Citation Nr: 20060204 Decision Date: 09/14/20 Archive Date: 09/14/20 DOCKET NO. 14-42 453 DATE: September 14, 2020 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service-connected hypertension, is remanded. Entitlement to service connection for diabetes mellitus, type II, to include as secondary to service-connected hypertension, is remanded. REASONS FOR REMAND This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7101(a)(2). The Veteran served on active duty from May 1955 to March 1959, with additional Reserve service. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In May 2017, the Veteran testified before the undersigned Veterans Law Judge at a live videoconference Board Hearing. A transcript of the hearing is of record. These matters were previously before the Board in August 2015, September 2017, and May 2019, where they were remanded for additional development. Regrettably, the Board finds that another remand is necessary prior to re-adjudication of the claims. 1. Entitlement to service connection for sleep apnea, to include as secondary to service-connected hypertension, is remanded. The Veteran contends that his current sleep apnea was directly related to his exposures to flammable liquids/environmental hazards while working as a medical specialist during practice “open pits” fire aircraft crash simulations while in service; or was otherwise proximately caused and/or aggravated by his service-connected hypertension. After review of the record, the Board finds that further development of the medical evidence is required prior to adjudicating the Veteran’s claim, in accordance with VA’s duty to assist. In January 2020 and February 2020, the Veteran was afforded two VA examinations and opinions to assess the current nature and etiology of his claimed condition, and in response to the Board’s May 2019 remand. Upon review of each, the examiner confirmed the diagnosis of obstructive sleep apnea; however, provided unfavorable opinions as this condition being etiologically related to the Veteran’s active duty service and/or proximately caused or aggravated by his service-connected disabilities. Nevertheless, the Board finds these opinions to be inadequate for adjudicative purposes, as the examiner rationalized for both secondary service connection opinions, specifically regarding the aggravation prong, that due to the fact that the Veteran did not have sleep apnea prior to his military service it could not be aggravated by his service-connected hypertension; to which the Board notes that it is not a requirement for a non-service-connected disability to be a preexisting condition for it to possibly be aggravated by a service-connected disability. Therefore, based on the above, the Board finds that the Veteran should be provided an addendum VA medical opinion that adequately addresses the Veteran’s claim under a secondary basis. Accordingly, a remand is necessary to address the matters discussed above. 2. Entitlement to service connection for diabetes mellitus, type II, to include as secondary to service-connected hypertension, is remanded. The Veteran contends that his current diabetes mellitus was directly related to his exposures to flammable liquids/environmental hazards while working as a medical specialist during practice “open pits” fire aircraft crash simulations while in service; or was otherwise proximately caused and/or aggravated by his service-connected hypertension. After review of the record, the Board finds that further development of the medical evidence is required prior to adjudicating the Veteran’s claim, in accordance with VA’s duty to assist. In January 2020 and February 2020, the Veteran was afforded two VA examinations and opinions to assess the current nature and etiology of his claimed condition, and in response to the Board’s May 2019 remand. Upon review of each, the examiner confirmed the diagnosis of diabetes mellitus, type II; however, provided unfavorable opinions as this condition being etiologically related to the Veteran’s active duty service and/or proximately caused or aggravated by his service-connected disabilities. Nevertheless, the Board finds these opinions to be inadequate for adjudicative purposes, as the examiner rationalized for both secondary service connection opinions, specifically regarding the aggravation prong, that due to the fact that the Veteran did not have diabetes mellitus prior to his military service it could not be aggravated by his service-connected hypertension; to which the Board notes that it is not a requirement for a non-service-connected disability to be a preexisting condition for it to possibly be aggravated by a service-connected disability. Additionally, the Board notes that regarding the examiner’s direct service connection opinions provided, the examiner, once again, relied heavily, and almost solely, on the lack of medical evidence pertinent to presumptive service connection for exposures to herbicides as a basis for the unfavorable opinions, with the mere and minute mention of the Veteran’s contentions/lay statements in the last sentence that simply stated that burn pits or flammable liquids are not known causes for diabetes mellitus. Therefore, based on the above, the Board finds that the Veteran should be provided an addendum VA medical opinion(s) that adequately addresses the Veteran’s claim under a secondary and direct basis (without reliance and/or mentioning of evidence required for presumptive service connection). Accordingly, a remand is necessary to address the matters discussed above. The matters are REMANDED for the following action: 1. Request the Veteran to identify all medical providers (VA and private) from whom he has received treatment for his sleep apnea and diabetes mellitus, and obtain any outstanding records and associate them with the Veteran’s claims file. 2. After associating all newly acquired records with the claims file, provide the Veteran with addendum VA medical opinions by appropriate clinicians to address the nature and etiology of the Veteran’s sleep apnea and diabetes mellitus. The claims file, including a copy of this remand, must be made available to the examiner in conjunction with the examination, and the examiner should note review of the record in the examination report. All pertinent medical complaints, symptoms, and clinical findings must be reported in detail. Following complete review of the record, the examiner must address the following: (a) whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea was caused by or aggravated (beyond the natural progression) by his service-connected disabilities, to include hypertension? Please note: the examiner must address both causation and aggravation in providing the opinions requested above. (b) whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s diabetes mellitus had its onset in service, or is otherwise etiologically related to his service, to include exposure to “open pits” and/or flammable liquids? Please note: the examiner must provide a rationale that does not include discussion, consideration and/or reliance of information/facts necessary for presumptive service connection. (c) whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s diabetes mellitus was caused by or aggravated (beyond the natural progression) by his service-connected disabilities, to include hypertension? Please note: the examiner must address both causation and aggravation in providing the opinions requested above. 3. Any opinion should include a detailed rationale. The examiner should consider the entire claims file and discuss the Veteran’s lay statements regarding the nature and onset of symptoms. The examiner is advised that the Veteran is competent to report symptoms, and that his reports must be considered in formulating the requested opinion. If the examiner(s) is unable to offer the requested opinion(s), it is essential that the examiner offer a rational for the conclusion that an opinion could not be provided without resorting to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382. (2010). M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Hodges, 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.