran’s service treatment records, including the separation examination and accompanying written statement from the Veteran explicitly denying any perceptions of having psychiatric disabilities. Failure to consider relevant information from the claims file, including probative medical records, can undermine the adequacy of a medical opinion. See id. at 308. Regarding whether the Veteran’s service-connected tinnitus aggravated any acquired psychiatric disorder, Dr. H. H.-G.’s opinion did not indicate a baseline level of severity to the extent that VA can concede aggravation. See 38 C.F.R. § 3.310 (b). She summarily stated that the severity of the Veteran’s symptom complex relates back to the date of the claim in September 2012. However, she did not cite medical evidence to support her conclusion regarding the baseline level of severity, or otherwise establish such a baseline by medical evidence as required under 38 C.F.R. § 3.310 (b). Considering the forgoing, the Board is unable to render a decision on the merits without further clarification of the medical evidence, and an additional VA examination is necessary. See Stefl, 21 Vet. App. at 123. The Veteran receives VA mental health treatment; therefore, any outstanding, relevant, VA treatment records for the condition on appeal should be procured. The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from August 2004 to the Present. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of each acquired psychiatric disability demonstrated during the appeal period or in proximity to the claim. The claims file, and a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was performed. The examiner is asked to provide responses to the following: a. Whether it is at least as likely as not (a probability of 50 percent or greater) that any diagnosed psychiatric disorder had its onset during active service or is related to any in-service injury, event, or disease. b. Whether it is at least as likely as not (a probability of 50 percent or greater) that any diagnosed psychiatric disorder is due to or caused by the Veteran’s service-connected tinnitus. c. Whether it is at least as likely as not (a probability of 50 percent or greater) that any diagnosed psychiatric disorder is aggravated beyond its natural progression by the Veteran's service-connected tinnitus. If aggravation is found, the examiner is asked to address the following issues to the extent feasible: 1) the baseline manifestations of the identified acquired psychiatric disorder, and 2) the increased manifestations which, in the examiner’s opinion, are proximately due to the Veteran’s service-connected tinnitus. Aggravation is defined as a worsening beyond the natural progression of the disease. The examiner must note that an opinion to the effect that one disability “is not caused by or a result of” another disability does not answer the question of aggravation and will necessitate a further opinion. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). The examiner should reconcile his/her opinion with that of Dr. H. H.-G., received April 2016, and the treatise evidence accompanying that opinion. The examination report must include a complete rationale for all opinions expressed. The examiner is reminded that the term “at least 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. (Continued on the next page)   3. Thereafter, readjudicate the issue on appeal. If the benefit sought remains denied, furnish the Veteran and his representative with a supplemental statement of the case. After allowing an appropriate amount of time for response, return the case to the Board for review. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Reed, Associate Counsel