Citation Nr: 18159042 Decision Date: 12/19/18 Archive Date: 12/18/18 DOCKET NO. 16-57 265 DATE: December 19, 2018 ORDER Entitlement to service connection for depression with anxiety as secondary to service-connected disability is granted. Restoration of a 10 percent rating for the Veteran’s costochondritis/Tietze’s syndrome is granted. Entitlement to a rating in excess of 10 percent for costochondritis/Tietze’s syndrome is denied. REMANDED Entitlement to service connection for sleep apnea is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, depression with anxiety which is causally related to service-connected costochondritis/Tietze’s syndrome. 2. In a May 2013 rating decision, the RO decreased the Veteran’s evaluation for costochondritis/Tietze’s syndrome from 10 percent to 0 percent effective from June 25, 2012; however, the preponderance of the evidence does not reflect that the Veteran had an improvement in his disability; thus, the reduction was not proper. 3. The Veteran’s costochondritis/Tietze’s syndrome manifests in pain, but does not manifest in symptoms that more nearly approximate a moderately severe or severe muscle group disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for depression with anxiety as secondary to service-connected disability have been met. 38 U.S.C. §§ 1101, 1110, 1154, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. A 10 percent rating to noncompensable for costochondritis/Tietze’s syndrome is restored from June 25, 2012. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.344, 4.55, 4.56, 4.7,4.73, Diagnostic Code (DC) 5399-5321. 3. The criteria for a rating in excess of 10 percent rating for costochondritis/Tietze’s syndrome have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.55, 4.56, 4.7,4.73, DC 5399-5321. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from February 2001 to August 2008. These matters come before the Board of Veterans’ Appeals (Board) from a May 2013 rating decision (costochondritis/Tietze’s syndrome, and depression) and a September 2017 rating decision (sleep apnea) of a Department of Veterans Affairs (VA), Regional Office (RO). In January 2018, VA received additional evidence from the Veteran with a waiver of RO consideration. In addition, VA vocational rehabilitation records were added to the electronic claims file since the September 2016 statement of the case (costochondritis/Tietze’s syndrome, and depression) and the November 2017 statement of the case (sleep apnea) and before the appeal was certified and transferred to the Board. However, as the VA vocational rehabilitation records do not provide relevant new evidence pertinent to the issues decided below, a remand for RO consideration is not warranted. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995).   Reductions With respect to disabilities where a rating has been in effect for less than five years, reexaminations disclosing improvement will warrant a rating reduction. 38 C.F.R. § 3.344(c). The duration of a rating is measured from the effective date assigned to a rating until the effective date of the actual reduction. Brown v. Brown, 5 Vet. App. 413, 417-18 (1995). Muscle Group Ratings 38 C.F.R. § 4.56 provides factors to be considered in classifying a muscle injury as slight, moderate, moderately severe, or severe. Under 38 C.F.R. § 4.56 muscle disabilities are evaluated as follows: (a) An open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. (b) A through-and-through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged. (c) For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. Under Diagnostic Codes 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows: (1) Slight disability of muscles--(i) Type of injury. Simple wound of muscle without debridement or infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles--(i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. (3) Moderately severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles--(i) Type of injury. Through and through or deep penetrating wound due to high- velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56 (d). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Reference to the Veteran’s disabilities are presented in additional evidence of record beyond the most detailed pertinent evidence discussed by the Board in this decision. The additional evidence of record does not present findings concerning the Veteran’s disabilities that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. Entitlement to service connection for depression as secondary to service-connected disability The Veteran is in receipt of service connection for several disabilities, to include costochondritis/Tietze’s syndrome; he contends that he has depression related to this disability (which leaves him unable to lift things without experiencing pain). The claims file includes several clinical records, lay statements, and private and VA examination reports with regard to the Veteran’s costochondritis and/or his mental health. The Board finds, based on the record as a whole, and as summarized below, that service connection is warranted for depression. Initially, the Board notes that the claims file contains correspondence from the Veteran’s spouse in which she writes that the Veteran’s depression is related to the fact that he wished to go to nursing school which would require lifting patients, and that he was unable to do this. The Veteran has submitted statements that he gets more depressed when he realizes there are things he cannot do (such as picking up his children) due to severe chest pain (see April 2012 correspondence). A February 2011 VA examination report reflects that the Veteran reported that he has chest pain which comes and goes with lifting. It was noted to cause a moderate effect on chores and exercise, and a mild effect on shopping, sports, and recreation. Subsequently, a December 2011 VA record reflects that the Veteran felt worthless when he attempts to lift things and his costochondritis interferes. An April 2012 VA examination report reflects that the Veteran has a diagnosis of recurrent major depressive disorder, panic disorder without agoraphobia which is related to his depressive disorder and mutually aggravating. The clinician found that the Veteran’s depression is at least as likely as not proximately due to or the result of the Veteran’s service-connected costochondritis/Tietze’s syndrome. The examiner found that some of the Veteran’s symptoms of major depressive disorder and anxiety are directly related to his medical condition of costochondritis. Specifically, the examiner found “his helplessness is related to his perceived lack of control over the development of the medication condition, it’s diagnosis, treatment and depression” and “feelings of worthlessness are related to his perceived inability to fulfill his role as a husband and a father due to his inability to carry heavy objects including his own children.” Additional records continue to show that the Veteran has complained of chest pain. For example, May 2012 VA clinical records reflect that the Veteran was seen for sternal chest pain, and was observed “wincing” by the clinician who saw him in urgent care. His pain was noted to be a level 7 without medication. A psychiatric note also reflects that the Veteran continued to complain of chest and back pain bothering him. (The Veteran is in receipt of service connection for a back disability.) The Veteran reported that his mood had been up and down, and that he tried to play with kids if he can but that he still cannot lift things. Another record reflects that the Veteran tried not to focus on the frustration of not being able to lift weight. June 2012 VA mental health records reflect that the Veteran was training for a new job which did not involve any lifting, and noted that no lifting was necessary in view of his chest pain. The Veteran stated that when he thinks about what he is not able to do, he “breaks down”, and that he copes with chronic pan by “ignoring” it. A June 2012 VA examination report with a May 2013 VA addendum notes that the Veteran did not have muscle atrophy (all his arm muscles were developed), he was able to take deep breaths without chest pain, and he was observed taking off and putting on his shirt without objective evidence of pain. A December 2013 record notes that the Veteran was taking meloxicam and tramadol with good benefit but did not want to permanently take medications to treat his symptoms. A September 2016 VA examination report reflects the opinion of the clinician that the Veteran likely experienced depression prior to the onset of costochondritis (due to the death of his father) but that it was at least as likely as not aggravated beyond its normal progression, noting that pain and loss of function associated with a physical condition likely aggravates the Veterans subjective experience of distress. The claims file includes a December 2017 private opinion by Dr. P.L. who opines that chronic pain does precipitate, aggravate, and exacerbate depression and “the clinical evidence in this case without question indicates [the Veteran]’s depression is related to his service connected conditions.” Dr. P.L. cited to several records to support his rationale. The Board finds that the evidence is at least in equipoise that the Veteran’s service-connected disability of costochondritis/Tietze’s syndrome is a causal factor in the Veteran’s depressive disorder. Resolving doubt in favor of the Veteran, the Board finds that service connection is warranted because his depression was caused by a service-connected disability. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Entitlement to a restoration of a 10 percent rating for costochondritis/Tietze’s syndrome from June 25, 2012 and Entitlement to an increased rating for costochondritis/Tietze’s syndrome Historically, the Veteran’s costochondritis/Tietze’s syndrome disability was rated as 10 percent disabling from August 16, 2008, the effective date of service connection. In April 2012, the Veteran filed a claim for an increased rating. The Veteran’s disability is rated under Diagnostic Code 5399-5321. His disability is rated by analogy. In the May 2013 rating decision on appeal, the RO decreased the Veteran’s evaluation to noncompensable effective June 25, 2012, the date of a VA examination report. The Board will address two issues: whether the Veteran’s 10 percent rating prior to June 25, 2012 should be restored, and whether the Veteran is entitled to a rating in excess of 10 percent. Restoration of 10 percent (propriety of reduction) As the rating reduction did not change his combined evaluation, the procedural requirements of 38 C.F.R. § 3.105 (revision of decisions) are not applicable. As the rating was in effect for less than 5 years, 38 C.F.R. § 3.344(c), which states that reexaminations disclosing improvement, physical or mental, in disabilities will warrant a reduction in rating, is applicable. The Board finds that the evidence of record as a whole, and summarized below, does not reflect that the Veteran had an improvement in his disability. In considering the propriety of a reduction, the Board must focus on the evidence available to the RO at the time the reduction was implemented, although post-reduction medical evidence may be considered in the context of evaluating whether the disability had demonstrated actual improvement. Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-82 (1992). In order for a rating reduction to be sustained, it must be shown by a preponderance of the evidence that the reduction was warranted. Sorakubo v. Principi, 16 Vet. App. 120 (2002). In order to determine if the Veteran’s disability showed improvement, the Board will first summarize the Veteran’s disability prior to the June 2012 VA examination and at the time of his examination in February 2011. The February 2011 VA examination report reflects that the Veteran reported that he was, at that time, taking Naproxen 500mg once a month. He reported problems with lifting and carrying, difficulty with reaching, lack of stamina, pain, and weakness or fatigue. A VA clinical record in January 2012 reflects that the Veteran complained that he cannot pick up his seven-pound newborn son, and cannot carrying groceries or do other chores which involve picking up/carrying weight. The Veteran’s spouse (E.K.) submitted a statement in April 2012 in which she stated that “within the last two years [the Veteran] has come to the [realization] that no matter what he does his chest is not going to get any better.” The Veteran also submitted an April 2012 statement in which he stated that since service, he has spent a “few years trying to heal [the chest pain] with ultra sounds, physical therapy and rest none of it ever provided any real help. I have continued to do things to help heal it, along with easy stretching, ice packs and heat packs. These things only provide temporary relief and never took the pain completely away.” A May 2012 VA clinical record reflects that the Veteran was seen for sternal chest pain which was a 7/10 and stated that NSAIDS were ineffective. He was offered an injection of Toradol to relieve the pain but he refused and stated that he wanted to go home and take ibuprofen or naproxen. A June 2012 VA examination report reflects that the Veteran reported pain has progressively gotten worse and the pain radiates to the entire upper chest, and that pain occurs every day whenever he tries to lift anything at all. He reported that pain occurs multiple times a day whenever he tries to lift something and lasts several hours at a time – essentially constant. It was noted that pain is usually a 5/10 but will increase to 8/10 with precipitating activities (e.g. lifting more than five pounds, yardwork, coughing, repetitive pushing and pulling), and also occurs without precipitating activities. Holding items closer to the chest decreased the pain level. It was noted that the Veteran reported alternating Ibuprofen with Naproxen 500 mg twice a week. The examiner concluded that the Veteran had consistent fatigue-pain of Muscle Group XXI. The Veteran had full muscle strength with no atrophy. He did not have any known fascial defects. He also did not have any of the following: impairment of muscle tonus, loss of muscle substance, soft flabby muscles, muscles that swell and harden, induration, visible or measurable atrophy, loss of power, weakness, lowered threshold of fatigue, impairment of coordination, and/or uncertainty of movement. The Veteran’s chest x-ray was normal and his chest excursion was normal. The Veteran complained of pain everywhere the examiner touched on his anterior chest. The examiner noted that the muscle injury impacted the Veteran’s ability to work in that the Veteran had decreased endurance and increased pain with lifting more than 5 pounds and repetitive pushing and pulling activities. The report reflects that the Veteran’s current symptoms are not consistent with his service-connected costochondritis /Tietze’s syndrome but are indicative that he has developed a generalized chest wall pain syndrome likely triggered by the costochondritis, which would be considered a progression of the disease, and indicates that the Veteran’s symptoms were not of the severity of which he alleged. The examiner noted that the Veteran was observed taking off and putting on a shirt without objective evidence of pain in the chest. He was also able to complete repetitions of modified wall pushups but complained of pain. Several hours after the VA examination, the Veteran went to the VA nurse walk-in clinic and reported diffuse pectoral pain. He had no shortness of breath, no numbness, no tingling, and denied sternal chest pain. The Veteran received Toradol, was in the office for 15 minutes, and stated that “the pain is virtually gone and I feel good.” He was able to leave with no difficulties and his pain was a 0/10. An April 2013 VA examination report addendum reflects that the objective physical findings of the 2012 examination were not consistent with the Veteran’s “subjective report of degree of severity of symptoms – specifically lack of atrophy of disuse, presence of symmetrical well-formed musculature and movements reported to cause pain with no objective evidence of pain.” The examiner found that the Veteran’s symptoms of pain on the day of the examination were also reflective of an acute exacerbation rather than a sustained increase in severity of the disability. A December 2013 VA record reflects normal sternal x-ray findings. A January 2014 VA mental health note reflects that the Veteran reported chronic chest pain; pain medication was ordered. The Veteran submitted a May 2014 statement in which he objected to the findings of the 2012 examiner. He stated that he can take two or three deep breaths depending on his chest pain but anything after that becomes extremely painful. He also wrote that he has learned how to take off and on his shirt with the minimal amount of pain. He reported that his condition had its up and downs with some treatments, but that finally in 2011, there was “nothing that worked anymore.” He also reported that at the time of his exam, he had lost strength, his muscles had shrunk, and he had atrophy. He noted that he had to receive Toradol after the examination and that it took him a month to recover from the examination. He also reported that he currently takes medication which numbs the pain and he can function as a “normal human being”, can lift, and notices his muscles returning to normal strength. He further stated that without medication, he would not be able to lift without pain. The Veteran stated that he performs isometric exercises to stay in shape when in pain. The Board finds that the June 2012 examination did not demonstrate improvement. At the time of his 2011 examination, he reported problems with lifting and carrying, difficulty with reaching, lack of stamina, pain, and weakness or fatigue. He reported similar problems in 2012, except he reported his symptoms had worsened. In 2012 the examiner concluded that the Veteran had consistent fatigue-pain of Muscle Group XXI and noted that the muscle injury impacted the Veteran’s ability to work in that the Veteran had decreased endurance and increased pain with lifting more than 5 pounds and repetitive pushing and pulling activities. Further, in 2011, the Veteran reported taking Naproxen 500mg once a month for his symptoms, but in 2012, he reported alternating Ibuprofen with Naproxen 500 mg twice a week. The Veteran’s continued complaints of pain and his report of an increase in frequency of medicine to treat the pain, are evidence against improvement in symptoms. While the Board does not find that the Veteran’s symptoms rise to the severity he contends (e.g. causing atrophy), the Board finds that the symptoms did not shown improvement at the time of the 2012 examination or thereafter. Thus, the Board finds that restoration of the 10 percent rating is warranted. Increased rating in excess of 10 percent As noted above, in April 2012, the Veteran filed a claim for an increased rating; the rating period on appeal is from April 2011, or one year prior if the evidence reflects a worsening of his disability in that one-year period. The Veteran would be entitled to a rating of 20 percent for severe or moderately severe symptoms. A 10 percent, his current rating, is warranted for moderate symptoms. A noncompensable rating is warranted for mild symptoms. Muscle disabilities are evaluated under 38 C.F.R. § 4.56. The Board finds that a rating in excess of 10 percent is not warranted for any period on appeal. The Veteran’s 10 percent rating compensates the Veteran for his reported symptoms of pain and fatigue-pain. The Board notes that the Veteran has taken medication for pain; however, the Board has not considered the ameliorative effects of medication in rendering its decision. See Jones v. Shinseki, 26 Vet. App. 56 (2012). The Board has considered the Veteran’s contentions; however, it finds that the clinical findings are more probative as to the extent of the Veteran’s disability. As noted above, the Veteran sought treatment and pain medication after his 2012 examination; this is highly indicative that he was not on medication at the time of the examination during which he was observed taking off and putting on his shirt. He was also observed breathing deeply without pain. In addition, and importantly, the examiner found that the Veteran did not have atrophy, and had well-formed musculature. At the time, the Veteran was not routinely taking Tramadol or Toradol, and was not even taking Naproxen and/or Ibuprofen on a daily basis for his chest pain (see VA examination reports). The examiner is competent, and more qualified than the Veteran, to determine if there is atrophy of the muscles, and found that there was not. The Board finds that the Veteran did not require pain medication to keep muscles from atrophying. (The Veteran has reported that he used isometric exercises to keep in shape.) The Board acknowledges that the Veteran is competent to report pain and has considered that the Veteran has reported that he could not keep up with the work requirements of being a nurse if he chose that occupation. The Board, in restoring the 10 percent rating, has considered that the Veteran has pain. In this regard, the Board notes that a 10 percent rating is the rating for a moderate muscle group XXI injury which is appropriate when a veteran has one or more of the cardinal signs and symptoms of a muscle disability- in this case, fatigue-pain. The objective evidence does not support that the Veteran has other cardinal signs; however, assuming arguendo that the Veteran had more severe symptoms such as weakness, loss of power, or loss of muscle substance, such would still be a moderate disability. There is no competent credible evidence that the Veteran’s disability more nearly approximates a moderately severe or severe disability of the muscle group. Based on the foregoing, and applying the benefit of the doubt where applicable, the Board finds that a 10 percent rating, and no higher is warranted. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). REASONS FOR REMAND Entitlement to service connection for sleep apnea is remanded. The Veteran has reported that his sleep apnea began after separation from service; the earliest clinical evidence of sleep apnea is in 2013, more than four years after separation from service. The Veteran contends that his sleep apnea is due his service-connected asthma and the medications to treat such. A December 2017 private opinion reflects the opinion of the clinician (Dr. P. L.) that the Veteran’s sleep apnea is as likely as not “related” to his service-connected asthma, and that there is a “service related connection with his sleep apnea, and his chronic low back pain”; however, an adequate rationale for the opinion was not provided. The claims file includes an article on asthma, corticosteroids, and sleep apnea; however, the record does not support that the Veteran was on corticosteroids at the time of his diagnosis of sleep apnea (see VA records and December 2013 record which reflects that the Veteran did not have steroid use). The claims file includes a September 2017 DBQ report in which the clinician opined that it is less likely than not that the Veteran’s sleep apnea is due to a service-connected disability. The clinician opined that there are several risk factors for obstructive sleep apnea to include age and being a male. The clinician also opined that while certain substances may exacerbate OSA, a causative link is not proven. The Board finds that a supplemental opinion which further discusses aggravation, and which discusses the Veteran’s service-connected back disability is warranted. Any opinion should include an adequate rationale. The matter is REMANDED for the following action: 1. Associate with the claims file all outstanding VA clinical records for the Veteran since June 2017. 2. Obtain a supplemental opinion as to whether it is as likely as not (50 percent or greater) that the Veteran’s sleep apnea is aggravated by a service-connected disability, to include asthma, a back disability, and/or medication to treat a service-connected disability. Any opinion should include an adequate rationale. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Wishard