Citation Nr: 18144110 Decision Date: 10/23/18 Archive Date: 10/23/18 DOCKET NO. 16-24 165 DATE: October 23, 2018 ISSUE Entitlement to service connection for narcolepsy. REMANDED Entitlement to service connection for narcolepsy is remanded. REASONS FOR REMAND The Veteran served on active duty from June 2009 to February 2010, and from March 2011 to December 2011. The first period of service was a period of Active Duty for Training (ACUDTRA). The Veteran is in receipt of the Iraq Campaign Medal with Campaign Star, reflecting service in the Southwest Asia theater of operations during the Persian Gulf War. This matter is before the Board of Veterans Appeals (Board) on appeal from an October 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The Veteran testified before the undersigned Veterans Law Judge (VLJ) in June 2018. A copy of the hearing transcript has been associated with the claims file. Entitlement to service connection for narcolepsy is remanded. A remand is necessary for additional development. As a threshold matter, the Board observes that to establish service connection, a Veteran must generally show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also 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). By way of background, a VA treatment record from July 22, 2015 shows, “Patient was switched from modafinil to methylphenidate last visit for treatment of Narcolepsy. Patient reports improvements in daytime sleepiness but still feels like there are some days where he needs an additional dose of the methylphenidate to maintain wakefulness.” Next, an October 2015 VA examination identified narcolepsy without cataplexy by way of a February 2014 sleep study. However, the negative nexus opinion rendered related to “a sleep disorder/centralized sleep apnea.” Still, the VA examiner’s rationale was, “Narcolepsy is not a presumptive condition of Gulf War service. I can find nothing in current medical literature which would support a Gulf War exposure as the causative factor for narcolepsy.” In the Veteran’s January 2016 Notice of Disagreement (NOD), he asserts in part, “While in Iraq I started noticing the symptoms of narcolepsy…I was diagnosed with narcolepsy around early 2014 which resulted in a permanent profile with the Military.” The Veteran perfected his appeal in May 2016. He describes that he was first seen in February 2012 with what was described as abnormal sleepiness. He was misdiagnosed as having a disorder that would be alleviated by surgery for a deviated septum. The issue persisted after the surgery. The Veteran highlights that he has been reporting related symptoms to VA since February 2012, later identified as attributable to narcolepsy. At the June 2018 hearing, there was evidence of disability, but the VLJ and Veteran discussed the critical third nexus requirement. The Veteran testified that he was essentially misdiagnosed with sleep apnea and underwent subsequent surgery for a deviated septum. During service, he would try to keep himself awake doing push ups and exercises, and would put hand sanitizer on his eyes. He started to complain about the symptoms immediately after he got back from Iraq. His roommate and good friends witnessed this. The Veteran asserted that there was no diagnosis of sleep apnea, and no link. There was just a diagnosis of narcolepsy. In other words, he was initially misdiagnosed. As he testified, “I know I did not go to Iraq with narcolepsy, but I came home with it.” The October 2015 VA examination does not fully address the Veteran’s theory of entitlement related to his current diagnosis of narcolepsy, as opposed to sleep apnea. It also does not consider a theory of entitlement related to direct service connection i.e. if it was manifest in service, rather than as a Gulf War disease. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). As such the Board finds that a supplemental VA examination is warranted. Evidence in the claims file to be considered includes the Veteran’s testimony regarding a possible link to service, and competently experienced and observed symptoms of fatigue for which he sought treatment shortly after discharge. In addition, the entire claims file should be made available to the VA examiner for review. Second, also at the June 2018 hearing, the VLJ further clarified a potential critical evidentiary defect regarding evidence of a nexus in the record. The VLJ highlighted that lay buddy statements may help the Veteran in substantiating his claim for service connection. The Veteran requested that the record be left open for 60 days for him to obtain such critical buddy statements. To date, none have been received. On remand, the Veteran will once again be afforded another opportunity to submit such statements. If none are received, and following the other development identified in the remand, the case will be adjudicated based upon the evidence of record. Lastly, any outstanding VA treatment records since 2016 should be included in the claims file. See Bell v. Derwinski, 2 Vet. App. 611 (1992). The matter is REMANDED for the following action: 1. Obtain updated copies of the Veteran’s VA treatment records, and any private treatment records if identified by the Veteran. 2. Please schedule the Veteran for a VA examination to determine the nature and etiology of any narcolepsy. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. The VA examiner should elicit a lay history of the onset of his fatigue in service. The Veteran is competent to report feeling low energy. He is competent to report what he has been told by a physician. Attention is generally directed to the Veteran’s testimony at the June 2018 hearing. The examiner should provide a rationale for all opinions expressed. After completing the above, and any other necessary development, the claim remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his representative an appropriate supplemental statement of the case (SSOC). Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel