Citation Nr: 21003877 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 15-08 851A DATE: January 25, 2021 ORDER Entitlement to service connection for obstructive sleep apnea is granted. REMANDED Entitlement to service connection for joint pain throughout the body with polyarticular joint pain, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Entitlement to service connection for lumbar spine disability with benign neoplasms with herniated discs is remanded. Entitlement to service connection for cervical spine disability with benign neoplasms with herniated discs is remanded. Service connection for lipomas in face and back (claimed as tumors), to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Entitlement to service connection for Gulf War Illness is remanded. Entitlement to service connection for bronchial asthma is remanded. Entitlement to service connection for nasal polyps, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Entitlement to service connection for digestive problems, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Entitlement to service connection for hernia is remanded. Entitlement to service connection for skin problems, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Entitlement to service connection for deposits in body, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Entitlement to service connection for headaches, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Entitlement to service connection for loss of feeling in the left arm, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Entitlement to service connection for loss of feeling in the right arm, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Entitlement to service connection for benign mandibular neoplasm is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) based on service-connected disability is remanded. FINDING OF FACT The Veteran’s obstructive sleep apnea is proximately due to his service-connected posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for service connection for obstructive sleep apnea as secondary to PTSD are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from December 1986 to July 1990; November 1990 to June 1991; and July 1993 to February 1994. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously before the Board in January 2019. Entitlement to service connection for obstructive sleep apnea The Veteran contends that sleep apnea is related to service. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). “To establish a right to compensation for a present disability, a veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service’ — the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). To establish a right to compensation for a present disability secondary to a service-connected disability, a veteran must demonstrate the existence of (1) a current disability; (2) a service-connected disability; and (3) a nexus between the current disability and the service-connected disability. 38 C.F.R. § 3.310(a); Wallin v. West, 11 Vet. App. 509 (1998). A November 2015 sleep study documented the Veteran’s mild obstructive sleep apnea. An October 2019 VA examination opined that the obstructive sleep apnea is at least as likely as not proximately due to his service-connected PTSD because “Medical evidence reveals there is a link between PTSD and obstructive sleep apnea.” Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current obstructive sleep apnea is proximately due to the Veteran’s service-connected PTSD. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for obstructive sleep apnea is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for benign mandibular neoplasm is remanded. Remand is required to attempt to obtain missing service treatment records for the Veteran’s second and third periods of service. The Board notes that records from these periods are not associated with the claims file. Accordingly, the agency of original jurisdiction (AOJ) must attempt to obtain these records on remand. 2. Entitlement to service connection for joint pain throughout the body with polyarticular joint pain, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Remand is necessary to obtain a VA medical opinion that addresses VA medical center (VAMC) and private medical records relating to the Veteran’s claim for joint pain throughout the body. An October 2019 VA examination attributes the Veteran’s joint pain to degenerative arthritis. The Veteran’s reports of joint pain pre-exist his diagnoses of lumbar degenerative disease (February 2005) and cervical strain (October 2010) outlined in other October 2019 VA examination. April 1995, June 1995, December 1997, and March 1999 VAMC records note arthralgia, and a February 2005 private medical record documents “10 years of joint pain and muscle pain, but no joint swelling.” Accordingly, these records should be considered by an appropriate clinician on remand. 3. Entitlement to service connection for lumbar spine disability with benign neoplasms with herniated discs is remanded. Remand is necessary to obtain an additional VA medical opinion that addresses the Veteran’s March 1990 in-service examination in which he states that “[He has] injured [his] back and neck more than once.” An October 2019 VA examination finds that the Veteran’s lumbar spine condition is not related to service and cited the fact that “The Veteran does not voice back pain or seek medical treatment during military service.” Because this contradicts the Veteran’s in-service statement, an additional VA medical opinion is needed. Furthermore, the VA medical opinion must address the Veteran’s June 1995 VAMC psychological assessment in which he complains of chronic back pain. The October 2019 VA examination appears to rely on the fact that the earliest treatment for back pain was in February 2005. Because the Veteran reports back pain after service as early as June 1995, this must be addressed on remand. Accordingly, these records should be considered by an appropriate clinician on remand. 4. Entitlement to service connection for cervical spine disability with benign neoplasms with herniated discs is remanded. Remand is necessary to obtain an additional VA medical opinion that addresses the Veteran’s March 1990 in-service examination in which he reports that “[He is] taking some motrin for [his] neck” and that “[He has] injured [his] back and neck more than once.” In the rationale for its finding that the Veteran’s cervical spine condition is not related to service, an October 2019 VA examination states, “The Veteran does not report neck pain until post military.” Because this is contradicted by the Veteran’s in-service statement, an additional VA medical opinion is required. 5. Service connection for skin problems, deposits in body, and lipomas in face and back (claimed as tumors), to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Remand is necessary to obtain an additional VA medical opinion. An October 2019 VA examination notes the Veteran’s reports of ingrown hairs and “black content coming from his pores.” The VA examination does not address the etiology of Veteran’s reported symptoms, however. Furthermore, the VA examination states that the “cause of lipomas isn’t fully understood” and that “genetic factors likely play a role in their development,” before determining that the lipomas are “most likely related to genetics.” This opinion does not address the potential effects of environmental hazards, however, as requested in the prior Remand. Thus, a remand is required. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that the Board errs as a matter of law when it fails to ensure compliance with its remand orders). 6. Entitlement to service connection for Gulf War Illness is remanded. Remand is required to meet the previous Remand directions. Although an October 2019 VA examination determines that the Veteran does not have chronic fatigue syndrome and accounts for many of the symptoms that are sometimes associated with chronic fatigue syndrome (headaches, muscle aches), the VA examination does not address the Veteran’s complaints of fatigue itself. Remand is therefore required. See Stegall, 11 Vet. App. at 271. 7. Entitlement to service connection for bronchial asthma is remanded. Remand is required for an additional VA medical opinion. An October 2019 VA examination determines that the Veteran’s asthma pre-existed service, but the VA examination uses the wrong standard for determining whether that pre-existing asthma was aggravated by service. Accordingly, remand is necessary. 8. Entitlement to service connection for nasal polyps, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. An October 2019 VA examination notes that nasal polyps are “associated with asthma, recurring infection, allergies, drug sensitivity, or immune system.” Accordingly, the Board finds it appropriate to obtain an opinion regarding whether the Veteran’s nasal polyps are at least as likely as not secondary to his bronchial asthma. 9. Entitlement to service connection for digestive problems, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Remand is necessary to complete the directions of the previous Remand. An October 2019 VA examination addresses whether dyspepsia is related to service but relies in part on the lack of medical documentation. The Veteran is competent to report dyspepsia without corroboration by medical records. Additionally, October 2019 VA examination does not address the etiology of diarrhea and flatus, as directed in the prior Remand. Therefore, remand is required. See Stegall, 11 Vet. App. at 271. 10. Entitlement to service connection for hernia is remanded. Remand is necessary to obtain an additional VA medical opinion. An October 2019 VA examination finds that the Veteran’s hernia is not related to service by citing at least in part to the fact that the Veteran had a hernia repair in 2000, after service. The VA examination also notes the hernia’s onset to be 1996, which is nearer to his last period of service. Thus, an opinion is necessary addressing whether the hernia with its onset in 1996 is related to service. 11. Entitlement to service connection for headaches, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. Remand is necessary to obtain a VA medical opinion. An October 2019 VA examination finds that the Veteran’s headaches are secondary to his cervical spine condition, which another VA examination references as having started in October 2010. An April 1995 Gulf War examination notea a history of “headaches - bitemporal, frequent,” however, fifteen years prior to the diagnosis of a cervical spine condition. Thus, this earlier reference to headaches must be addressed on remand. In addition, the October 2019 VA examination notes in its opinion that obstructive sleep apnea “plays a factor in causing headaches.” Considering that entitlement to service connection for obstructive sleep apnea has been granted, an opinion addressing whether the Veteran’s headaches are secondary to his obstructive sleep apnea is necessary. 12. Entitlement to service connection for loss of feeling in the bilateral arms, to include as due to an undiagnosed illness related to service in Southwest Asia, is remanded. October 2019 VA examinations indicates that the Veteran’s bilateral arm symptoms are the result of nerve conditions secondary to his cervical spine condition. The issue of entitlement to service connection for cervical spine disability is being remanded; the outcome of that remand will accordingly have a significant impact on the claims regarding loss of feeling in the bilateral arms. Thus, a remand is required. 13. Entitlement to a TDIU based on service-connected disability is remanded. The Board has granted entitlement to service connection for obstructive sleep apnea and remanded multiple service-connection issues which could significantly impact a decision on the issue of entitlement to service connection for a TDIU. A remand is therefore required. The matters are REMANDED for the following action: 1. Obtain the Veteran’s complete service treatment records. If the records are determined to be unavailable, the AOJ should provide appropriate notice to the Veteran (and document it in the claims file). 2. Obtain an addendum opinion from an appropriate clinician regarding (a.) Whether symptoms related to joint pain throughout the body with polyarticular joint pain are part of a diagnosed disability, an undiagnosed illness, or a medically unexplained chronic multisymptom illness. (b.) Whether the condition is at least as likely as not related to an in-service injury, event, or disease, including exposure to environmental hazards. In making this determination, the clinician must address the April 1995, June 1995, December 1997, and March 1999 VAMC records noting arthralgia (see VAMC records received September 30, 2019) as well as a February 2005 private medical record documenting “10 years of joint pain and muscle pain, but no joint swelling” (see SSA records received June 6, 2014). 3. Obtain an addendum opinion from an appropriate clinician that determines whether the Veteran’s lumbar spine disability with benign neoplasms with herniated discs is at least as likely as not related to an in-service injury, event, or disease, including lifting equipment weighing 100 to 300 pounds. In making this determination, the clinician must address the March 1990 in-service examination in which the Veteran states that “[He has] injured [his] back and neck more than once” (see service treatment records received July 15, 2014) as well as the June 1995 VAMC psychological assessment in which the Veteran complains of chronic back pain (see VAMC records received September 30, 2019). 4. Obtain an addendum opinion from an appropriate clinician that determines whether the Veteran’s cervical spine disability with benign neoplasms with herniated discs is at least as likely as not related to an in-service injury, event, or disease, including lifting equipment weighing 100 to 300 pounds. In making this determination, the clinician must address the March 1990 in-service examination in which the Veteran states that “[He is] taking some motrin for [his] neck” and that “[He has] injured [his] back and neck more than once” (see service treatment records received July 15, 2014). 5. Obtain an addendum opinion from an appropriate clinician regarding (a.) Whether symptoms related to skin problems, ingrown hairs, deposits in body, and lipomas in the face and back are part of a diagnosed disability, an undiagnosed illness, or a medically unexplained multisymptom illness. (b.) Whether it is at least as likely as not that skin problems, ingrown hairs, deposits in body, and lipomas in the face and back are related to an in-service injury, event, or disease, including exposure to environmental hazards. 6. Obtain an addendum opinion from an appropriate clinician regarding (a.) Whether the Veteran’s fatigue is part of a diagnosed disability, an undiagnosed illness, or a medically unexplained multisymptom illness. (b.) Whether it is at least as likely as not that the Veteran’s fatigue is related to an in-service injury, event, or disease, including exposure to environmental hazards. 7. Obtain an addendum opinion from an appropriate clinician determining whether the Veteran’s bronchial asthma, which existed prior to service, at least as likely as not increased in severity during service. If the Veteran’s bronchial asthma increased in severity during service, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? 8. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s nasal polyps are (a.) At least as likely as not proximately due to bronchial asthma. (b.) At least as likely as not aggravated beyond their natural progression by bronchial asthma. 9. Obtain an addendum opinion from an appropriate clinician regarding (a.) Whether the Veteran’s diarrhea, flatus, and dyspepsia are part of a diagnosed disability, an undiagnosed illness, or a medically unexplained multisymptom illness. (b.) Whether it is at least as likely as not that the Veteran’s diarrhea, flatus, and dyspepsia are related to an in-service injury, event, or disease, including exposure to environmental hazards. 10. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hernia with onset in 1996 is at least as likely as not related to an in-service injury, event, or disease, including exposure to environmental hazards. 11. Obtain an addendum opinion from an appropriate clinician regarding (a.) Whether the Veteran’s headaches are part of a diagnosed disability, an undiagnosed illness, or a medically unexplained chronic multisymptom illness. (b.) Whether the Veteran’s headaches are at least as likely as not related to an in-service injury, event, or disease, including exposure to environmental hazards. In making this determination, the clinician must address the April 1995 Gulf War examination that notes a history   of “headaches - bitemporal, frequent” (see VAMC records received September 30, 2019). M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board W. Ripplinger, 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.