Citation Nr: 20054110 Decision Date: 08/14/20 Archive Date: 08/14/20 DOCKET NO. 16-10 435 DATE: August 14, 2020 REMANDED Service connection for diabetes mellitus is remanded. Service connection for sleep apnea is remanded. Service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1977 to October 1977 and October 2005 to February 2006, with additional periods of ACTUDTRA and INACDUTRA with the Reserves, and with the Air National Guard. The matters are before the Board of Veterans Appeals (Board) on appeal from a May 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously considered the matters in September 2018 and remanded them for additional development. The matters now return for adjudication. Unfortunately, the Board finds another remand is necessary to ensure compliance with previous remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). In its September 2018 remand order, the Board remanded the matters for a VA examination with the instruction that the examiner consider whether the Veteran’s diabetes, sleep apnea, and/or hypertension were related to his period of service, and specifically his service in Southwest Asia in 2003. A review of the July 2019 VA examination shows that it does not contain any mention of the Veteran’s service in Southwest Asia in 2003. Accordingly, the matters must be remanded again for compliance with the Board’s remand orders. Although inadequate, the July 2019 VA examination does raise the possibility that the Veteran’s hypertension and sleep apnea are interrelated conditions, possibly secondarily caused or aggravated by each other as well as by the Veteran’s diabetes. If warranted, the examiner should consider and opine on these possibilities as discussed in the remand order below. See McLendon v. Nicholson, 20 Vet. App. 79, 86 (2006). The matters are REMANDED for the following action: Provide the record to an appropriate examiner to obtain a medical opinion to determine the etiology of the Veteran’s diabetes, sleep apnea, and hypertension. The record and a copy of this Remand must be made available to the examiner. The examiner must consider the Veteran’s active duty service in Southwest Asia in 2003 and his periods of ACDUTRA alongside the Veteran’s other history and complaints. The need for an additional in-person examination of the Veteran is left to the discretion of the clinician selected to write the opinion. The examiner should opine as to the following: (a.) The examiner must discuss both the etiology and pathophysiology of diabetes, sleep apnea, and hypertension stating whether 1) the etiology and 2) pathophysiology of the condition are understood or at least partially understood in the context of the Veteran’s unique circumstances. (b.) If any of the claimed disabilities have both an etiology and pathophysiology that are at least partially understood in the context of the Veteran’s unique circumstances, the examiner must then address whether the condition is at least as likely as not (50 percent probability or greater) the result of disease or injury in active service. If the examiner concludes either that the Veteran’s diabetes, sleep apnea, and hypertension either do not have at least partially understood etiologies or pathophysiologies or is at least as likely as not (50 percent probability or more) that one or more of the Veteran’s claimed disabilities (diabetes, sleep apnea, hypertension) are related to his periods of service, the examiner should opine as to the following: (c.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s hypertension is due to one of the Veteran’s other claimed disabilities (diabetes, sleep apnea). (d.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s hypertension is aggravated by one of the Veteran’s other claimed disabilities (diabetes, sleep apnea). “Aggravation” is defined as any worsening beyond the natural progression of the disability. (e.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s sleep apnea is due to one of the Veteran’s other claimed disabilities (diabetes, hypertension). (f.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s sleep apnea is aggravated by one of the Veteran’s other claimed disabilities (diabetes, hypertension). “Aggravation” is defined as any worsening beyond the natural progression of the disability. In offering any opinion, the examiner must consider the complete record, to include the lay statements addressing the onset and continuity of relevant symptomatology. A detailed rationale must be provided for all opinions and conclusions reached. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner’s medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael D. Wagner, 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.