Citation Nr: 21064332 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 17-36 861 DATE: October 19, 2021 ORDER Service connection for obstructive sleep apnea is denied. REMANDED Service connection for bilateral arm pain, swelling, and blistering is remanded. FINDING OF FACT The preponderance of the evidence is against finding that obstructive sleep apnea began during active service or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for obstructive sleep apnea are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty in the United States Air Force from August 1986 to August 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Board remanded this matter for further development. Obstructive Sleep Apnea The Veteran contends that his sleep apnea is due to exposure to Gulf War combat experiences. For the following reasons, the Board disagrees and finds that service-connection is not warranted. Service connection may be granted for a Persian Gulf veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability is a chronic disability that may result from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2)(i). The term MUCMI refers to a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). A multisymptom illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Stewart v. Wilkie, 30 Vet. App. 383, 389-90 (2018). A multisymptom illness is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. Id. The determination of whether a MUCMI is "medically unexplained," that is, the etiology and pathophysiology of the multisymptom illness, must be particular to the claimant's case. Id. at 291. Here, the Veteran had active service in Saudi Arabia from July 1994 to December 1994. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). A May 2017 sleep study shows the Veteran has a diagnosis of obstructive sleep apnea. As the Veteran's obstructive sleep apnea is a diagnosed condition, it cannot be considered an undiagnosed illness, but it is eligible for consideration as a MUCMI. 38 C.F.R. § 3.317(a)(1)(ii), (a)(2)(ii). A March 2020 VA examination indicates that the Veteran's obstructive sleep apnea has a fully understood etiology and a fully understood pathophysiology. The examiner explained that obstructive sleep apnea is a collapse of the airway due to impaired throat musculature with risk factors including but not limited to smoking, obesity, enlarged tonsils, and sinus issues. The Board finds this opinion probative because the examiner explains the etiology and pathophysiology of obstructive sleep apnea and provides examples of risk factors. Accordingly, as both the etiology and the pathophysiology of the Veteran's obstructive sleep apnea are fully understood, it is not considered a MUCMI, and presumptive service connection is not warranted. The Board now turns to whether direct service connection is warranted. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish service connection for a 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. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran has a current diagnosis of obstructive sleep apnea. He contends he was exposed to Gulf War combat experiences. Service records show that the Veteran participated in Operation Vigilant Warrior in Saudi Arabia. The Veteran is competent to describe the circumstances of service. As such, the Board finds this to satisfy the first two elements of service connection. Turning to the third element, medical nexus, the evidence consists of a March 2020 VA examination. The examiner found that it was less likely than not that the Veteran's obstructive sleep apnea was due to exposure to Gulf War combat experiences. Their rationale was that the Veteran had no sleep apnea during service and that current literature does not link sleep apnea to Gulf War service as the etiology is collapse of airway due to impaired throat musculature. The examiner noted that risk factors of obstructive sleep apnea included smoking, obesity, enlarged tonsils, and sinus issues but not Gulf War exposure. The examiner is competent to provide this opinion, the Board finds them to be credible, and affords the opinion great probative weight. Accordingly, the preponderance of the evidence is against a finding that the Veteran's obstructive sleep apnea is due to service. Because the preponderance of the evidence weighs against this claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. As such, service connection for obstructive sleep apnea is denied. REASONS FOR REMAND Bilateral arm pain, swelling, and blistering In April 2020, the Veteran underwent a VA examination for his prostate cancer. The examiner found the Veteran to have no other pertinent physical findings, complications, conditions, signs, or symptoms attributatble to his prostate cancer. However, in a September 2016 examination report, a VA examiner found the Veteran's bilateral arm condition to be attributable to his prostate cancer. The Board notes that the September 2016 examiner did not provide a diagnosis for his symptoms. The April 2020 examiner did not explain this inconsistency. As such, a remand is necessary to obtain an addendum opinion. Furthermore, in a November 2020 brief the Veteran's representative raised a contention that his bilateral arm symptoms are radiation dermatitis attributable to radiation treatment for prostate cancer. A VA examiner has not opined on this theory, and as such a remand is necessary to obtain an addendum opinion. The matter is REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's bilateral arm pain, swelling, and blistering is at least as likely as not proximately due his service-connected prostate cancer or aggravated beyond its natural progression by his service-connected prostate cancer. The examiner is to also opine whether at any point during the period on review did the Veteran have radiation dermatitis of his bilateral arms. The Board draws to the examiner's attention the findings of the April 2016 VA examiner that the Veteran's bilateral arm conditions were attributable to his prostate cancer. If the examiner is unable to diagnose the Veteran with any bilateral arm disability, a complete rationale must be provided, specifically addressing their findings in comparison with the findings of the April 2016 VA examiner. JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael Chandeck, 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.