Citation Nr: 21003071 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 16-03 134 DATE: January 19, 2021 REMANDED Entitlement to right bundle branch block (RBBB), claimed as secondary to anthrax vaccine, is remanded. Entitlement to service connection for sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from January 1971 to August 2007. In November 2018, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the proceeding has been associated with the claims file. The matter was remanded in June 2019. While the Board regrets the additional delay, a remand is required before the claims can be adjudicated. 1. Right Bundle Branch Block (RBBB) The June 2019 remand requested that an examiner opine as to whether there was EKG evidence of a RBBB, whether complete or incomplete, during active service; and whether it is at least as likely as not (probability of 50 percent or better) that the Veteran’s current RBBB had its onset during service or is otherwise the result of a disease or injury during service. The clinician was specifically asked to discuss the February 2012 findings and conclusions of the Veteran’s treating clinicians (suggesting service records showed RBBB and/or incomplete RBBB) and the 2014 VA opinion (which interpreted the STRs as showing normal ECGs) and to reconcile the findings. The clinician was also asked to address the Veteran’s lay statements, to include his contention that the RBBB was due to an anthrax vaccine. Although a VA medical opinion was obtained in December 2019, its rationale was incomplete. In the December 2019 examination report, the examiner noted that there was no evidence of a RBBB in service, but the examiner failed to discuss the Veteran’s treating physician 2012 comments that appeared to be to the contrary, nor address the Veteran’s lay statements, particularly his contention that his RBBB occurred due to an anthrax vaccination. Therefore, a remand is required to obtain an addendum opinion. The examiner also commented that obstructive sleep apnea could have caused RBBB, and since the sleep apnea service connection claim needs further development, service connection for RBBB secondary to sleep apnea, cannot be decided. 2. Sleep Apnea The prior remand requested that an examiner opine as to whether it was at least as likely as not (probability of 50 percent or better) that the Veteran’s current sleep apnea had its onset in service, as well as to opine if the Veteran’s sleep apnea was caused or aggravated by his RBBB. The Veteran was afforded a VA examination for his sleep apnea in December 2019. The examiner noted a date of diagnosis of October 2009, and concluded that it was less likely than not that the Veteran’s obstructive sleep apnea was caused by or incurred in his military service, because the Veteran did not use a continuous positive airway pressure machine (CPAP) while in service. Obviously, this is inadequate since if the Veteran was using a CPAP machine in service, it would have long since been established his sleep apnea had its onset in service. Also in the report, the examiner commented it was possible or not the Veteran had underlying sleep apnea while in service. Since one of the purposes of the opinion was to resolve that question, further clarification is necessary. Lastly, the examiner suggested the sleep apnea could have been caused or aggravated by RBBB, but since the question of whether service connection is warranted for RBBB is not final, a final determination of the sleep apnea service connection claim cannot be made. Under these circumstances additional medical opinions are required as set out below. The matters are REMANDED for the following action: 1. Obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of the Veteran’s currently diagnosed RBBB. The claims file should be made available for review. After a review of the claims file, the examiner should complete these actions: (a.) State whether it is at least as likely as not (a 50 percent or higher degree of probability) that the Veteran’s RBBB had its onset during service or is otherwise the result of a disease or injury during service. In doing so, discuss the characteristics of the in-service ECG tracings that support your conclusion that RBBB is or is not present, and how this helps to refute or support the 2012 physician’s comments that suggest the presence of RBBB in service. (b.) Discuss the meaning of “R-S transition zone in V leads displaced to the right” as noted in a June 2003 ECG report. (c.) Address whether it is as likely as not obstructive sleep apnea has caused or has aggravated the Veteran’s RBBB. (d.) Address whether RBBB may be due to Anthrax vaccination. 2. Obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of the Veteran’s currently diagnosed sleep apnea. The claims file should be made available for review and noted as such in the examination report. After a review of the claims file, the examiner should complete these actions: (a.) State whether it is at least as likely as not (probability of 50 percent or better) that the Veteran’s sleep apnea had its onset during service. (b.) State whether it is at least as likely as not (probability of 50 percent or better) that the Veteran’s current sleep apnea was caused or aggravated by his RBBB. (c.) The examiner’s opinion should discuss the medical opinions/comments currently of record on the subject from February 2012, May 2012, and the VA DBQ opinions. (d.) The examiner’s opinion should address the lay evidence of record, including the treatment sought for sleep issues in service, the proximity of the Veteran’s diagnosis of sleep apnea to his active service, and his November 2018 testimony that his wife had complained about his snoring between 2002-2006. 3. A rationale should be provided for all opinions. The examiner must connect all opinions made to the evidence of record and any medical literature referenced. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. 4. After completing the above actions, to include any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claim should be readjudicated based on the entirety of the evidence. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board V. Geer, 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.