Citation Nr: 1322552 Decision Date: 07/15/13 Archive Date: 07/24/13 DOCKET NO. 10-02 729 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for sleep apnea as secondary to service-connected asthma. (The issue of entitlement to additional vocational rehabilitation training services under the provisions of Chapter 31, Title 38 of the United States Code, is the subject of a separate decision of the Board of Veterans' Appeals.) REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from January 1984 to December 1987. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2009 decision of the Columbia, South Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND Unfortunately, a remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that the Veteran is afforded every possible consideration. With regard to the issue of service connection for sleep apnea as secondary to service-connected asthma, the Veteran has submitted a statement from her private physician, dated in February 2010, in which the physician stated that it was more likely than not the Veteran's asthma has caused her sleep apnea. However, there was no rationale or underlying reason provided. In contrast, in May 2010, a VA nurse practitioner opined that the Veteran's asthma did not cause her sleep apnea, which was primarily caused by her body habitus. However, the nurse practitioner did not provide an opinion regarding whether the Veteran's asthma aggravates her diagnosed sleep apnea. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991). A medical opinion is considered 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). To be adequate, a medical opinion must do more than state a conclusion that the etiology of a medical condition, for example, is unknown or unknowable, the conclusion must be supported with sufficient rationale and explanation. Stefl, 21 Vet. App. At 124. The United States Court of Appeals for Veterans Claims ("the Court") in Stefl explained some of the types of information that a factor might discuss in his or her opinion, even if ultimately inconclusive such as why the examiner finds cited studies persuasive or unpersuasive, whether the Veteran has other risk factors for developing the claimed condition, and whether the claimed condition has manifested itself in an unusual manner. Further, once VA undertakes the effort to provide an examination for a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). Both the private opinion and the VA examination report are incomplete for the reasons stated. The Veteran is hereby notified that she may submit additional information from her private physician as to the etiology of her sleep apnea, although she should also be sent a Veterans Claims Assistance Act (VCAA) updated letter to this effect since the claim is being remanded. In addition, the Board finds that an addendum opinion must be obtained from the VA examiner who provided the May 2010 opinion, or, if unavailable, from another VA examiner, to address the question of aggravation. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be notified in an updated VCAA letter that she may submit additional explanation from her private physician regarding the etiology of her sleep apnea. 2. Obtain a VA medical addendum from the VA examiner who provided the May 2010 opinion, or, if unavailable, from another VA examiner, to address the question of aggravation. The record must be made available to the examiner and the examiner should indicate in his/her report whether or not the record was reviewed. The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that any current sleep apnea disorder is permanently aggravated (permanently worsened) by the Veteran's service-connected asthma. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 3. The AMC should review the medical opinion obtained above to ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, AMC should return the case to the examiner for completion of the inquiry. 4. The AMC should then readjudicate the claim for service connection for sleep apnea on appeal in light of all of the evidence of record. If the issue remains denied, the Veteran should be provided with a supplemental statement of the case as to the issue on appeal, and afforded a reasonable period of time within which to respond thereto. The appellant 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). 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 2002 & Supp. 2012). _________________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).