Citation Nr: 20022414 Decision Date: 03/31/20 Archive Date: 03/31/20 DOCKET NO. 16-30 427 DATE: March 31, 2020 REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a gastrointestinal disorder, to include IBS is remanded. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from February 1973 to May 1976 and in the United States Army from January 1991 to April 1991, including service in the Persian Gulf. The Veteran presented sworn testimony at a hearing before the undersigned in June 2018. In October 2018, the Board remanded these issues for additional development. 1. Entitlement to service connection for sleep apnea is remanded. The Veteran asserts that he developed sleep apnea secondary to his weight gain, as a result of his service-connected post-traumatic stress disorder (PTSD), major depressive disorder. See June 2018 Hr’g Transcript at 4. The Veteran has a current diagnosis of obstructive sleep apnea. See April 2019 Sleep Apnea DBQ. In October 2018, the Board remanded this issue for additional development. In April 2019, the Veteran was afforded a sleep apnea examination. The examiner diagnosed the Veteran with obstructive sleep apnea. In the February 2020 addendum opinion, the examiner provided a negative nexus opinion. In her reasoning the examiner acknowledged that scientific evidence to date shows an increase in comorbidity related to PTSD/depression and sleep apnea and she stated that there is no evidence to show a causal factor. She also stated that part of her opinion was based on the Veteran having a long history of no sleep problems on entrance or exit physical examination and through the records in 1991. The Board notes, however, the Veteran’s theory of entitlement is based on secondary service connection so the onset of his condition 30 years after service is less relevant. Additionally, in providing her reasoning, the examiner did not address the Veteran’s contention that his service-connected disabilities, specifically his PTSD, major depression, caused a loss in motivation that resulted in weight gain and resulted in him developing sleep apnea. Clarity is needed regarding whether the Veteran's diagnosed sleep apnea were caused or aggravated by his service-connected PTSD, major depression. As such, a remand is warranted. 2. Entitlement to service connection for IBS is remanded. The Veteran asserts that he is entitled to service connection for a gastrointestinal condition that is the result of active duty service. See June 2018 Hr’g Tr. at 10, 11. The Veteran testified that he had been diagnosed with irritable bowel syndrome around 2008. Id at 11. Additionally, he testified that his gastrointestinal symptoms, including diarrhea, had been present and recurrent since his service in the Persian Gulf. In October 2018, the Board remanded this issue for additional development, to include a VA examination. In April 2019 the Veteran was afforded a VA examination. The examiner noted the Veteran did not have a diagnosis of IBS. Additionally, the examiner provided a negative nexus opinion regarding the Veteran’s the Veteran's diverticulitis and active duty service. See April 2019 Intestinal Conditions DBQ. The examiner acknowledged that the Veteran has a history of diarrhea after meals which is documented in his files and that he confirms that after meals he requires restroom facilities at all times, which is consistent with diverticulitis/diverticulitis. The examiner acknowledged the Veteran has a long history of opioid use, for which a stool softener was given in 2016, but added there is no active prescription for a stool softener in the VA records. At his June 2018 Board hearing, the Veteran testified that the severity of his service-connected disabilities and the use of medications to treat those conditions resulted in a decrease in motivation and negatively impacted his health. See June 2018 Hr’g Tr. The Board requires clarity to determine whether there is a relationship between the Veterans use of opioids, his service-connected disabilities and his gastrointestinal condition(s). The Board finds that a new VA examination and opinion is necessary. REASONS FOR REMAND The matters are REMANDED for the following action: 1. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service psychiatric, sleep and gastrointestinal symptoms. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 2. Schedule the Veteran for an appropriate VA examination to determine the nature, onset and etiology of any sleep disorder, to include sleep apnea, found to be present. The examiner is asked to review evidence of record. After reviewing the claims file, please respond to the following: a. Diagnose all sleep conditions found to be present. The Veteran has a current diagnosis of obstructive sleep apnea. b. Is it at least as likely as not that the Veteran's sleep apnea was caused his service-connected PTSD? c. Is it at least as likely as not that the Veteran’s sleep disorder is aggravated by his PTSD? If the examiner finds that the Veteran's sleep apnea was not caused by his PTSD or any of the medications taken to treat that condition, but has been aggravated by them, then he/she should state the baseline level of severity of the apnea, established by the earliest available medical evidence, and describe the extent to which the condition was permanently worsened by the Veteran's or any prescribed medications. The examiner should acknowledge and address the Veteran’s statements and contention that his service-connected physical and psychological conditions caused him to lose motivation and resulted in inactivity and weight gain that resulted in the development of his diagnosed sleep apnea. Gastrointestinal Disorder, claimed as IBS 3. Schedule the Veteran for a VA examination to determine the nature, onset and etiology of his gastrointestinal disability. The claims file should be made available to and reviewed by the examiner. All appropriate tests deemed necessary should be administered. Based on review of the record, and interview/examination of the Veteran, the examiner should provide an opinion that responds to the following: a. Diagnose all gastrointestinal disabilities found to be present. Please note, the Veteran has a diagnosis of diverticulitis. A diagnosis of irritable bowel syndrome must be ruled in or excluded. b. For each diagnosis condition found to be present, the examiner should opine whether it is at least as likely as not that such disorder is related to or had its onset in service. The examiner must acknowledge and address the Veteran’s statements that he had symptoms including diarrhea, stomach cramping and the immediate need to use the restroom after eating that began during his Gulf War deployment in 1991 and have been recurrent since that time. c. For each diagnosed disorder, is any condition proximately due to, the result of, or caused by any service-connected disability(ies)? d. For each diagnosed disorder, has any disorder been aggravated (made permanently worse or increased in severity) by any of the Veteran’s service-connected disability(ies). (Continued on the next page)   In responding to the above inquiries, the examiner must address whether the Veteran’s use of any drugs is related to his service-connected PTSD. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jacquelynn M. Jordan, Associate 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.