Citation Nr: 18140626 Decision Date: 10/03/18 Archive Date: 10/03/18 DOCKET NO. 16-09 134 DATE: October 3, 2018 REMANDED Entitlement to service connection for a neck disorder, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for a bilateral hip disorder, to include as secondary to service-connected disabilities is remanded. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1995 to July 1999. In October 2009, the Veteran appointed a Veterans Service Organization, AMVETS, as his representative. In September 2015, prior to certification of this appeal, AMVETS informed the Veteran and VA that it was withdrawing its representation. The Veteran has not appointed a new representative since that time, and is understood to be unrepresented. As discussed below, the Board is remanding this appeal. The Veteran is free to appoint a new representative while his appeal is pending. Entitlement to service connection for a neck disorder, a bilateral hip disorder, and obstructive sleep apnea, to include as secondary to service-connected disabilities, are remanded. The Veteran claims entitlement to service connection for a neck disorder, a bilateral hip disorder, and obstructive sleep apnea, both on a direct basis and/or as secondary to his service-connected disabilities. With regard to his claimed neck disorder, the Veteran attributes his neck pain to his service-connected migraine headaches. See October 2015 VA Form 21-4138, Statement in Support of Claim. With regard to his bilateral hip disorder, the Veteran claims that he began experiencing hip pain in service and that it has continued to this day. In support of his claim, the Veteran argued an in-service X-ray of his hips constituted evidence of his in-service symptoms. See October 2015 VA Form 21-4138, Statement in Support of Claim. With regard to his obstructive sleep apnea, the Veteran claims that such had its onset during his active duty service as evidence by his complaints of waking headaches during service. Alternatively, he claims that such is secondary to his service-connected gastroesophageal reflux disease (GERD) and/or migraine headaches. See October 2015 VA Form 21-4138, Statement in Support of Claim. In support of his claim, the Veteran cited a number of internet articles that discussed the relationship between obstructive sleep apnea and waking headaches, migraine headaches, and GERD. In December 2015, the Veteran underwent a VA examination in connection with his claims. He was diagnosed with bilateral hip sprains, degenerative joint disease of the cervical spine, and obstructive sleep apnea. With regard to his bilateral hips, the Veteran reported that he had experienced bilateral hip pain since service. With regard to his neck, the Veteran reported experiencing neck pain associated with his headaches since service. Ultimately, the examiner opined that the Veteran’s bilateral hip disorder was less likely than not proximately due to or caused by his service-connected condition. Although, the examiner’s opinion addressed secondary causation, the rationale provided was that there was no documentation in the Veteran’s service treatment records related to hip diagnoses or treatments, and his in-service X-rays of the hips were normal, and that his current bilateral hip disorder may be due to normal strains throughout the years. With regard to the Veteran’s alleged neck disorder, the examiner opined that such was less likely than not due to or caused by the Veteran’s service-connected migraine headaches. The examiner reasoned that the Veteran’s current neck arthritis was due to physical stress and/or wears and tears, and that it was hard to assign headaches or migraines as causes of abnormal findings of the neck. With regard to the Veteran’s obstructive sleep apnea, the examiner opined that such was less likely than not proximately due to or a result of the Veteran’s service-connected disabilities. The examiner reasoned that the medical literature and the pathophysiology of obstructive sleep apnea showed no causal relationships between sleep apnea and migraine headaches, back pain, or digestive issues. Separately, the examiner reasoned that the Veteran’s service treatment records did not document any sleep apnea symptoms. The Board finds that the December 2015 VA examination is inadequate for a number of reasons. Initially, although the examiner opined that the Veteran’s bilateral hip disorder, neck disorder, and obstructive sleep apnea were less likely than not proximately due to or caused by his service-connected disabilities, the examiner failed to offer an opinion as to whether his claimed disabilities were aggravated beyond their natural progression by his service-connected disabilities. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Additionally, with regard to the Veteran’s bilateral hip disorders, although the examiner provided a negative opinion as to secondary causation, the rationale provided exclusively focused on whether those disabilities were directly related to the Veteran’s military service. Furthermore, insofar as the examiner’s rationale addresses service connection on a direct basis, it fails to reflect consideration of the Veteran’s lay statements concerning the onset and continuity of symptoms. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (an examination is deemed to be inadequate where the examiner relies on the absence of evidence of disability in the service treatment records, and does not account for competent lay testimony as to onset and continuity of symptoms, to provide a negative opinion). Finally, the examiner did not address the articles cited by the Veteran in October 2015 that discussed the potential relationship between obstructive sleep apnea and waking headaches, migraine headaches, and GERD. On remand, the Veteran should be asked to provide copies of the medical treatise evidence referenced in his October 2015 correspondence that he wishes considered by VA The Court has held that a medical examination report must not contain only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). Given that the medical evidence of record fails to adequately address the issues raised, the Bo ard finds that a new examination is necessary. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). On remand, the AOJ should associate with the record any outstanding VA treatment records that are not currently associated with the claims file. Records dated through April 24, 2018, are currently of record. Additionally, the Veteran should be given the opportunity to identify any outstanding pertinent evidence. The matters are REMANDED for the following action: 1. Associate any VA treatment records dated after April 24, 2018, with the Veteran’s claims file. 2. Give the Veteran an opportunity to identify any outstanding pertinent evidence that has not already been associated with the claims file. The AOJ should then attempt to obtain those records if the Veteran provides the appropriate authorization. 3. Ask the Veteran to submit copies of the medical treatise and Internet research he identified in his October 8, 2015 Statements in Support of Claim that he wishes VA to consider in this appeal. 4. After completing the above development, the Veteran should be afforded a new VA examination to determine whether his bilateral hip disorders, neck disorder, and/or obstructive sleep apnea are related to his military service or secondary to his service-connected disabilities. The record and a copy of this Remand must be made available to, and reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. Following a review of the entire record, to include the Veteran’s lay statements concerning onset and continuity of symptomatology, the examiner(s) should address the following questions: a) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s bilateral hip disorders, neck disorder, and/or obstructive sleep apnea had its onset in, or is otherwise related to his period of active duty service? In offering any opinion, the examiner must consider the full record, to include the Veteran’s lay statements regarding in-service incurrence and continuity of symptomatology. Moreover, the examiner should address the Veteran’s contention that the waking headaches he experienced during service were initial manifestations of his obstructive sleep apnea. b) Regardless of the answers provided to the question above, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s bilateral hip disorders, neck disorder, and/or obstructive sleep apnea was caused or aggravated beyond its natural progression by his service-connected disabilities, to include his service-connected migraine headaches and/or GERD? In this regard, the Board emphasizes that causation and aggravation are two separate inquiries, and both must be answered. In offering any opinion, the examiner must consider the full record, to include medical evidence cited by the Veteran in his October 8, 2015 Statements in Support of Claim that discusses the potential relationship between migraines and neck pain, as well as the potential relationship between obstructive sleep apnea and GERD and migraine headaches. A complete rationale must be provided for all opinions provided. (Continued on Next Page) 5. Thereafter, and after any further development deemed necessary, the issues on appeal should be reajudicated. If the benefits sought on appeal are not granted, the Veteran should be provided with a Supplemental Statement of the Case and afforded the appropriate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD James R. Springer, Associate Counsel