Citation Nr: 20007239 Decision Date: 01/28/20 Archive Date: 01/28/20 DOCKET NO. 18-42 774A DATE: January 28, 2020 REMANDED Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for obstructive sleep apnea, to include as secondary to the service-connected posttraumatic stress disorder (PTSD) and to include as due to exposure to chemicals and/or environmental hazards in the Southwest Asia theater of operations in the Persian Gulf, is remanded. REASONS FOR REMAND The Veteran served on active military service from April 1990 to April 1992, to include service in Southwest Asia during the Persian Gulf War. These issues are on appeal from an October 2014 rating decision. 1. Entitlement to service connection for a left knee disorder is remanded. The Board cannot make a fully-informed decision on the left knee issue because an adequate VA medical opinion is not of record. The March 2018 provided a negative nexus opinion based on the fact that the Veteran had a pre-existing left knee injury. However, the VA examiner used the incorrect legal standard because the Veteran’s February 1990 military entrance examination does not document a left knee condition. Additionally, the April 2018 VA medical opinion only addressed one left knee incident from the Veteran’s service treatment records, as opposed to all seven notations. Upon remand, a VA medical opinion must be obtained. 2. Entitlement to service connection for obstructive sleep apnea, to include as secondary to the service-connected PTSD and to include as due to exposure to chemicals and/or environmental hazards in the Southwest Asia theater of operations in the Persian Gulf, is remanded. The Board cannot make a fully-informed decision on the sleep apnea issue because the Veteran has not been afforded a VA medical opinion to address whether his currently diagnosed obstructive sleep apnea is related to his active military service or to his service-connected PTSD. The Veteran argues that his sleep apnea is related to his exposure to chemicals and/or environmental hazards in the Southwest Asia theater of operations in the Persian Gulf, or is caused or aggravated by his service-connected PTSD. The post-service treatment records also contain a diagnosis of morbid obesity, and no examiner has addressed the relationship, if any, between the Veteran’s service-connected PTSD and his obesity. Upon remand, a VA medical opinion must be obtained. The matters are REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s currently diagnosed meniscal tear and osteoarthritis of the left knee clearly and unmistakably (undebatable) preexisted the Veteran’s service. The examiner must address the Veteran’s normal February 1990 military entrance examination and his August 1991 statement of left knee pain since high school. If the examiner finds either diagnosis did clearly and unmistakably preexist service, the examiner must opine whether it was clearly and unmistakably not aggravated by service. If the examiner finds that the Veteran’s currently diagnosed meniscal tear and osteoarthritis of the left knee either did not clearly and unmistakably preexist service, or were not clearly and unmistakably aggravated by service, then the examiner must opine whether the Veteran’s currently diagnosed meniscal tear and osteoarthritis of the left knee are at least as likely as not related to an in-service injury, event, or disease, including the June 1990, July 1990, and August 1991 in-service complaints of left knee pain, swelling, and injury, and to include the normal rigors of active duty. If the examiner finds that the osteoarthritis either did not clearly and unmistakably preexist service, or was not clearly and unmistakably aggravated by service, then the examiner must opine whether the Veteran’s current osteoarthritis diagnosis of the left knee at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s currently diagnosed obstructive sleep apnea is at least as likely as not related to an in-service injury, event, or disease, including as due to exposure to chemicals and/or environmental hazards in the Southwest Asia theater of operations in the Persian Gulf. The examiner must address the lay statements of record from the Veteran, his mother, and his fellow solider. The examiner must also opine whether the Veteran’s currently diagnosed obstructive sleep apnea is at least as likely as not (1) proximately due to the service-connected PTSD, or (2) aggravated by the service-connected PTSD. State whether there was an increase in the obstructive sleep apnea that was medically ascertainable, regardless of permanence. Any increase in the obstructive sleep apnea should be described in terms of diagnosis, severity, and duration. Secondary service connection is warranted for any incremental increase in disability. In this regard, the examiner must address the Veteran’s contention that his service-connected PTSD aggravates his asthma, which then aggravates his obstructive sleep apnea. The examiner must also opine whether it is at least as likely as not that the Veteran’s service-connected PTSD as likely as not caused him to become obese? If so, the examiner must opine whether it is at least as likely as not that the Veteran’s obesity was a substantial factor in the development of his obstructive sleep apnea? If so, the examiner must also opine as to whether it is at least as likely as not that the Veteran’s obstructive sleep apnea may not have occurred but for the obesity? 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefits sought are not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Shauna M. Watkins, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.