Citation Nr: 1042812 Decision Date: 11/15/10 Archive Date: 11/24/10 DOCKET NO. 09-25 356 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Medical and Regional Office (RO) Center in Wichita, Kansas THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for gastrointestinal reflux disease (GERD) and, if so, whether service connection is warranted. 2. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for bronchitis and, if so, whether service connection is warranted. 3. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a disability of the right knee and, if so, whether service connection is warranted. 4. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for a disability of the left knee and, if so, whether service connection is warranted. 5. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for residuals of a hysterectomy. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J.M. Rutkin, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1984 to December 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision of the RO in Wichita, Kansas, which declined to reopen the claims at issue. In March 2010, the Veteran testified at a Board hearing before the undersigned in Washington, DC. A transcript of the hearing has been associated with the claims file. The claims for service connection for GERD, bronchitis, and disabilities of the right and left knees are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The June 2005 rating decision declined to reopen the Veteran's claim for GERD; the Veteran was properly notified of the adverse outcome and her appellate rights in a July 2005 letter; she did not file a timely substantive appeal. 2. Additional evidence received since the June 2005 rating decision is neither cumulative nor redundant and raises a reasonable possibility of substantiating the Veteran's claim for service connection for GERD. 3. The April 2007 rating decision declined to reopen the Veteran's claim for bronchitis; the Veteran was properly notified of the adverse outcome and her appellate rights in an April 2007 letter; she did not file a timely notice of disagreement (NOD). 4. Additional evidence received since the April 2007 rating decision is neither cumulative nor redundant and raises a reasonable possibility of substantiating the Veteran's claim for service connection for bronchitis. 5. The April 2007 rating decision declined to reopen the Veteran's claim for a disability of the right knee; the Veteran was properly notified of the adverse outcome and her appellate rights in an April 2007 letter; she did not file a timely NOD. 6. Additional evidence received since the April 2007 rating decision is neither cumulative nor redundant and raises a reasonable possibility of substantiating the Veteran's claim for service connection for a disability of the right knee. 7. The April 2007 rating decision declined to reopen the Veteran's claim for a disability of the left knee; the Veteran was properly notified of the adverse outcome and her appellate rights in an April 2007 letter; she did not file a timely NOD. 8. Additional evidence received since the April 2007 rating decision is neither cumulative nor redundant and raises a reasonable possibility of substantiating the Veteran's claim for service connection for a disability of the left knee. 9. At the March 2010 Board hearing, the Veteran withdrew her petition to reopen the claim of entitlement to service connection for residuals of a hysterectomy. CONCLUSIONS OF LAW 1. The June 2005 rating decision, denying a petition to reopen a claim for service connection for GERD, is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2010). 2. New and material evidence has been submitted for the claim of entitlement to service connection for GERD; the claim is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2010). 3. The April 2007 rating decision, denying a petition to reopen a claim for service connection for bronchitis, is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2010). 4. New and material evidence has been submitted for the claim of entitlement to service connection for bronchitis; the claim is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2010). 5. The April 2007 rating decision, denying a petition to reopen a claim of service connection for a disability of the right knee, is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2010). 6. New and material evidence has been submitted for the claim of entitlement to service connection for a disability of the right knee; the claim is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2010). 7. The April 2007 rating decision, denying a petition to reopen a claim of service connection for a disability of the left knee, is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2010). 8. New and material evidence has been submitted for the claim of entitlement to service connection for a disability of the left knee; the claim is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2010). 9. The criteria for withdrawal of a substantive appeal with regard to reopening a service connection claim for residuals of a hysterectomy have been met. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each piece of evidence. See id. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. Id. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Id. I. Veterans Claims Assistance Act of 2000 (VCAA) The Veteran's petitions to reopen the claims for service connection for GERD, bronchitis, and disabilities of the bilateral knees have been reopened, as discussed below. The Veteran has withdrawn her petition to reopen the claim for service connection for residuals of a hysterectomy. Accordingly, the Board finds that any error related to the VCAA on these issues is moot. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2009); 38 C.F.R. § 3.159 (2009); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) II. New and Material Evidence The Veteran initially filed for service connection for GERD, bronchitis, and disabilities of the bilateral knees in April 2003. The RO denied these claims in an August 2003 rating decision. The Veteran was notified of this decision and her appellate rights in a September 2003 letter. She did not appeal the decision. Consequently, the decision became final. See 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2010). Thereafter, the Veteran sought to reopen her claim of entitlement to service connection for GERD most recently in June 2005. The petition to reopen was denied in a June 2005 rating decision and the Veteran was informed of her appellate rights in a July 2005 letter. In September 2005, she filed a timely NOD in response to this decision and a December 2005 statement of the case (SOC) was duly issued. However, the Veteran did not perfect her appeal by filing a substantive appeal (such as a VA Form 9) and therefore this decision became final. See id. The Veteran's petitions to reopen her claims for service connection for bronchitis and disabilities of the bilateral knees were most recently denied in an April 2007 rating decision. The Veteran was informed of this decision and her appellate rights in an April 2007 letter. She did not appeal this decision and therefore it became final. See id. Under 38 U.S.C.A. § 5108 (West 2002), VA may reopen a previously and finally disallowed claim when "new and material" evidence is presented or secured with respect to that claim. "New evidence" means evidence not previously submitted to agency decision makers, and "material evidence" means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a) (2010). The 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. Id. The provisions of 38 U.S.C.A. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-3 (1996). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion. Duran v. Brown, 7 Vet. App. 216, 220 (1994); Justus v. Principi, 3 Vet. App. 510, 513 (1992). A claimant's assertions of medical causation or diagnosis often do not constitute competent evidence, as lay persons without the appropriate medical expertise are not competent to offer medical opinions. Tirpak v. Derwinski, 2 Vet. App. 609, 610-11 (1992); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. 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. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder, there must be (1) competent evidence of a current disability; (2) competent evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The Veteran's petitions to reopen her claims for service connection for GERD, bronchitis, and disabilities of the right and left knees were denied in the June 2005 and April 2007 rating decisions because the RO found that these disabilities were not incurred in or related to service. The evidence of record at the time of these rating decisions consisted of the Veteran's service treatment records and post-service treatment records as well as statements made by the Veteran. Since the June 2005 and April 2007 rating decisions were issued, the Veteran submitted a December 2008 private medical evaluation from Dr. Bash. In the evaluation report, the doctor stated that he had reviewed the Veteran's service treatment records and post service medical records and had also interviewed the Veteran. With respect to the Veteran's GERD, the doctor noted that the Veteran had gastric distress while in service and was prescribed Pepto Bismol. He opined that the Veteran's GERD was due to her gastric distress in service as the two processes often occur simultaneously. With respect to the Veteran's bronchitis, the doctor noted that the Veteran had bronchitis in service. He opined that the Veteran's current respiratory disorders were caused by her military service because bronchial infections and scarring are caused by bronchitis and once the bronchi are scarred and dilated they are susceptible to recurrent infections. With respect to the Veteran's right knee disability, the doctor noted that the Veteran had a right knee injury during service and a March 2005 private magnetic resonance imaging (MRI) report showed a meniscus tear. As there was no other plausible etiology of the Veteran's right knee disability, the doctor found that it was caused by the Veteran's military service. With respect to the Veteran's left knee disability, the doctor noted that the Veteran had a left knee injury in service which resulted in several medical visits and profiles. He further noted that a March 2005 private MRI report showed a meniscus tear in the left knee. Therefore, as there was no other plausible etiology of the Veteran's left knee disability, the doctor opined that it was caused by the Veteran's military service. The Board finds that the December 2008 private medical evaluation constitutes new and material evidence. At the time of the June 2005 and April 2007 rating decisions, there was no competent medical opinion of record stating that there was a link between the disabilities at issue and the Veteran's service. Thus, this evidence relates to an unestablished fact necessary to substantiate the Veteran's claims, namely whether there is a nexus between the Veteran's GERD, bronchitis, and disabilities of the bilateral knees and her period of service. Accordingly, the Board finds that new and material evidence has been submitted to reopen the claim of entitlement to service connection for GERD, bronchitis, and disabilities of the right and left knees. The petitions to reopen are granted. See 38 C.F.R. § 3.156(a). III. Withdrawal of Claim At the March 2010 Board hearing, the Veteran stated that she wished to withdraw her petition to reopen a claim for service connection for residuals of a hysterectomy. VA regulation provides for the withdrawal of an appeal to the Board by the submission of a written request to that effect at any time before the Board issues a final decision on the matter in question. See 38 C.F.R. § 20.204(b) (2010); Hanson v. Brown, 9 Vet. App. 29, 31 (1996) (holding that when a claim is withdrawn by a veteran, it ceases to exist; it is no longer pending, and is not viable). After an appeal is transferred to the Board, an appeal withdrawal is effective the date it is received by the Board. 38 C.F.R. § 20.204(b). Appeal withdrawals must be in writing and must include the name of the Veteran, the applicable claim number, and a statement that the appeal is withdrawn. Id. Here, because there is a transcript of the March 2010 Board hearing, the Veteran's request for a withdrawal at the hearing is in writing. The transcript also includes the Veteran's name and claim number. As of the March 2010 hearing, the Board had not yet issued a final decision on this claim. Therefore, the Veteran's withdrawal of this claim is valid. See id. When pending appeals are withdrawn, there is no longer an allegation of error of fact or law with respect to the determinations that had been previously appealed. Consequently, in such an instance, dismissal of the pending appeal is appropriate. See 38 U.S.C.A. § 7105(d) (West 2002). Accordingly, further action by the Board on the Veteran's petition to reopen a claim for service connection for residuals of a hysterectomy is not appropriate and the appeal should be dismissed. Id. ORDER New and material evidence has been received to reopen the claim of service connection for GERD; the appeal is granted to this extent only. New and material evidence has been received to reopen the claim of service connection for bronchitis; the appeal is granted to this extent only. New and material evidence has been received to reopen the claim of service connection for a disability of the right knee; the appeal is granted to this extent only. New and material evidence has been received to reopen the claim of service connection for a disability of the left knee; the appeal is granted to this extent only. The issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for residuals of a hysterectomy is dismissed. REMAND The Veteran claims entitlement to service connection for GERD, bronchitis, and disabilities of the right and left knees. For the following reasons, the Board finds that further development is warranted to ensure a full record before these claims can be properly adjudicated. Under the Veterans Claims Assistance Act of 2000, VA has a duty to assist the claimant in developing a claim for VA benefits. The duty to assist includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79 (2006). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). With respect to the Veteran's claim for GERD, an August 1985 service treatment record reflects that the Veteran was taking Pepto-Bismol which, according to the December 2008 private medical evaluation by Dr. Bash, is indicative that the Veteran was experiencing gastric distress. Further, in the Veteran's December 1986 separation examination report, she indicated having a history of frequent indigestion. The Veteran's current VA treatment records reflect a diagnosis of GERD in October 2005. The December 2008 private medical opinion states that the Veteran's GERD is related to the gastric distress she experienced in service. Thus, the Board finds that there is evidence of a current disability, an in-service disease, injury, or event, and an indication supported by competent medical evidence that the Veteran's current gastrointestinal problems are related to service. Finally, there is insufficient evidence to decide this claim as the Board is not competent to substitute its own opinion regarding medical issues for that of a medical expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Accordingly, the elements of McLendon are met and a VA examination is warranted. With respect to the Veteran's claim for bronchitis, a March 1984 service treatment record reflects a diagnosis of bronchitis. In an April 2005 service treatment record, the Veteran reported that her chest felt sore when coughing and that she experienced shortness of breath with activity. The Veteran was diagnosed with bronchitis and a respiratory infection. The Veteran's VA treatment records show that she was diagnosed with chronic obstructive pulmonary disease (COPD) in October 2005 and was treated for bronchitis in January 2008. In the December 2008 private evaluation report, Dr. Bash stated that the Veteran's current respiratory problems were related to her military service because the Veteran had episodes of bronchitis during service and bronchitis is known to cause lung infections and scarring which would predispose her to future lung problems. Thus, the Board finds that there is evidence of a current disability, an in- service disease, injury, or event, and an indication supported by competent medical evidence that the Veteran's current respiratory problems are related to service. Finally, there is insufficient evidence to decide this claim as the Board is not competent to substitute its own opinion regarding medical issues for that of a medical expert. See Colvin v. Derwinski, 1 Vet. App. at 175. Accordingly, the elements of McLendon are met and a VA examination is warranted. With respect to the Veteran's claim for a right knee disability, the Veteran's service treatment records reflect that in February 1985 she reported a one-year history of pain in the right knee which started after she fell during basic training. It was noted that she had a bump in the right knee. She was diagnosed with Osgood-Schlatter's disease and put on profile for two weeks. At the March 2010 Board hearing, the Veteran stated that she has experienced pain in her right knee ever since her period of service but did not seek treatment right away as she did not have medical insurance. A March 2005 private MRI report revealed a meniscus tear in the right knee. In the December 2008 private evaluation report, the doctor stated that the Veteran's right knee disability was related to service because of the in-service injury and because there was no other plausible etiology of this disability. Thus, the Board finds that there is evidence of a current disability, an in-service disease, injury, or event, and an indication supported by competent medical evidence that the Veteran's current right knee disability is related to service. Finally, there is insufficient evidence to decide this claim as the Board is not competent to substitute its own opinion regarding medical issues for that of a medical expert. See Colvin v. Derwinski, 1 Vet. App. at 175. Accordingly, the elements of McLendon are met and a VA examination is warranted. With respect to the Veteran's claim for a left knee disability, in a January 1985 service treatment record it was noted that she had a bump on her left knee which had been present for one year. She was diagnosed with a possible cyst. In February 1985 she reported pain in her left knee which had been present for one year after she fell in basic training. It was noted that she had a bump in the left knee. She was diagnosed with Osgood- Schlatter's disease and put on profile for two weeks. In a June 1986 service treatment record, the Veteran reported proximal left leg pain that had been present for one and a half years after prolonged marching. It was noted that the Veteran had a moderately severe contusion to the same area two years earlier. The Veteran was diagnosed with pes anserine bursitis. In July 1986 the Veteran reported recurrent swelling of the medial left knee with soreness after running. An August 1986 service treatment record reflects that the Veteran again reported left knee pain and was diagnosed with mild recurrent pes anserine bursitis. She put on medical profile for ten days. The Veteran's December 1986 separation examination reflects a diagnosis of bursitis of the left leg. After service, a March 2005 private MRI report showed a possible meniscus tear, an osteochondral defect, and multi-locular cysts likely related to posttraumatic or degenerative changes. The December 2008 private medical evaluation report reflects that the Veteran's left knee disability was related to her military service because of the in- service injury and follow-up complaints and the March 2005 MRI showing a meniscus tear in conjunction with the fact that there was no other plausible etiology of this disability. Thus, the Board finds that there is evidence of a current disability, an in-service disease, injury, or event, and an indication supported by competent medical evidence that the Veteran's current right knee disability is related to service. Finally, there is insufficient evidence to decide this claim as the Board is not competent to substitute its own opinion regarding medical issues for that of a medical expert. See Colvin v. Derwinski, 1 Vet. App. at 175. Accordingly, the elements of McLendon are met and a VA examination is warranted. On remand, the agency of original jurisdiction (AOJ) should also obtain the Veteran's recent VA treatment records. Accordingly, the case is REMANDED for the following actions: 1. The AOJ should obtain the Veteran's VA treatment records from the Veterans Affairs Medical Center (VAMC) in Philadelphia from 2009 to the present. 2. The AOJ should schedule the Veteran for an examination to determine the nature and etiology of her gastrointestinal disorder, to include GERD. The entire claims file and a copy of this REMAND must be made available to the examiner prior to the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. After reviewing the file and examining the Veteran, the examiner should render an opinion as to whether the Veteran's gastrointestinal disorder, to include GERD, is at least as likely as not (i.e., to at least a 50:50 degree of probability) a result of active military service, or whether such a relationship is unlikely (i.e., less than a 50:50 degree of probability). In this regard, the examiner should take into account, among other evidence of record, the March 1980 private treatment record reflecting that the Veteran was diagnosed with chronic cholecystitis and underwent a cholecystectomy and operative cholangiogram with complete relief of GI symptoms; the August 1985 service treatment record reflecting that the Veteran was taking Pepto- Bismol; the Veteran's December 1986 separation examination report indicating a history of frequent indigestion; and the December 2008 private medical evaluation reflecting that the Veteran's GERD is related to the gastric distress she experienced in service. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for any opinion provided. The AOJ should ensure that an adequate rationale has been provided before returning this case to the Board. If the examiner is not able to provide an opinion without resorting to speculation, the examiner must state the reasons why such an opinion cannot be rendered. In this regard, the examiner should state whether a definitive opinion cannot be provided because required information is missing or because current medical knowledge yields multiple possible etiologies with none more likely than not the cause of the claimed disability. The examiner should be as specific as possible. 3. The AOJ should schedule the Veteran for an examination to determine the nature and etiology of her respiratory disorder, to include bronchitis and COPD. The entire claims file and a copy of this REMAND must be made available to the examiner prior to the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. After reviewing the file and examining the Veteran, the examiner should render an opinion as to whether the Veteran's respiratory disorder, to include bronchitis and COPD, is at least as likely as not (i.e., to at least a 50:50 degree of probability) a result of active military service, or whether such a relationship is unlikely (i.e., less than a 50:50 degree of probability). In this regard, the examiner should take into account the Veteran's diagnoses of bronchitis in service, the October 2005 VA treatment record reflecting a diagnosis of COPD, and the December 2008 private medical evaluation report reflecting that the Veteran's current respiratory disorder was caused by her military service. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for any opinion provided. The AOJ should ensure that an adequate rationale has been provided before returning this case to the Board. If the examiner is not able to provide an opinion without resorting to speculation, the examiner must state the reasons why such an opinion cannot be rendered. In this regard, the examiner should state whether a definitive opinion cannot be provided because required information is missing or because current medical knowledge yields multiple possible etiologies with none more likely than not the cause of the claimed disability. The examiner should be as specific as possible. 4. The AOJ should schedule the Veteran for an examination to determine the nature and etiology of her disabilities of the left and right knees. The entire claims file and a copy of this REMAND must be made available to the examiner prior to the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. After reviewing the file and examining the Veteran, the examiner should render an opinion as to whether the Veteran's bilateral knee disabilities are at least as likely as not (i.e., to at least a 50:50 degree of probability) a result of active military service, or whether such a relationship is unlikely (i.e., less than a 50:50 degree of probability). Separate opinions should be provided for the Veteran's left and right knees. In this regard, the examiner should take into account the Veteran's in-service treatment for bilateral knee pain, the March 2005 private MRI's, and the December 2008 private evaluation report reflecting that the Veteran's bilateral knee disabilities were caused by active service. The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for any opinion provided. The AOJ should ensure that an adequate rationale has been provided before returning this case to the Board. If the examiner is not able to provide an opinion without resorting to speculation, the examiner must state the reasons why such an opinion cannot be rendered. In this regard, the examiner should state whether a definitive opinion cannot be provided because required information is missing or because current medical knowledge yields multiple possible etiologies with none more likely than not the cause of the claimed disability. The examiner should be as specific as possible. 5. After the above development is completed, and any other development that may be warranted based on additional evidence received, the AOJ should readjudicate the claim on the merits. If the benefits sought are not granted, the Veteran and her representative should be furnished a supplemental statement of the case (SSOC) and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of her claims. Her cooperation in VA's efforts to develop these claims, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655 (2009). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs