Citation Nr: 18151122 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 17-37 459 DATE: November 16, 2018 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 November 1997 to November 2002. This appeal is before the Board of Veterans’ Appeals (Board) from a February 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service connected disabilities, is remanded. The Veteran asserts that service connection for obstructive sleep apnea is warranted because it was incurred in service, or otherwise related to service, to include caused by or aggravated by his service-connected disabilities. See March 2017 notice of disagreement and July 2017 substantive appeal (VA Form 9). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). When VA undertakes to obtain an examination, it must ensure that the examination and opinion therein is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). In review of the VA opinion provided in June 2017, the Board notes that the examiner failed to directly address the Veteran’s theory of secondary service connection. While the examiner gave an adequate opinion explaining that there was no direct relationship between the Veteran’s service-connected musculoskeletal disabilities and obstructive sleep apnea, the Veteran explicitly stated that these musculoskeletal disabilities made it too painful for him to exercise, causing his obesity. Indeed, in the opinion addressing direct service connection the examiner suggested that the likely cause of the Veteran’s obstructive sleep apnea was his morbid obesity. Remand is therefore necessary to obtain an opinion as to what extent, if any, the Veteran’s service-connected disabilities contributed to his obstructive sleep apnea through the intermediate step of causing his obesity. See VAOPGCPREC 1-2017 (January 6, 2017). The matter is REMANDED for the following action: 1. Obtain and associate with the claims file any additional medical evidence that may have come into existence but has not been associated with the record. 2. Return the Veteran’s claims file to the June 2017 VA examiner who provided the medical opinion on the Veteran’s obstructive sleep apnea or to a qualified medical professional if the examiner is unavailable, to provide an addendum opinion. The examiner must review the claims file. The examiner may schedule an examination if deemed necessary. The examiner is informed that the Veteran is service-connected for 1) bilateral pes planus with rupture of left extensor hallucis longus tendon; 2) residuals, right foot bunionectomy with hallux valgus; 3) tinnitus; 4) residuals, right knee patellofemoral syndrome; 5) left foot hallux valgus; 6) lumbar spine sprain; 7) scar, right foot bunionectomy; 8) hearing loss, right ear; and 9) arthritis, bilateral first metatarsophalangeal joints. The examiner must offer an opinion as to whether it is at least as likely as not (i.e. 50 percent probability or more) that the Veteran’s obstructive sleep apnea was caused by the level of his obesity, if any, that is attributable to his service-connected disabilities. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. After completing the above, and any other development deemed necessary, readjudicate the appeal. If the benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board. J. GALLAGHER Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Cheng, Associate Counsel