Citation Nr: 18143272 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 10-35 613 DATE: October 18, 2018 ORDER Entitlement to service connection for fibromyalgia, claimed as joint and muscle pain as due to undiagnosed illness is denied. Entitlement to service connection for actinic and seborrheic keratoses is granted. Entitlement to a rating in excess of 20 percent for right knee disability prior to March 11, 2015, and in excess of 30 percent from May 1, 2016 is denied. REMANDED Entitlement to service connection for rash is remanded. Entitlement to service connection for migraine headaches is remanded. Entitlement to service connection for sleep apnea is remanded. FINDINGS OF FACT 1. The Veteran is not diagnosed with fibromyalgia, or any other joint and muscle pain condition as due to undiagnosed illness. 2. During the course of the appeal, the Veteran was diagnosed with seborrheic keratoses and actinic keratoses that have been attributed to inservice sun exposure. 3. The Veteran’s right knee disability did not produce limited range of motion in flexion to 60 degrees or less, or extension to five degrees or more prior to March 11, 2015, but the Veteran had pain with motion of the right knee. The Veteran had episodes of locking, pain, and effusion in the right knee. 4. The Veteran did not have severe painful motion or weakness in the right knee after May 1, 2016. The Veteran’s right knee showed extension limited to 10 degrees after May 1, 2016. 5. The Veteran had a knee replacement surgery on March 11, 2015. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for fibromyalgia, claimed as joint and muscle pain as due to undiagnosed illness have not been met. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.317. 2. The criteria for entitlement to service connection for actinic and seborrheic keratoses are met. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.317. 3. The criteria for entitlement to a rating in excess of 20 percent for right knee disability prior to March 11, 2015, or in excess of 30 percent from May 1, 2016 have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. § 3.159, 4.59, 4.71a, Diagnostic Codes (DCs) 5055, 5258, 5260, 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1965 to April 1991, to include Naval service during the Persian Gulf era. The Board acknowledges that the issues of entitlement to an increased rating for a right shoulder disability, has been perfected and certified to the Board. However, the Board’s review of the claims file reveals that in regard to this claim, the Veteran has requested a videoconference hearing. To date, a hearing on this issue has not been conducted. Given such, the Board will not address this issue at this time, but it will be the subject of a subsequent decision, if otherwise in order. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996). It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102. The Board notes that some of the Veteran’s service treatment records (STRs) are not available in the present case and that there has been a formal finding of unavailability. The Court has held that in cases where records once in the hands of the government are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board’s analysis has been undertaken with this heightened duty in mind. The case law does not, however, lower the legal standard for proving a claim for service connection, but rather increases the Board’s obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the Veteran. Russo v. Brown, 9 Vet. App. 46 (1996). 1. Entitlement to service connection for fibromyalgia, claimed as joint and muscle pain as due to undiagnosed illness The Veteran contends that he has fibromyalgia, claimed as a joint and muscle pain condition, that is due to an undiagnosed illness as a result of service in the Persian Gulf. If a veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, then service connection may be established presumptively for a chronic disability resulting from an undiagnosed illness or medically unexplained chronic multi-symptom illness if such illness became manifest either during active service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1)(i). An “undiagnosed illness” is defined as one that by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). After a thorough review of the evidence, the Board finds that the Veteran does not have a diagnosis of fibromyalgia, and the joint and muscle pain is attributed to known etiologies. Accordingly, entitlement to service connection for fibromyalgia, claimed as joint and muscle pain, is not warranted. The Veteran’s available STRs and post-service medical treatment records document complaints of pain, for example, December 1966 complaint of left knee pain, or ongoing complaints of right shoulder pain. The medical treatment records document that the various complaints of pain are attributed to know etiologies, e.g., the December 1966 left knee pain resulted from falling while playing basketball, and the right shoulder pain is attributed to the Veteran’s service-connected right shoulder disability. In a March 2010 VA examination, the examiner listed the Veteran’s diagnosed conditions and concluded that there was no evidence of an undiagnosed illness, as the symptoms that the Veteran reported all had known etiologies. The October 2014 VA examiner noted the Veteran’s complaints of generalized joint and muscle pain in the arms and legs. The examiner remarked that the Veteran has diagnoses such as left and right torn rotator cuff with degenerative arthritis, and left elbow tendonitis, and that his symptoms and complaints had known etiologies. The examiner also noted that there were no reports of complaints about generalized myalgias. The examiner opined that the evidence did not support that the complaints of joint and muscle pain were attributable to an undiagnosed illness. In an April 2018 VA examination, the examiner concluded that the Veteran did not have a diagnosis of fibromyalgia. The examiner noted the Veteran’s symptoms such as shooting pain down the legs that was attributable to the lower back condition. The examiner reported that there were no objective findings for fibromyalgia with regard to the Veteran. Based on a review of the record, the Board finds that service connection for fibromyalgia, claimed as joint and muscle pain, including as due to an undiagnosed illness, is not warranted. A preponderance of the evidence shows that fibromyalgia was not manifested in service, or to a degree of 10 percent or more since service. Moreover, a preponderance of the evidence shows that the Veteran does not have a current disability of fibromyalgia. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. 38 U.S.C. § 5107. 2. Entitlement to service connection for actinic and seborrheic keratoses The Veteran contends that his diagnosed keratoses are a result of sun exposure during active service. The Veteran is currently service-connected for squamous cell and basal cell cancer associated to inservice sun exposure. The Veteran has been diagnosed with actinic and seborrheic keratoses during the course of the appeal. Among other evidence of record there is an August 2011 dermatology note indicating that these conditions are an active problem. An October 2014 VA examiner opined that the while these conditions are not the result of an “undiagnosed illness,” his intense sun exposure during service posed an increased risk for developing these lesions. Further it was noted that these skin conditions could evolve into both squamous and basal cell carcinomas. Service connection for skin cancer has been awarded. Given the positive opinion linking the Veteran’s keratoses to sun exposure and the Veteran’s history of intense sun exposure during service, and the clinic evidence showing that the Veteran keratoses during part of the appeal period, the Board will grant service connection for actinic and seborrheic keratoses. In reaching this conclusion, the Board notes that the Agency of Original Jurisdiction cited to VA’s policy not to assign multiple evaluations to disabilities with overlapping symptomatology. In this regard, the evaluation of the same “disability” or the same “manifestations” under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as “such a result would overcompensate the claimant for the actual impairment of his [or her] earning capacity.” See 38 U.S.C. § 1155; Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). This provision applies to the assignment of the appropriate disability evaluation and does not preclude the establishment of service connection for keratoses. Rather, to the extent that the Veteran’s symptomatology associated with his keratoses overlaps with his symptomatology associated with skin cancer, separate compensable disability evaluations would be precluded. The Board conceives that a situation may arise in which the Veteran has symptoms attributable to keratoses that have not yet or may never develop into cancer. In order to ensure and clarify that the Veteran should be compensable for any manifested skin disability attributed to his inservice sun exposure, the Board will award service connection for actinic and seborrheic keratoses. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. 38 C.F.R. § 4.14. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. 38 C.F.R. § 4.45. The intent of the rating schedule is to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 3. Entitlement to an increased rating for right knee disability The Veteran contends that his right knee disability was worse than contemplated by the assigned 20 percent rating prior to March 11, 2015, and worse than the 30 percent rating since May 1, 2016. After a review of the rating, the Board finds that an increased rating in excess of 20 percent prior to March 11, 2015, or in excess of 30 percent since May 1, 2016 is not warranted. The Veteran had a knee replacement surgery on March 11, 2015, and was rated at temporary convalescent level of 100 percent from that date until April 30, 2016. That period is not on appeal. As background, the Board granted a 20 percent rating for the Veteran’s right knee disability prior to March 11, 2015 in a July 2014 decision. In that decision, the Board adjusted the rating from 10 percent based on DC 5260, for painful motion, to 20 percent based on DC 5258, semilunar cartilage dislocated with frequent episodes of locking, pain, and effusion into the joint. In a July 2015 joint motion for remand (JMR) with the Court of Appeals for Veterans Claims (Court), the Board’s July 2014 decision was partially vacated as to the assignment of DC 5258 at 20 percent only, and the Court requested a new decision that took into account whether the Veteran was entitled to an additional separate rating for painful motion under another DC. Prior to the July 2014 Board decision, the Veteran was rated at 10 percent for painful motion under DC 5257-5010 for the right knee disability. In a December 2008 VA examination addendum, the Veteran’s knee showed range of motion from 0 degrees to 140 degrees. In the examination itself, the examiner reported the Veteran complained of mild pain in the right knee when walking for long distances. The Veteran’s right knee was stable. The Veteran’s VA treatment records dated December 2008 show complaints of pain and swelling in the right knee after the Veteran “turned it the wrong way.” The Veteran also reported that the knee “gives way” for the past several years. In the May 2014 Board hearing, the Veteran reported that his knee “snaps backward” about once a month when he steps in uneven spots and is generally painful. In an addendum opinion in April 2018, an examiner assessed the Veteran’s range of motion from 2008 as zero to 130 degrees for the right knee and pointed out that the range of motion on the current examination in April 2018 was also zero to 130 degrees. Under DC 5260, a non-compensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a. Under DC 5261, a non-compensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not “duplicative of or overlapping with the symptomatology” of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). See also VAOPGCPREC 9-04 (holding that separate ratings under DC 5260 for limitation of flexion of the knee and DC 5261 for limitation of extension of the knee may be assigned). A compensable rating for arthritis can be awarded on the basis of X-ray findings and painful motion under 38 C.F.R. § 4.59 even without motion being compensable under the rating schedule. In summary, prior to March 11, 2015, the Board finds that the Veteran’s right knee disability manifested in limitation of flexion greater than 60 degrees, and limitation of extension greater than 5 degrees. The Veteran had painful motion of the right knee, as such he had been awarded a 10 percent rating although he did not meet the criteria for compensable rating under the limitation of motion DC 5260 or 5261. The Veteran also reported episodes of locking, pain, and effusion (swelling), and this was confirmed in VA examination. There was no recurrent subluxation or lateral instability. The July 2014 Board decision awarded a 20 percent rating for the Veteran’s right knee disability based on the locking, pain, and effusion, under DC 5258. The Veteran was assessed with a possible torn right knee meniscus in October 2006. As discussed earlier, disability ratings for the same symptoms under separate ratings are not permitted under the pyramiding rule. 38 C.F.R. § 4.14. Accordingly, the 10 percent rating for painful limitation of motion was discontinued, and the Veteran was awarded a higher 20 percent rating under DC 5258. This is the action that is the subject of the Court’s July 2015 JMR. The Board finds that the appropriate rating is 20 percent under DC 5258 based on the Veteran’s episodes of locking, pain, and effusion. As pain is part of the criteria in DC 5258, and the Veteran did not meet the limitation of motion criteria under DC 5260, or 5261, and had previously been awarded a 10 percent rating for painful motion only, maintaining separate ratings under these DCs would constitute impermissible pyramiding. As the Veteran did not have ankylosis, or tibia and fibula impairment, DC 5256 and 5262 would not be appropriate. Accordingly, a rating in excess of 20 percent prior to March 11, 2015 is denied and a separate additional rating for the right knee disability under a DC other than 5258 is not warranted. As for the Veteran’s right knee rating since May 1, 2016, the Board finds that the evidence does not support a rating in excess of the currently assigned 30 percent under DC 5055. Under Diagnostic Code 5055, following the 100 percent rating for one year, a 60 percent rating is warranted if there are chronic residuals consisting of severe painful motion or weakness in the affected extremity. With intermediate degrees of residual weakness, pain or limitation of motion, the disability is to be rated by analogy to Diagnostic Codes 5256 (ankylosis of the knee), 5261 (limitation of extension) or 5262 (impairment of the tibia and fibula). The regulation prescribes a minimum rating of 30 percent under this diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5055. At a December 2017 VA examination for the right knee, post-surgery in 2015, the examiner noted that the Veteran complained of pain and stiffness limiting ability to bear weight and walk lasting 3 to 4 hours and occurring 2 to 3 times per month. The Veteran’s extension was measured to 10 degrees and flexion to 112 degrees. On repetitive testing, the range of motion was unchanged. Additional reported factors contributing to right knee disability included less movement than normal, weakened movement, swelling, disturbance of locomotion, interference with sitting and standing. The Veteran’s muscle strength for the right knee was 4/5 for flexion and extension. There was no muscle atrophy or ankylosis. There was no right knee joint instability with testing. There was no recurrent patellar dislocation, shin splints, stress fractures, or tibial or fibular impairment. The examiner noted the history of right knee meniscal tear with frequent episodes of locking, joint pain, and effusion. The Veteran did not use any assistive devices for locomotion. Passive knee range of motion testing was the same as for active range of motion testing. There was objective evidence of pain with non-weight bearing. In April 2018, the Veteran underwent another VA examination for the knees. The Veteran’s range of motion was to 130 degrees flexion and 0 degrees extension for the right knee. The examiner noted that there was no pain noted on examination. There was no additional loss of range of motion after repetitive testing. The right knee had 5/5 on the flexion and extension strength testing. There was no muscle atrophy or ankylosis. Joint stability testing showed no instability in the right knee. The examiner noted that there was no weakness. There was no pain with weight bearing or passive range of motion. The Board finds that the Veteran’s pain upon range of motion and weakness are accounted for under DC 5055 and that separately applying DCs 5260 or 5261 would result in pyramiding. See 38 C.F.R. § 4.14; see also Esteban, 6 Vet. App. at 261-62 (1994). The Veteran’s right knee disability has not manifested in chronic residuals consisting of severe painful motion or weakness that would warrant a 60 percent rating under DC 5055. Moreover, the application of DCs 5260 and 5261 would not, if applied in DC 5055’s stead, warrant a higher rating as the Veteran’s findings upon physical examinations did not support a rating in excess of 10 percent for limitation of extension at the December 2017 examination to 10 degrees. Additionally, the April 2018 examiner noted no objective evidence of painful motion and range of motion from zero degrees extension to 130 degrees flexion. Accordingly, the appeal for a rating in excess of 30 degrees for the Veteran’s right knee disability since May 1, 2016 is denied. REASONS FOR REMAND 1. Entitlement to service connection for rash is remanded. The April 2018 VA examination notes that the Veteran does not have a current diagnosis of skin rash, claimed as tinea pedis. The October 2014 VA examiner recorded the Veteran’s report that he had a rash at one time around his ankles, but there was no evidence of rash at the exam. The Veteran’s medical treatment records show treatment for tinea pedis in August 2011. The Veteran’s STRs show record of rash of one week’s duration in the March 1967 examination, and a note of mild “dermatophytosis” on both feet at the May 1967 re-enlistment examination. These records have not been considered in the VA medical opinions regarding the Veteran’s claim for rash, claimed as tinea pedis. Accordingly, a remand is required for an addendum medical opinion for rash claimed as tinea pedis to address these issues. 2. Entitlement to service connection for migraine headaches is remanded. The Veteran’s medical entrance examination dated March 1965 noted no defects. On the March 1965 medical history report, the Veteran noted a history of headaches, and a doctor recorded, “headaches – relieved by aspirin.” The VA examiner in April 2018 diagnosed the Veteran as having “migraine and migraine variant” headaches. The Veteran’s records contain diagnoses of sinus headaches, as well as “muscle contraction headaches,” e.g. May 2002 private treatment record. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the “correct standard for rebutting the presumption of soundness under section 1111 requires the government to show by clear and unmistakable evidence both that (1) the Veteran’s disability existed prior to service and (2) that the pre-existing disability was not aggravated during service.” Wagner v. Principi, 370 F.3d 1089, 1097 (Fed. Cir. 2004). In determining whether a condition preexisted service, the Veteran’s medical history, accepted medical principles, evidence regarding the basic character, origin, and development of the condition, and lay and medical evidence concerning the inception, development, and manifestations of the condition must be considered. 38 C.F.R. § 3.304(b); see Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered “aggravation in service” unless the underlying condition, as contrasted to symptoms, is worsened. Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991). The medical opinions for migraine headaches associated with the Veteran’s claim do not provide a medical opinion as to whether the Veteran’s current migraine headaches clearly and unmistakably preexisted service, and if so, whether the migraine headaches were more likely than not aggravated by active service. The rating decisions, statements of the case, and prior VA opinions impermissibly rely on the assumption that the Veteran’s migraine headache condition preexisted service, e.g. April 2018 VA examiner, and June 2010 statement of the case. Then the rating decisions and statements of the case conclude without a medical opinion that the purported preexisting migraine headache condition was not aggravated by service, e.g. June 2010 statement of the case. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b) (A history of conditions existing prior to service recorded at the time of the entrance examination does not constitute a notation of such conditions for the purpose of establishing whether the Veteran was of sound condition at enlistment). The Veteran’s medical records also show that he sustained a head trauma in or around 1997 as noted by a November 2000 treatment record from Madigan Army hospital. The note explained that the Veteran “fell to the ground landing on his head and shoulder” and since that time had headaches once a month that had increased in the previous 6 months to 3 times weekly. In a June 1996 Madigan Army Hospital record, the Veteran complained of a headache at the base of his skull. On a November 1995 medical checklist, also in the Madigan Army hospital records, the Veteran did not choose “frequent and severe headaches” as an ongoing medical concern. Accordingly, a remand is required for an addendum medical opinion for migraine headache condition to address these issues. 3. Entitlement to service connection for sleep apnea The Veteran contends that as a result of exposure to environmental hazards during the Gulf War, he has developed sleep apnea. However, he also contends that he has had symptoms of sleep apnea for a long time, prior to separating from service, and his wife also contends the same. The medical opinions reference the environmental causation claims, but do not opine on whether the Veteran’s sleep apnea may have developed prior to leaving active service. Accordingly, a remand is required for an addendum medical opinion for sleep apnea to address these issues. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran: (a.) has had a rash, claimed as tinea pedis, at any time during the appeal period (since February 2009); (b.) and if any rash or other similar skin condition (not the skin cancer or keratoses) seen during the appeal period (e.g. August 2011 note of treatment for tinea pedis, CAPRI) was at least as likely as not incurred in service, to include the rash reported in March 1967 service records, or the May 1967 dermatophytosis on both feet reported in the service records. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s sleep apnea. (a.) Was the Veteran’s sleep apnea at least as likely as not (50% probability) incurred during active service? The examiner should take into account the lay statements by the Veteran and any others regarding the development of claimed symptoms such as snoring. 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s migraine headache condition. The examiner should respond to the following inquiries: (a.) Did the Veteran’s current migraine headache condition clearly and unmistakably preexist active service. In your opinion, please reference the March 1965 entrance medical history on which the Veteran reported, and the physician wrote down, a history of headaches “relieved by aspirin.” (b.) If the Veteran had a migraine headache condition that clearly and unmistakably preexisted active service, did the Veteran’s migraine headache condition undergo an increase in severity during active service? (c.) If the Veteran’s migraine headache condition increased in severity during active service, is there clear and unmistakable evidence that the migraine headache condition was not aggravated beyond its natural progression by active service? (d.) If the Veteran’s current migraine headache condition did not preexist service, was it at least as likely as not (50% probability) incurred in or a result of injury, disease, or otherwise caused by active service? (e.) Please reference the Madigan Army hospital records from in an around 1996 to 2000 in explaining the etiology of any currently diagnosed migraine headache condition. If any of the benefits sought on appeal are denied, the Veteran and his representative should be provided a supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Miller, Erin (BVA)