Citation Nr: 21001726 Decision Date: 01/11/21 Archive Date: 01/11/21 DOCKET NO. 18-00 843 DATE: January 11, 2021 ORDER Entitlement to service connection for colon cancer is denied. Entitlement to service connection for peripheral neuropathy other than right and left leg sciatica, is denied. REMANDED Entitlement to service connection for a low back disability, also claimed as lumbar spine disorder, is remanded. Entitlement to service connection for right leg sciatica is remanded. Entitlement to service connection for left leg sciatica is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s colon cancer began during active service or is otherwise related to an in-service event, injury, or disease, to include in-service exposure to contaminants in the water supply at Camp Lejeune and in-service exposure to ionizing radiation. 2. The preponderance of the evidence indicates that the Veteran’s peripheral neuropathy other than right and left leg sciatica is caused by his colon cancer and its treatment, which have not been service connected, and is not related to an in-service event, injury, or disease, including treatment of tuberculosis with INH. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for colon cancer have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.311. 2. The criteria for entitlement to service connection for peripheral neuropathy other than right and left leg sciatica, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January 1972 to December 1973, from February 1974 to February 1976, and from March 1979 to March 1985. In June 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In October 2019, the Board issued a decision denying entitlement to service connection for a low back disability and for bilateral leg sciatica. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In August 2020, the Court vacated the October 2019 Board decision and remanded the issues for further consideration consistent with a Joint Motion for Partial Remand filed by counsel for the Veteran and the VA Secretary. Those issues are now before the Board for further appellate consideration. The October 2019 Board decision also remanded the issues of entitlement to service connection for colon cancer, peripheral neuropathy other than bilateral leg sciatica, and sleep apnea and entitlement to a TDIU. Relevant to the issues decided herein, the remand directed the Agency of Original Jurisdiction (AOJ) to follow the procedures set forth in 38 C.F.R. § 3.311 to develop the Veteran’s claim for entitlement to service connection for colon cancer as due to exposure to ionizing radiation and obtain the Veteran’s Social Security Administration disability records. As is discussed in more detail below, the AOJ appropriately completed the procedures for developing the Veteran’s colon cancer claim under 38 C.F.R. § 3.311. The AOJ also obtained the Veteran’s Social Security Administration disability records. Accordingly, the Board finds that VA at least substantially complied with the October 2019 remand directives as they pertain to the issues decided herein. See 38 U.S.C. § 5103A(b); Stegall v. West, 11 Vet. App. 268, 271 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). The October 2019 Board decision also instructed the AOJ to issue a statement of the case, pursuant to the holding in Manlincon v. West, 12 Vet. App. 238 (1999), as to the issue of entitlement to a compensable initial rating for tuberculosis. The AOJ issued that statement of the case in July 2020. The Veteran did not submit a timely substantive appeal as to that issue following issuance of the July 2020 statement of the case. Therefore, the Veteran did not perfect an appeal to the Board of that issue, and the issue is not on appeal before the Board at this time. In April 2012, the Veteran submitted several VA Forms 21-4142 authorizing the release of information from private treatment sources. However, VA did not attempt to obtain the records identified in those VA Forms 21-4142 prior to expiration of the authorizations. In October 2013, VA informed the Veteran that the April 2012 authorizations had expired and asked the Veteran to complete and return new VA Forms 21-4142 for the previously identified records. The Veteran did not respond to the October 2013 notice letter and, in September 2017, VA again attempted to obtain from the Veteran new authorizations to obtain the previously identified records and any other relevant private treatment records. To date, the Veteran has not provided any such authorizations. Therefore, VA cannot obtain the identified records. See 38 C.F.R. § 3.159(c)(1). Neither the Veteran nor his representative has raised any issues with regard to the duty to notify or duty to assist as they pertain to the issues denied in this decision. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show. The Veteran should not assume that evidence that is not explicitly discussed in the decision has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Service Connection 1. Entitlement to service connection for colon cancer The Veteran seeks entitlement to service connection for colon cancer, which he contends is due either to in-service exposure to contaminants in the water supply at Camp Lejeune or to in-service exposure to ionizing radiation while serving aboard a United States Navy submarine. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The diseases listed in 38 C.F.R. § 3.309(f) have been associated with exposure to contaminants in the water supply at Camp Lejeune and may be service connected on a presumptive basis for veterans who had no less than 30 days of service at Camp Lejeune during the period from August 1, 1953, to December 31, 1987. 38 C.F.R. § 3.309. Service connection based on exposure to ionizing radiation can be established under 38 C.F.R. § 3.303(d) with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311, if the condition at issue is a radiogenic disease. A “radiogenic disease” means a disease that may be induced by ionizing radiation and includes colon cancer. 38 C.F.R. § 3.311(b)(2). Under 38 C.F.R. § 3.311, in claims not involving participation in atmospheric nuclear testing or the American occupation of Hiroshima or Nagasaki, Japan, a request must be made for any available records concerning a veteran’s exposure to radiation. These records normally include but may not be limited to the Veteran’s Record of Occupational Exposure to Ionizing Radiation (DD Form 1141), if maintained, service treatment records, and other records which may contain information pertaining to the Veteran’s radiation dose in service. All such records will be forwarded to the Under Secretary for Health, who will be responsible for preparation of a dose estimate, to the extent feasible, based on available methodologies. 38 C.F.R. § 3.311(a)(2)(iii). The claim, including the dose estimate, will be reviewed by the Under Secretary for Benefits pursuant to 38 C.F.R. § 3.311(c). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, although the Veteran was diagnosed with colon cancer in January 2010 and the evidence shows that he was exposed to contaminants in the water supply at Camp Lejeune and to a non-zero amount of radiation during his active service, the preponderance of the evidence weighs against finding that the Veteran’s colon cancer began during service or is otherwise related to an in-service injury, event, or disease. With regard to in-service incurrence, the Veteran has not contended, and the record does not show, that the colon cancer had its onset during his active service. The service treatment records are silent for such a condition, and the medical treatment records do not show a diagnosis for the condition until many years after the Veteran’s separation from active service. With regard to exposure to contaminants in the water supply at Camp Lejeune, the record confirms that the Veteran was stationed at Camp Lejeune for at least 30 days during his active service. However, colon cancer is not listed as a disease associated with exposure to contaminants in the water supply at Camp Lejeune in 38 C.F.R. § 3.309(f). Therefore, the condition may not be service connected on a presumptive basis under 38 C.F.R. §§ 3.307(a)(7) and 3.309(f). Nevertheless, the presumptive service-connection regulations do not preclude a claimant from establishing service connection with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In this case, the record does not contain any probative evidence of record attributing the Veteran’s colon cancer to his exposure to contaminants in the water supply at Camp Lejeune. To the contrary, a VA examiner opined in February 2014 that it is less likely than not that the Veteran’s colon cancer was caused by potential exposure to contaminated water at Camp Lejeune. As a rationale for that opinion, the examiner explained that a review of the current medical literature does not reveal an association between colon cancer and the types of contaminants identified at in the water at Camp Lejeune. Colon cancer is the third most commonly diagnosed cancer. The Veteran has risk factors for developing colon cancer of age, race, and being overweight. The examiner further referenced and cited to specific sources of information, including from the National Research Council, which determined that there is inadequate or insufficient evidence to determine that an association exists between colon cancer and the contaminants in the water at Camp Lejeune. The Board finds the examiner’s opinion to be probative because it is supported by appropriate rationale with citation to relevant medical sources. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444 (2000). Accordingly, the only probative evidence of record as to the possible etiological connection between the contaminants in the water at Camp Lejeune and colon cancer is against finding such a connection. Therefore, the preponderance of the evidence is against finding that the Veteran’s colon cancer was caused by in-service exposure to exposure to contaminants in the water supply at Camp Lejeune. With regard to exposure to ionizing radiation, the Veteran’s service treatment records contain a DD Form 1141 showing a total lifetime accumulated does of 00.001 rem through the Veteran’s service on a United States Navy submarine. All records of exposure to radiation were requested from the service department in December 2019. The service department provided all available such records in January 2020. There are no service records other than the DD Form 1141 documenting exposure to ionizing radiation. In August 2020, the Director of Compensation Service referred the case to the VA Under Secretary for Health for preparation of a dose estimate and an opinion as to “whether it is likely, unlikely, or as likely as not” that the Veteran’s colon cancer resulted from exposure to radiation in service. In September 2020, a response was provided by a health physicist examiner. The examiner noted review of the Veteran’s report of exposure and of the Veteran’s service treatment records, including the DD Form 1141 showing a total accumulated radiation dose of 00.001 rem. The examiner further noted that the Veteran was approximately 29 years old at the time of initial exposure to ionizing radiation, that he is an African American male, and that he is a nonsmoker. He also found that no post-service radiation exposure has been reported or noted. He posited that, based on the nature and location of the Veteran’s service as described in the claim file, a dose of 1.5 rem (total effective dose equivalent) could be assigned to the Veteran, calculated as 0.5 rem per year for each of the 3 years of service the Veteran had aboard a United States Navy submarine. He noted that such an estimate gives the Veteran the benefit of the doubt as the Navy’s record of monitored dose is minimal, but likely accurate. He cited to information from the Health Physics Society, including that a person might accumulate an effective dose from natural background radiation of about 50 mSv (5 rem) in the first 17 years of life and about 250 mSv (25 rem) during an average 80-year lifetime, and that scientific data shows evidence of health effects following high-dose exposures, but that below levels of about 100 mSv (10 rem) above background from all sources combined, the observed radiation effects in people are not statistically different from zero. Based on a review of the Veteran’s relevant record and the information from the Health Physics Society, the examiner concluded that, because the Veteran’s lifetime total radiation dose did not exceed 100 mSv (10 rem) above natural background, it is unlikely that his colon cancer was caused by exposure to ionizing radiation during military service. The Board notes that the health physicist examiner’s response was reviewed by a medical doctor. The Board finds that the examiner’s dose estimate constitutes sound scientific and medical evidence. As a health physicist, the examiner is particularly qualified to provide statements as to environmental levels of radiation and as to the way in which radiation interacts with matter and living systems. The examiner explained that the radiation dose estimate was determined “based on the nature and location of the Veteran’s service as described in the claim file.” The examiner accounted for all three years the Veteran served aboard a United States Navy submarine. The examiner’s dose estimate therefore is consistent with current medical knowledge and based on the particular facts of the Veteran’s case. VA may therefore rely on that dose estimate and the examiner’s opinion to make a determination as to the Veteran’s claim. See 38 C.F.R. § 3.311(c); see also Skaar v. Wilkie, 32 Vet. App. 156 (2020). The Board affords great weight to the September 2020 examiner’s opinion because it was based on a review of the relevant service records and relevant medical literature. The examiner provided excerpts from that literature that support his conclusion that it is unlikely that the Veteran’s colon cancer was caused by his in-service radiation exposure. He explained that the Veteran’s total lifetime radiation exposure, even in consideration of the DD Form 1141, did not exceed 100 mSv (10 rem) above natural background noise. This conclusion is consistent with the record, as the Radiation Exposure History shows an additional ionizing radiation exposure of only 00.001 rem and the examiner provided a dose estimate of 1.5 rem for the Veteran’s three years of service on a United States Navy submarine. Both of those measurements are far less than 10 rem, which is the level at which the Health Physics Society determined statistically significant differences become evident. See Nieves-Rodriguez, 22 Vet. App. 295; Prejean v. West, 13 Vet. App. 444. The Board acknowledges that the term “unlikely” is vague when considered in isolation. However, the Board finds that the term, as used by the September 2020 examiner, is adequately specific when considered in the context of the other evidence of record. Specifically, as summarized above, the August 2020 memorandum referring the case to the Under Secretary for Health asked for preparation of an opinion as to “whether it is likely, unlikely, or as likely as not” that the Veteran’s colon cancer resulted from exposure to radiation in service. When compared to the other options of “likely” and “as likely as not”, the term “unlikely” clearly was intended to mean less likely than not. In using the term “unlikely”, the September 2020 examiner was merely providing the opinion requested by selecting from the options presented. Accordingly, the examiner also clearly intended the term to mean less likely than not. Therefore, the Board interprets the examiner’s use of the term as meaning less likely than not. As such, the opinion is adequate for decision-making purposes despite using a term that would otherwise be vague. The Board further acknowledges that the Veteran believes his colon cancer is related to in-service exposure to contaminants in the water supply at Camp Lejeune and in-service exposure to ionizing radiation. However, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the pathology of colon cancer and the health effects of specific environmental exposures. Therefore, the issue is outside the competence of the Veteran because the record does not show he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). Consequently, his assertions are not entitled to probative value and do not weigh against the probative opinion of record. In summary, the probative evidence of record indicates that it is less likely than not that the Veteran’s colon cancer began during active service or is otherwise related to an in-service injury or disease, to include in-service exposure to contaminants in the water supply at Camp Lejeune and in-service exposure to ionizing radiation. In view of the foregoing, the Board concludes that the preponderance of the evidence is against the claim for entitlement to service connection for colon cancer. Because the preponderance of the evidence is against the claim, the doctrine of reasonable doubt is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for peripheral neuropathy other than right and left leg sciatica The Veteran seeks entitlement to service connection for peripheral neuropathy other than right and left leg sciatica. In March 2012, he asserted that he developed irreversible neuropathy due to his colon cancer and the chemotherapy he underwent for that condition. He also asserted that the neuropathy was a side effect of being treated with INH for tuberculosis during his active service. The Veteran’s medical treatment records show that he underwent surgery for colon cancer in January 2010 and thereafter underwent chemotherapy for the condition. A September 2011 VA treatment note states that his “decreased sensation bilaterally in no apparent dermatomal distribution is likely from chemotherapy induced peripheral neuropathy.” At a February 2013 VA treatment visit, the Veteran reported that his peripheral neuropathy started after he received chemotherapy for his colon cancer. The attending physician concluded that the Veteran had peripheral neuropathy secondary to chemotherapy. At a January 2014 VA peripheral nerves conditions examination, the Veteran reported that developed numbness and tingling in the bilateral upper and lower extremities in September 2010 while he was undergoing chemotherapy for his postoperative colon cancer. The January 2014 VA examiner opined that the Veteran’s peripheral neuropathy is at least as likely as not related to or caused by his in-service treatment with INH. As a rationale for that opinion, the examiner explained, “The Veteran’s peripheral neuropathy was diagnosed in 2010, and was thought to have been a side effect of his INH treatment for TB. It is likely that the Veteran’s neuropathy could occur 26 years after INH therapy. Also the neuropathy is a known side effect to chemotherapy which may have also contributed to the Veteran’s neuropathy.” However, in February 2014, another VA examiner opined that it is less likely than not that the Veteran’s peripheral neuropathy is due to the INH he was treatment with during service. As a rationale for that opinion, the examiner explained that the service treatment records show that there were no ill effects from IHN at the time of the Veteran’s separation from active service. He further explained that the January 2014 VA examiner is in error in stating that the in-service treatment with INH caused the Veteran’s peripheral neuropathy over 20 years after service because the VA treatment records support that the Veteran’s peripheral neuropathy is due to the chemotherapy he had for his colon cancer. Thus, there are medical opinions both for and against finding that the Veteran’s peripheral neuropathy is related to his in-service treatment with INH. The probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims folder and the thoroughness and detail of the opinion. See Prejean, 13 Vet. App. at 448-9; Nieves-Rodriguez, 22 Vet. App. 295. Here, the January 2014 VA examiner supported his opinion with speculative and tentative statements, including that “[i]t is likely” that peripheral neuropathy “could” occur 26 years after INH therapy. In addition, the examiner stated that the Veteran’s peripheral neuropathy “was thought to have been a side effect of his INH treatment for TB” when it was diagnosed in 2010. This is contrary to the evidence of record, which shows that the Veteran’s medical treatment providers have attributed the Veteran’s peripheral neuropathy to his chemotherapy. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (Opinions based on an inaccurate factual premise are not probative). Finally, the examiner stated that neuropathy is a known side effect of chemotherapy, “which may have also contributed to the Veteran’s neuropathy.” That statement is vague. Moreover, the examiner did not explain to what extent the Veteran’s peripheral neuropathy could be attributed to his colon cancer and the chemotherapy used to treat that condition. Therefore, the Board assigns the January 2014 VA examiner’s opinion no probative weight. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Bloom v. West, 12 Vet. App. 185, 187 (1999). In contrast, the February 2014 VA examiner was based on a review of the Veteran’s records and is accompanied by a sufficient explanation as to why the Veteran’s is more likely related to his chemotherapy and not to his in-service treatment with INH. Specifically, the examiner provided excerpts from the record, including findings by the Veteran’s medical treatment providers that his peripheral neuropathy is due to his chemotherapy. The examiner also noted that the Veteran’s service treatment records do not show any ill effects from the in-service INH treatment. Because the January 2014 VA examiner’s opinion is based on appropriate rationale, the Board affords probative weight to that opinion. The Board acknowledges that the Veteran believes his peripheral neuropathy is related to in-service treatment with INH. However, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the pathology of peripheral neuropathy and the medical likelihood that his particular peripheral neuropathy is due to treatment with INH decades ago. Therefore, the issue is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, 492 F.3d at 1377 n.4; see also Kahana, 24 Vet. App. 428. Consequently, his assertions are not entitled to probative value and do not weigh against the February 2014 VA examiner’s probative medical opinion. In summary, the probative evidence of record, which in this case is the February 2014 VA examiner’s opinion, indicates that the Veteran’s peripheral neuropathy other than right and left leg sciatica is medically attributed to his colon cancer and the treatment for that condition, which have not been service connected, and is not related to an in-service event, injury, or disease, including treatment of tuberculosis with INH. In view of the foregoing, the Board concludes that the preponderance of the evidence is against the claim for entitlement to service connection for peripheral neuropathy other than right and left leg sciatica. Because the preponderance of the evidence is against the claim, the doctrine of reasonable doubt is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. REASONS FOR REMAND 1. Entitlement to service connection for a low back disability, also claimed as lumbar spine disorder, is remanded. The February 2014 VA examiner opined that it is less likely as not that the Veteran’s current low back disabilities are in any way related to service. In support of that opinion, the examiner acknowledged that the Veteran was treated in 1982 for a muscle spasm/strain of the low back, but explained that the condition resolved and that there is no documentation that the Veteran had an ongoing back condition in the years right after service. In addition, the record shows that the Veteran’s current low back problems started in 2009 after heavy lifting and that the Veteran did not began complaining of back pain until 2010. Furthermore, the Veteran’s current diagnoses of degenerative disc disease, spinal stenosis, and facet arthropathy were not found during service. However, the examiner did not explain why the currently diagnosed low back disabilities are not etiologically related to the in-service low back muscle spasm/strain. The issue must be remanded so that an addendum opinion may be obtained in consideration of whether the current disabilities may be etiologically related to the in-service low back muscle spasm/strain. 2. Entitlement to service connection for right and left leg sciatica is remanded. The record shows that the Veteran’s right and left leg sciatica is caused by or a symptom of his low back disabilities. Therefore, a decision on the remanded issue of entitlement to service connection for a low back disability could significantly impact a decision on the issue of entitlement to service connection for right and left leg sciatica, the issues are inextricably intertwined. A remand of the claim for entitlement to service connection for right and left leg sciatica is required. 3. Entitlement to service connection for sleep apnea is remanded. The October 2019 Board remand directed the AOJ to afford the Veteran an examination and opinion as to his claimed sleep apnea. It specified that the examiner must consider the statements provided by the Veteran’s brother and sister, to the effect that they witnessed him have sleep disturbances during service. In December 2019, a VA examiner opined that the Veteran’s sleep apnea was less likely than not incurred in or caused by an injury, event, or disease during service. As a rationale for that opinion, the examiner essentially stated that the service treatment records do not show documentation of sleep apnea or sleep problems and that the Veteran was not diagnosed with sleep apnea until many years after service. Although the examiner acknowledged the statements from the Veteran’s brother and sister, he did not explain why those statements do not constitute evidence of in-service sleep problems or an in-service onset for the Veteran’s sleep apnea. A remand is required so that an addendum opinion may be obtained in consideration of whether the statements from the Veteran’s brother and sister constitute evidence of an in-service onset for the Veteran’s sleep apnea. 4. Entitlement to TDIU is remanded. A decision on the other remanded issues could significantly impact a decision on the issue of entitlement to a TDIU. Therefore, the issues are inextricably intertwined. A remand of the claim for entitlement to a TDIU is required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s current low back disabilities are at least as likely as not (50 percent probability or greater) related to the low back muscle spasm/strain the Veteran was treated for in October 1982. Provide a rationale to support the opinion. The opinion should explain why the evidence and medical knowledge do or do not support finding that the current low back disabilities are related to the in-service low back muscle spasm/strain. Merely stating that the Veteran did not have further treatment for a low back disability following the October 1982 muscle spasm/strain, that the Veteran did not seek treatment for a low back disability until many years after service, and that the record shows that the Veteran had post-service low back injuries does not sufficiently address the issue. If the examiner determines that the current low back disabilities are more likely than not related to the post-service low back injuries rather than the in-service low back injury, then he or she should clearly state that opinion and provide supporting rationale for the opinion. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s sleep apnea at least as likely as not (50 percent probability or greater) had its onset during his active service or is related to an in-service event, injury, or disease. Provide a rationale to support the opinions. The opinion must discuss the statements from the Veteran’s brother and sister that were received in August 2017. The Veteran’s brother states that the Veteran would fall asleep during the day, snore loudly while sleeping, and stop breathing while sleeping during his active service and after separation from active service. His sister similarly states that, during his active service, the Veteran had daytime sleepiness, and would snore, choke, and stop breathing while sleeping. The examiner should discuss whether such symptoms indicate that the Veteran’s current sleep apnea had its onset during his active service. If such symptoms alone are not indicative of an in-service onset of sleep apnea, then the examiner should clearly state that opinion and provide supporting rationale for the opinion. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. J. Anthony, 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.