Citation Nr: 21009900 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 10-38 698 DATE: February 23, 2021 ORDER Entitlement to service connection for a left leg disability is denied. REMANDED Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a right hip disability is remanded. Entitlement to service connection for a respiratory disability is remanded. Entitlement to service connection for shin splints is remanded. Entitlement to service connection for a psychiatric disability, other than posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a left foot disability is remanded. FINDING OF FACT A left leg disability manifested more than one year after separation and is not shown to be causally related to an in-service injury or disease or to have been caused or aggravated by another service-connected disability. CONCLUSION OF LAW The criteria for service connection for a left leg disability have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1978 to October 1986. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in September 2007 by a Department of Veterans Affairs (VA) Regional Office (RO). By way of background, in September 2007 the RO denied service connection for a right hip disability, bilateral shin splints, a psychiatric disability, a left leg disability, a respiratory disability, a right ankle disability and a left foot disability. In July 2008, the Veteran filed a notice of disagreement with the denials of service connection for the above disabilities. Two statements of the case were issued in July 2010, which in combination denied entitlement to service connection for a right hip disability, a respiratory disability, left leg shin splints, a psychiatric disability, a left leg disability and a left foot disability. The Veteran perfected an appeal of these denials to the Board. In September 2014, the Board remanded the issue of service connection for right leg shin splints for the issuance of a statement of the case, and remanded the other claims for service connection for a right hip disability, a respiratory disability, left shin splints, a psychiatric disability, a left leg disability and a left foot disability for further development. A statement of the case denying service connection for right leg shin splints was issued in January 2017, but was returned as undeliverable. A second statement of the case adjudicating that issue was mailed in February 2017, and was not returned as undeliverable. Ashley v. Derwinski, 2 Vet. App. 307 (1992) (citing United States v. Chemical Foundation, Inc., 272 U.S. 1, 14–15 (1926)). Further, the opinions and records requested in September 2014 were obtained in May 2017 and September 2017. The appeal was then returned to the Board. The Board notes that the Veteran did not file a substantive appeal in response to the February 2017 statement of the case denying entitlement to right leg shin splints, and therefore did not properly perfect an appeal as to that issue. 38 C.F.R. §§ 20.202, 20.302 (2017). However, the Board took jurisdiction over the issue all the same in its June 2018 remand. As such, VA has now waived any jurisdictional objections as to that issue. See Percy v. Shinseki, 23 Vet. App. 37 (2009); see also Gonzalez-Morales v. Principi, 16 Vet. App. 556, 557 (2003). The Board again remanded the issues on appeal for additional development in June 2018. The requested opinions were obtained in October 2019 and October 2020. The Veteran was also asked to clarify the nature of her claim for service connection for a left leg disability and to submit or authorize for release all private treatment records in June 2019 correspondence. As such, the directives have been substantially complied with and the appeal is again properly before the Board. D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). In June 2018, the Board also granted service connection for dermatitis of the bilateral lower extremities. As this is a full grant of the benefits sought, that issue is no longer on appeal. Ab v. Brown, 6 Vet. App. 35 (1993). The Board further denied entitlement to a compensable rating for left wrist scars and service connection for an abdominal muscle disability. These denials were not appealed, and therefore those issues are also no longer on appeal. 38 U.S.C. § 7266; 38 C.F.R. § 20.1100. The Veteran, as a layperson, is not competent to distinguish between competing psychiatric diagnoses, and so a claim of service connection for one is considered a claim for all. Clemons v. Shinseki, 23 Vet. App. 1 (2009). As such, the claim for service connection for emotional issues has been recharacterized as one for service connection for an acquired psychiatric disorder. While this issue generally encompasses all diagnosed psychiatric disabilities, the Board notes that the Veteran was specifically and separately denied service connection for posttraumatic stress disorder (PTSD) in the September 2014 Board decision, which the Veteran did not appeal. 38 C.F.R. § 20.1100. As such, the current claim for service connection for a psychiatric disability does not include a claim for PTSD. Veterans Claims Assistance Act of 2000 (VCAA) The duty to assist includes assisting the claimant in the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). In this case, in June 2019 the RO requested that the Veteran either submit or authorize for release any private treatment records relevant to the current appeal, and provided the necessary forms to authorize records for release. To date the Veteran has neither submitted any private treatment records nor authorized any records for release so that VA may obtain them on her behalf. The duty to assist in the development and the adjudication of a claim is not a one-way street. Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996); Zarycki v. Brown, 6 Vet. App. 91, 100 (1993); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). As the Veteran has not submitted any records or taken steps to allow VA to obtain them, the Board finds that the RO has made sufficient efforts to obtain any outstanding private treatment records, and therefore the duty to assist with obtaining relevant records has been satisfied. 38 C.F.R. § 3.159(c)(1). Neither the Veteran, the representative nor the record has raised any other issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). As such, the Board will proceed to adjudicate the issues on appeal. Service Connection Generally, to establish service connection 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.” Davidson v. Shinseki, 581 F.3d 1313, 1315–16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). Generally, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” 38 C.F.R. § 3.303(b). When the disease identity is established, there is no requirement of evidentiary showing of continuity. Id. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. Continuity of symptomatology is only applicable to those diseases recognized as chronic for VA purposes. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated (worsened) by a service-connected disability. Id. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336–37 (Fed. Cir. 2006). 1. Entitlement to service connection for a left leg disability. As an initial matter, the Board notes that the Veteran is currently service-connected for a left knee disability, left lower extremity dermatitis, a left ankle disability, and a left knee scar. Further, separate claims for service connection for the Veteran’s diagnosed left foot disabilities and left lower extremity shin splints are currently on appeal. As these disabilities are already subject to compensation or the subject of separate claims, they will not be addressed further herein. Other that the disabilities noted above, an October 2019 VA examination report diagnosed the Veteran with bilateral lower extremity diabetic neuropathy and left lower extremity L-5 radiculopathy. Further, service treatment records show that the Veteran as treated for left leg pain in July 1979. As current disabilities and an in-service injury have been shown, the dispositive issue is whether there is a nexus between the disabilities and the Veteran’s service. The Veteran has asserted that her left leg disability is causally related to her active service. However, the Veteran is not competent to provide such an opinion, as to do so requires medical training and knowledge beyond that which may be expected of a lay person. Jandreau, 492 F.3d 1372; Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). As such, the Veteran’s assertions are entitled to no probative weight. An opinion concerning the etiology of the Veteran’s left leg disability was obtained in October 2019. The examiner stated that it was less likely than not that the claimed disability was causally related to service. The examiner first noted that the Veteran’s reported left leg pain was the result of several disabilities, including her service-connected left knee replacement and her diabetic neuropathy and L-5 radiculopathy. The examiner continued on to state that while the Veteran complained of left leg pain in service, she was diagnosed with muscle spasms at the time. The examiner then stated that muscle spasms are an acute disability, and did not result in the currently diagnosed and nonservice-connected radiculopathy and neuropathy. Further, by the nature of the rendered diagnoses the examiner attributed the neuropathy and the radiculopathy to the Veteran’s diabetes and low back disability, respectively. There is no evidence that the above examiner was either not competent or credible. Further, the examiner supported the opinion with a well-reasoned rationale which cited to the nature and course of the documented in-service injury as well as the etiology of the currently diagnosed and nonservice-connected left lower extremity disabilities. As such, the Board finds that the opinion is entitled to significant probative weight as to the presence of a nexus. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). VA treatment records reflect that the Veteran’s diagnosed neuropathy has been repeatedly linked to her diabetes, with multiple treatment records noting diagnoses of either diabetes mellitus with neuropathy or diabetic neuropathy. A diagnosis of neuropathy was rendered in April 2006, based on a VA electromyography (EMG) study. A July 2003 private treatment record noted an onset of left lower extremity pain three days prior, which was described as radiating from the low back. The record provided an assessment of left lower extremity sciatica. A magnetic resonance imaging (MRI) report associated with the July 2003 record also diagnosed impairment of the L5 nerve root associated with an extruded disc fragment at L5-S1. Based on the foregoing, the preponderance of the evidence is against a finding that the diagnosed neuropathy or radiculopathy are causally related to the Veteran’s service. While the Veteran has asserted that such a nexus is present, her assertions to that end are not competent and therefore entitled to no probative weight. Conversely, the VA examiner noted that the Veterans’ diagnosed neuropathy and radiculopathy were associated with her diabetes mellitus and low back disability, respectively. This conclusion is supported by the VA and private treatment records associated with the file, which also consistently note that the neuropathy and radiculopathy are due to the low back disability and diabetes mellitus. As the preponderance of the evidence is against a finding that the Veteran’s remaining nonservice-connected left lower extremity disabilities are causally related to service, service connection for a left lower extremity disability is not warranted on a direct basis. 38 C.F.R. §§ 3.102, 3.303. While both neuropathy and radiculopathy are not specifically considered to be chronic diseases for VA purposes, the Board notes that they may potentially be considered to be organic diseases of the nervous system. 38 C.F.R. § 3.309(a). However, even assuming that the neuropathy and radiculopathy are organic diseases of the nervous system, the Veteran was at no point diagnosed with either disability in service. Further, there is no evidence of manifestation to a compensable degree within one year of separation. A July 2003 private treatment record notes that the Veteran reported an onset of left leg pain three days prior, and a diagnosis of neuropathy was not rendered until an April 2006, based on a VA nerve conduction study. As there is no evidence of diagnosis in service or manifestation within the first post-service year, service connection based on the presumption in favor of chronic diseases is not warranted. 38 C.F.R. §§ 3.303(b), 3.309(a). Finally, the Board notes that both the radiculopathy and neuropathy have been attributed to other disabilities, specifically a low back disability and diabetes mellitus, respectively. However, the Veteran is not service connected for either of these disabilities. As such, secondary service connection is not warranted in this case. 38 C.F.R. § 3.310. The preponderance of the evidence weighs against a finding that the Veteran’s left leg disability is causally related to his service or was caused or aggravated by another service-connected disability. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55–57 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. REASONS FOR REMAND 1. Entitlement to service connection for a right ankle disability. Service connection for right ankle pain was denied in the September 2007 rating decision on appeal. In July 2008, the Veteran submitted a notice of disagreement which was accepted as disagreeing only with the denial of service connection for a left ankle disability, and not the right ankle. The claim for service connection for the right ankle disability was then omitted from the July 2010 statements of the case and the August 2014 Board decision and remand. The issue of entitlement to service connection for a right ankle disability was then suddenly added to a November 2017 supplemental statement of the case and remanded in the June 2018 by the Board, with no explanation as to why the issue was on appeal. In reviewing the July 2008 notice of disagreement, what appears to have been construed as the letter “L” before the word ankle is in fact an opening parenthesis, as indicated by the fact that a closing parenthesis is present three lines later. As such, the July 2008 notice of disagreement in fact disagreed with the denial of service connection for ankle pain generally, which would encompass both the right ankle and left ankle claims. Therefore, the Veteran filed a valid notice of disagreement as to the denial of service connection for a right ankle disability in July 2008. 38 C.F.R. §§ 20.201, 20.302 (2008). The filing of a valid notice of disagreement requires that the RO take appropriate action and issue a statement of the case summarizing the evidence and applicable laws and regulations and then re-adjudicating the issue. 38 C.F.R. §§ 19.26, 19.29, 19.30 (2008). In this particular case, the RO never issued a statement of the case that adjudicated service connection for a right ankle disability. Manlincon v. West, 12 Vet. App. 238 (1999). While as noted the issue was adjudicated later in a November 2017 supplemental statement of the case, a supplemental statement of the case may not be used to announced decisions by the RO on issues not previously addressed in a statement of the case or to respond to a notice of disagreement on issues not addressed in a statement of the case. 38 C.F.R. § 19.31(a). In light of this specific regulatory prohibition, the Board cannot find that the RO’s inclusion of the right ankle claim in the November 2017 supplemental statement of the case cured the failure to issue a statement of the case on that issue. Id. As such, the Board finds that it has no choice but to remand the issue for the issuance of a statement of the case. Manlincon, 12 Vet. App. 238. 2. Entitlement to service connection for a right hip disability. In the June 2018 remand directives, the Board stated that if the Veteran was diagnosed with right hip arthritis of any kind, the examiner should opine as to whether the arthritis is related to the natural aging process, prior trauma, or some other etiology. The October 2019 diagnosed the Veteran, in pertinent part, with osteoarthritis and degenerative arthritis based on imaging results. However, as part of the opinion on direct service connection the examiner did not address whether the arthritis present was consistent with aging, trauma or some other etiology. As such, the opinion does not substantially comply with the June 2018 remand directives, and therefore a remand is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Further, in October 2020 VA obtained an addendum opinion concerning whether the right hip disability was caused or aggravated by the right ankle disability. While the examiner clearly explained that the right hip disability was not causally related to the right ankle disability, the examiner did not separately and clearly address whether the right hip disability was aggravated by the right ankle disability. Both causation and aggravation must be discussed for an opinion on secondary service connection to be adequate. El-Amin v. Shinseki, 26 Vet. App. 136, 140–41 (2013); see also Allen v. Brown, 7 Vet. App. 439 (1995). Further, the examiner did not consider any of the Veteran’s other service-connected lower extremity disabilities, including a left knee disability, a right knee disability and a left ankle disability. Therefore, a remand for a new secondary service connection opinion is also necessary. 3. Entitlement to service connection for a respiratory disability. VA obtained an opinion concerning the Veteran’s claimed respiratory disability in October 2019. The examiner stated that the current sinusitis was less likely than not related to service, as while the Veteran was treated for various respiratory issues in service it would require speculation to state whether these symptoms were in fact acute sinusitis or not. The examiner then stated that even if the in-service symptoms were acute sinusitis there was no evidence of treatment for sinusitis, rhinitis or respiratory issues until 2003, which was 17 years after separation from service. However, the examiner’s opinion essentially entirely relies on the lack of evidence of treatment between separation and the first notation of treatment in 2003. A medical opinion based solely on the absence of documentation in the record is inadequate. Dalton v. Peake, 21 Vet. App. 23 (2007). As such, a remand is necessary for a new opinion concerning direct service connection. 4. Entitlement to service connection for shin splints. In October 2020, VA obtained an addendum opinion concerning secondary service connection for the Veteran’s bilateral shin splints. The examiner stated that the shin splints were less likely than not caused by or the result of a service-connected disability because a diagnosis of shin splints could not be confirmed based on the records or an examination of the Veteran. However, a diagnosis of bilateral shin splints was rendered just one year earlier in an October 2019 VA knee and lower leg examination. As the October 2020 opinion is based on an inaccurate factual premise, it is inadequate for adjudicatory purposes. Reonal v. Brown, 5 Vet. App. 458, 460–61 (1993). Therefore, a remand is necessary so that a new opinion may be obtained. 5. Entitlement to service connection for a psychiatric disability is remanded. VA obtained a medical opinion concerning the claimed psychiatric disability in October 2019. The examiner stated that it was less likely than not that the diagnosed depressive disorder and anxiety disorder were causally related to the Veteran’s service. The examiner stated that while the Veteran was treated for psychiatric symptoms in service, those symptoms were not consistent with the Veteran’s currently displayed psychiatric symptoms. However, the examiner failed to address the Veteran’s primary assertions that her psychiatric disability is due to an abusive relationship she was involved in during her period of service A medical opinion is inadequate if it does not take into account the Veteran’s reports of symptoms and history (even if recorded in the course of the examination). Dalton, 21 Vet. App. 23. As such, a remand is necessary for a new opinion concerning direct service-connection. 6. Entitlement to service connection for a left foot disability is remanded. VA obtained an opinion concerning the etiology of the claimed left foot disability in October 2019. The examiner noted diagnoses of pes planus, hammertoes and hallux valgus, but stated that none of the disabilities were causally related to the Veteran’s service. However, in support of this conclusion the examiner simply stated that there was no evidence of treatment in service and that the separation examination was normal. As the examiner relied entirely on the absence of evidence, the opinion is inadequate. Id. Further, the examiner did not reconcile his opinion with the March 2018 private opinion, which indicated that the Veteran’s foot disabilities may have been caused her time in the military, to include running in boots. As such, a remand is necessary so that a new opinion may be obtained. The matters are REMANDED for the following action: 1. Issue a statement of the case adjudicating the issue of entitlement to service connection for a right ankle disability. If the Veteran perfects an appeal by submitting a timely substantive appeal, the issue should be returned to the Board for further appellate consideration. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s right hip disability. The examiner should answer the following: a) Is it at least as likely as not (a fifty percent probability or greater) that the right hip disability was caused by a service-connected disability? The Veteran is service connected for a left knee disability, a right knee disability and a left ankle disability. b) If not, is it at least as likely as not (a fifty percent probability or greater) that the right hip disability was aggravated (worsened) by a service-connected disability? c) Is it at least as likely as not (a fifty percent probability or greater) that the right hip disability is causally related to the Veteran’s active service? In answering question (c) above, attention is invited to a June 1985 service treatment record showing treatment for right hip tendonitis following aerobics (labelled “STR - Medical” – pg. 7 – uploaded 07/12/16). d) If a diagnosis of right hip arthritis is rendered, opine as to whether the arthritis is due to the natural process of aging, trauma, or some other etiology. A detailed rationale for the opinion must be provided. 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 against it. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s respiratory disability. The examiner should answer the following: a) Identify all current respiratory disabilities. b) For each disability identified, is it at least as likely as not (a fifty percent probability or greater) that the disability, to include sinusitis or rhinitis, is causally related to the Veteran’s active service? In answering question (b), attention is invited to service treatment records noting treatment for respiratory symptoms and rhinitis in April 1976, November 1977, December 1979, October 1981, January 1986 and a diagnosis of rhinitis in November 1977 (labelled “STR - Medical” – pg. 2 – uploaded 7/12/16) and private treatment for respiratory symptoms beginning in October 2003 (labelled “Medical Treatment Record - Non-Government Facility” – pg. 5 – uploaded 11/08/06) A detailed rationale for the opinion must be provided. 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 against it. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s bilateral shin splints. The examiner should answer the following: a) Is it at least as likely as not (a fifty percent probability or greater) that the bilateral shin splints were caused by a service-connected disability? The Veteran is service connected for a left knee disability, a right knee disability and a left ankle disability. b) If not, is it at least as likely as not (a fifty percent probability or greater) that the bilateral shin splints were aggravated (worsened) by a service-connected disability? c) If not, is it at least as likely as not (a fifty percent probability or greater) that the bilateral shin splints are causally related to the Veteran’s active service? In answering question (c), attention is invited to a February 1980 service treatment record reflecting treatment for shin splints (labelled “STR - Medical” – pg. 11 – uploaded 7/12/16). A detailed rationale for the opinion must be provided. 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 against it. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s claimed psychiatric disability (other than PTSD). The examiner should answer the following: Is it at least as likely as not (a fifty percent probability or greater) that the psychiatric disability is causally related to the Veteran’s active service? Attention is invited to the Veteran’s reports concerning an abusive relationship in service and other post-service events (labelled “CAPRI” – pgs. 13, 31 – uploaded 8/15/07); an April 1983 denial of a promotion based on hostile and disrespectful behavior (labelled “STR - Medical” – pg. 5 – uploaded 7/12/16); and a March 1985 in-service psychiatric assessment (labelled “STR - Medical” – pg. 4 – uploaded 7/12/16). A detailed rationale for the opinion must be provided. 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 against it. 6. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s left foot disability. The examiner should answer the following: Is it at least as likely as not (a fifty percent probability or greater) that the diagnosed foot disabilities, to include pes planus, hammertoes and hallux valgus, are causally related to the Veteran’s active service? In answering the above, attention is invited to a March 2018 private medical opinion linking the Veteran’s foot disabilities to service (“Medical Treatment Record - Government Facility” – pg. 34 – uploaded 4/11/18). A detailed rationale for the opinion must be provided. 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 against it. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Wendell, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.