Citation Nr: 1803119 Decision Date: 01/17/18 Archive Date: 01/29/18 DOCKET NO. 11-23 039 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for sleep apnea, to include as secondary to post-traumatic stress disorder (PTSD). 2. Entitlement to a disability rating in excess of 10 percent for pilonidal cyst. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. N. Nolley, Associate INTRODUCTION The Veteran had honorable active duty service with the United States Army from September 1988 to November 1994. The Veteran's service includes time in Southwest Asia. This case comes before the Board of Veterans' Appeals (Board) on appeal of February 2009 and November 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. Jurisdiction over the case was subsequently transferred to the RO in St. Petersburg, Florida. The February 2009 rating decision continued the 10 percent disability rating assigned to the Veteran's service-connected recurring pilonidal cyst. The November 2009 rating decision denied service connection for sleep apnea. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Pilonidal Cyst The Board previously remanded this matter in February 2016. The Board noted that the Veteran's pilonidal cyst was treated with Augmentin and remanded the matter for another VA examination to determine whether the pilonidal cyst required systemic therapy such as corticosteroids or other immunosuppressive drugs. In addition, August 2010 VA treatment records indicated that he was prescribed doxycycline for his cyst. A VA examination was provided in October 2016. The VA examiner noted that the Veteran's skin disorder was treated with antibiotics, to include Augmentin. The treatment was described as a systemic treatment. However, the examiner opined that the Veteran's skin disorder did not require the use of systemic therapies such as corticosteroids or immunotherapy. The Board finds that the October 2016 VA opinion is inadequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). A medical opinion must support its conclusion with an analysis the Board can consider and weigh against other evidence in the record. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). Here, the examiner acknowledged that the Veteran's skin disorder was treated with systemic therapy, but did not explain why the systemic therapy was not like corticosteroids or immunotherapy. As such, a remand is required to obtain an adequate medical opinion. Sleep Apnea The Veteran asserted that his currently diagnosed sleep apnea is secondary to his service-connected posttraumatic stress disorder (PTSD). He also asserted that his sleep apnea started in 1991, and submitted a statement from his ex-wife describing his abnormal sleep patterns following his return from deployment. He reported that he was deployed to Kuwait, Saudi Arabia, and Iraq. His DD-214 confirmed that he served in Saudi Arabia. He also stated that he was exposed to unknown chemicals, gases, oil fires, and bombs. The RO obtained VA medical opinions in April 2011, April 2015, and December 2016, to determine whether the Veteran's sleep apnea was related to his service-connected PTSD. The April 2015 VA examiner also addressed whether his sleep apnea had its onset during service. However, the VA examiners did not consider the Veteran's lay statements concerning exposure to unknown chemicals, gases, oil fires, and bombs during service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury, but relied on the service treatment records to provide a negative opinion). Accordingly, a remand is required to obtain another VA medical opinion to determine whether his sleep apnea is related to environmental exposures in the Gulf War. Accordingly, the case is REMANDED for the following action: 1. 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claims, to include any more recent treatment records related to the claimed disabilities. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 2. The RO or the AMC should afford the Veteran a VA examination by a physician with sufficient expertise to determine the current severity of his service-connected pilonidal cyst. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated studies should be performed. The examiner must provide all information required for rating purposes. The examiner must provide an opinion as to whether the Veteran used Augmentin, doxycycline, and/or any other oral medications to treat his skin disorder at any point throughout the period on appeal, e.g. from June 2008. If so, the examiner must determine whether the Veteran's use of Augmentin, doxycycline, and/or any other oral medications are like or similar to a corticosteroid or other immunosuppressive drug. The examiner must determine at what points during the appeal period, e.g. since June 2008, the Veteran used systemic therapy like or similar to corticosteroids or other immunosuppressive drug. The examiner must discuss the frequency and duration of such use. A complete rationale must be provided for all opinions offered, and if the examiner cannot offer an opinion without resorting to mere speculation, the examiner should fully explain why this is the case and identify what additional evidence/information, if any, would allow for a more definitive opinion. 3. Then, the RO or the AMC should afford the Veteran a VA examination by a physician with sufficient expertise to address the etiology of the Veteran's sleep apnea. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated studies should be performed. Following a review of the relevant records and lay statements, the examiner should state an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the disorder originated during service or is otherwise etiologically related to his active service, to include his service in Southwest Asia (to include exposure to unknown chemicals, gases, oil fires, and bombs). The examiner must provide a complete rationale for all proffered opinions. In this regard, the examiner must discuss and consider the Veteran's statements indicating his exposure to unknown chemicals, gases, oil fires, and bombs and that he experienced sleep apneasymptoms during service. If the examiner is unable to provide any requested opinions, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she must provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. Then, the RO or the AMC should adjudicate the reopened claim for service connection for sleep apnea. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. 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 2014). _________________________________________________ B. MULLINS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2016).