Citation Nr: 21066402 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 17-38 474 DATE: October 29, 2021 ORDER Throughout the appeal period, an increased evaluation of 50 percent, but no higher, for a service-connected tension headache disability is granted. Throughout the appeal period, an evaluation of 30 percent, but no higher, for a service-connected left shoulder disability is granted. Service connection for bilateral hearing loss is denied. REMANDED Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. FINDINGS OF FACT 1. Resolving all doubt in the Veteran's favor, throughout the appeal period the service-connected headache disability was manifest by very frequent and completely prostrating prolonged attacks of migraine headaches productive of severe economic inadaptability. 2. Resolving all doubt in the Veteran's favor, throughout the appeal period, the left shoulder disability was manifest by pain and limitation of motion of the arm midway between side and shoulder. 3. The Veteran does not currently have bilateral sensorineural hearing loss to an extent recognized as a disability for VA purposes. CONCLUSIONS OF LAW 1. 2. Throughout the appeal period, the criteria for an initial 50 percent rating for migraine headaches are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8100. 2. Throughout the appeal period, the criteria for a rating of 30 percent, but no higher for a left shoulder disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5010-5201. 3. The criteria for entitlement to service connection for bilateral hearing loss have not been satisfied. 38 U.S.C. §§ 1101, 1110, 1112, 1154, 5107, 7104; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.385, 4.85. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from June 2001 to June 2014 with service in Southwest Asia from March 2003 to July 2003, from January 2004 to April 2004, August 2005 to February 2006, and from July 2007 to February 2008. He was awarded the Combat Action Ribbon and Iraq Campaign Medal with 4 stars, as well as other decorations, for this service. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decision in September 2014 and May 2017 by the San Diego, California, Regional Office (RO) of the Department of Veterans Affairs (VA). The Board remanded the claims in December 2019 to obtain VA examinations and further develop the record. After review, the Board finds that there has been substantial compliance with the December 2019 remand directives. Specifically, the requested examinations were obtained, their adequacy is discussed below, and the appropriate Supplemental Statement of the Case has been issued. Stegall v. West, 11 Vet. App. 268, 271 (1998). These matters are therefore properly before the Board for adjudication. 1. Increased Evaluation for Service-Connected Headaches. The Veteran contends that the service-connected headache disability is more severe than is reflected by the currently assigned 30 percent evaluation. In his notice of disagreement, the Veteran indicated that he is seeking a 40 percent rating. After review of the lay and medical evidence of record, the Board finds that the service-connected headaches more closely approximate a 50 percent evaluation throughout the entire appeal period. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's tension headaches are rated under diagnostic code 8199-8100. Hyphenated codes are intended to show that the Veteran's service-connected disability is rated by analogy. See 38 C.F.R. § 4.20 (an unlisted condition may be rated under a closely related disease or injury in which the functions affected, anatomical localization, and symptomatology are closely analogous). Here, the first number, 8199, represents tension headaches and the second number, 8100, represents migraine headaches. Under DC 8100, a 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent rating is warranted for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 50 percent rating is the highest schedular rating under DC 8100. The rating criteria of DC 8100 are considered successive, meaning that a claimant cannot fulfill the criteria of the higher rating without fulfilling those of the next lower rating. Johnson v. Wilkie, 30 Vet. App. 245, 252 (2018). This renders 38C.F.R. §§4.7 and 4.21 inapplicable. Johnson, 30 Vet. App. at 252. The phrase "characteristic prostrating attacks" is used in the criteria corresponding to 10 percent and 30 percent ratings under DC 8100 to describe the nature and severity of migraines, but it is not defined in the regulation. Pursuant to Dorland's Illustrated Medical Dictionary 1531 (32d ed. 2012), prostration is defined as "extreme exhaustion or powerlessness." Thus, the phrase "characteristic prostrating attacks" is understood to describe migraine attacks that typically produce extreme exhaustion or powerlessness. The rating criteria for a 50 percent rating contains several undefined phrases. The descriptive phrase "very frequent" connotes a frequency at least greater than once a month, as is required by the rating criteria corresponding to a lesser 30 percent rating. Johnson, 30 Vet. App. at 253. The phrase "completely prostrating" generally means that the migraines attack must render the veteran entirely powerless. Id. The completely prostrating attacks must also be "prolonged," which is defined as "to lengthen in time: extend duration: draw out: continue, protract." Id. (internal citation omitted). Lastly, the 50 percent rating criteria requires that the very frequent completely prostrating and prolonged attacks be "productive of severe economic inadaptability." Productive can be read as having either the meaning of "producing" or "capable of producing," and, with regard to severe economic inadaptability, nothing in DC 8100 requires that the claimant be completely unable to work in order to qualify for a 50 percent rating. Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004). In September 2014, the Veteran underwent a VA examination to determine the nature and etiology of any current headache disability. He reported headaches that start from the right side of the head that spread to the whole head without nausea or vomiting that last less than one day. The VA examiner diagnosed tension headaches with secondary dizziness that occurred more frequently than once a month. The VA examiner further indicated that the Veteran did not have characteristic prostrating attacks but that the headaches did impact his ability to work in that the Veteran could only perform light physical and sedentary activities. A September 2014 rating decision granted service connection for tension headaches and assigned a 30 percent evaluation. The Veteran filed a timely notice of disagreement with the assigned evaluation and this appeal followed. In December 2017, the Veteran underwent a VA examination to determine the severity of the service-connected headaches. He reported daily headaches with constant pain that lasted less than a day. The VA examiner indicated that the Veteran experienced prostrating attacks once a month that did not produce severe economic inadaptability and did not impact his ability to work. In February 2019, the Veteran underwent an additional examination to determine the severity of the service-connected headaches. The Veteran reported constant head pain that worsened with physical activity and that he experienced nausea, vomiting, sensitivity to light, changes in vision, and sensory changes that lasted one to two days. He further reported at least one incapacitating headache every two to three weeks where he had to cease all activities and stay in bed due to an extreme sensitivity to light, sound, and quick movements. The examiner indicated both that the Veteran did not have characteristic prostrating attacks of migraine headaches and that he did not have very frequent prostrating attacks of migraines. The examiner then indicated the non-migraine headaches occur more frequently than once per month and that the Veteran did have very frequent prostrating and prolonged attacks of non-migraine headache pain. VA treatment records throughout the appeal period are consistent with the examinations of record. During a July 2014 VA TBI examination, the examiner indicated the Veteran experienced moderate headaches that could be random and triggered by sunlight. In a January 2015 correspondence the Veteran indicated that the service-connected headaches were consistent and occurred during exercise and many social events. During a February 2017 telehealth appointment, the Veteran reported usually waking with a tension headache. In February 2019, the Veteran reported getting a massive headache when the heat was turned on. Based on the forgoing, the Board finds that giving the Veteran the benefit of the doubt and considering the nature and frequency and severity of his headaches, the condition more closely associates the criteria for a 50 percent rating, namely, frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Specifically, the record shows the Veteran experienced very frequent prostrating and prolonged attacks of non-migraine headache pain. As early as the September 2014 examination, VA examiners were indicating that the headaches impacted his ability to work and that during a headache the Veteran could only perform light physical and sedentary activities. As mentioned above, the term "productive of severe economic inadaptability" can be read as having either the meaning of "producing" or "capable of producing," severe economic inadaptability. Here, the limitations on the September 2014 VA examiner indicated that the service-connected headaches were capable of severely reducing the Veteran's ability to work. The Board notes that the December 2017 VA examiner indicated that the headaches did not produce severe economic inadaptability, however, the Veteran clarified in February 2019 that he had at least one incapacitating headache every two to three weeks where he had to cease all activities and stay in bed due to an extreme sensitivity to light, sound, and quick movements. Given the reported frequency this would be between 17 and 26 incapacitating headaches a year or almost one full month. A 50 percent rating is the highest schedular rating available under Diagnostic Code 8100 and higher than the rating sought by the Veteran; therefore, the Board finds that a rating in excess of 50 percent is not warranted. 2. Increased Evaluation for Service-Connected Left Shoulder Disability. The Veteran contends that the service-connected left shoulder disability is more severe than the currently assigned 20 percent evaluation. After review of the lay and medical evidence of record, the Board finds that throughout the appeal period, a 30 percent evaluation is warranted for the service-connected left shoulder. As an initial matter, the record reflects that the Veteran is ambidextrous. As such, in the light most favorable ot the Veteran, the service-connected left shoulder has been treated as the dominant hand. The Veteran's left shoulder disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5201, for limitation of motion of the arm. Hyphenated codes are intended to show that the Veteran's service-connected disability is rated by analogy. See 38 C.F.R. § 4.20 (an unlisted condition may be rated under a closely related disease or injury in which the functions affected, anatomical localization, and symptomatology are closely analogous). Here, the first number, 5010, represents traumatic arthritis and the second number, 8100, represents limitation of motion of the arm. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major extremity. Limitation of motion of the arm midway between side and shoulder warrants 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Prior to February 7, 2021, Diagnostic Code 5201 "does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm." Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). Effective February 7, 2021, VA amended Diagnostic Code 5201 to reflect that limitation of motion may be shown by flexion and/or abduction and clarified the degrees of limitation of motion that correspond to each rating. Now, limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Flexion and/or abduction limited to 25 degrees from the side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. When applicable regulations are amended during the pendency of an appeal, the version of the regulations most favorable to the veteran is to be applied. However the prior version must be used to rate the veteran's disability for periods preceding the effective date of the regulatory change. VAOPGCREC 3-2000. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Turning to the evidence, in September 2014, the Veteran underwent a VA examination to determine the nature and etiology of any left shoulder disabilities. He reported pain in the left shoulder with certain movement and with heavy lifting but denied swelling. On examination, range of motion strength, and instability testing in both shoulders testing was normal, but the VA examiner estimated that during a flare-up range of motion in flexion and abduction would be reduced by 5 degrees. The VA examiner diagnosed the Veteran with shoulder strain. A September 2014 rating decision granted service connection for a left shoulder disability, evaluated at 20 percent, effective June 24, 2014. The Veteran filed a notice of disagreement with the assigned evaluation and this appeal followed. In April 2017, the Veteran underwent a VA examination to determine the severity of the service-connected left shoulder. He reported an aching-constant pain (6-7/10) with occasional sharp pain (9-10/10). The left shoulder disability was treated with medication, steroid injections, H-wave stimulation, heating pad, and cold compress. A September 2016 MRI of the shoulder demonstrated a tear of the posterior labrum, mild rotator cuff tendonitis, and osteoarthritis of the glenohumeral joint. On examination, range of motion testing in the left shoulder revealed flexion of 150 degrees, abduction of 170 degrees, external rotation to 60 degrees, and internal rotation to 90 degrees with pain, crepitus, and tenderness noted. There was no additional functional loss after repetitive testing. The examination was conducted during a flare-up and the VA examiner indicated there was no weakness, pain, or incoordination that significantly limited functional ability during a flare-up. Strength testing was normal in the left shoulder and there was no ankylosis or atrophy but there was instability, a history of mechanical symptoms, and a positive crank apprehension and relocation test. An April 2017 rating decision continued the 20 percent evaluation for the service-connected left shoulder. In July 2017, the Veteran perfected his appeal. In March 2019, the Veteran underwent an additional examination to determine the severity of the service-connected left shoulder. He reported left shoulder pain that was aggravated by daily tasks with loss of range of motion, painful flare-ups that cause loss of strength and impact functionality in daily activities with work and family. The VA examiner further indicated that during a flare-up the Veteran was unable to complete basic functions including lift, carry and hold items, due to pain and numbness in the upper extremities. On examination, range of motion testing in the left shoulder revealed flexion of 75 degrees, abduction of 75 degrees, external rotation to 40 degrees, and internal rotation to 40 degrees with pain and no additional loss of range of motion following repetitive testing. The examiner estimated that during a flare-up range of motion in the left shoulder would be limited to 45 degrees of flexion, 40 degrees abduction, and 25 degrees external rotation, and 25 degrees internal rotation. Strength testing was 4/5 with no muscle atrophy or ankylosis. In November 2020, the Veteran underwent an additional examination to determine the severity of the service-connected left shoulder. He reported pain with decreased range of motion and that it was hard to use the left arm when he needed it. The Veteran reported flare-ups that were moderate to severe that last 1 to 3 hours and are precipitated by yard work, moving items, and are alleviated by ice and rest. On examination, range of motion testing in the left shoulder revealed flexion of 150 degrees, abduction of 170 degrees, external rotation to 60 degrees, and internal rotation to 90 degrees with pain. Repetitive range of motion testing in the left shoulder revealed flexion of 120 degrees, abduction of 150 degrees, external rotation to 40 degrees, and internal rotation to 90 degrees with pain. The examiner estimated that during a flare-up range of motion in the left shoulder would be limited to 120 degrees of flexion, 150 degrees abduction, and 40 degrees external rotation, and 90 degrees internal rotation. Strength testing was 5/5 with no muscle atrophy or ankylosis. VA treatment records are consistent with the examinations of record. In a January 2015 statement, the Veteran indicated his shoulder pain increased on cold days. In May 2016, the Veteran indicated he continued to experience shoulder pain treated with pain medication and physical therapy. In May 2017, the Veteran received corticosteroid injections for pain. In the present case, the evidence reflects limitation of motion to at worst 45 degrees of flexion and 40 degrees of abduction. As noted above, the Board is resolving all doubt in favor of the Veteran and treating the arm as if it were the dominant arm. In light of the limitation to 45 degrees and applying it to the dominant arm would result in a 30 percent rating. The Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for the service-connected left shoulder disability. As stated above, the Board has considered the Veteran left-handed to allow for the highest evaluation. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, excess fatigability, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that would not result in symptoms more nearly approximating limitation of motion of the arm to 25 degrees from the side of the major extremity. To be sure, during the examination most favorable to the Veteran (March 2019), the examiner estimated that even during a flare-up range of motion in the left shoulder would be limited to 45 degrees of flexion, 40 degrees abduction. No other examination shows limitation of motion less than an estimated 120 degrees of flexion and 150 degrees abduction which would not warrant 20 percent evaluation, as such, even when consider the lay evidence and the lowest estimated range of motion by a medical professional, the Board finds no evidence to support range of motion in the left shoulder limited to 25 degrees, warranting an evaluation in excess of 30 percent. In conclusion, the Board finds that the preponderance of the evidence supports an increased evaluation of 30 percent, but no higher, for the service-connected left shoulder. 3. Service Connection for Bilateral Hearing Loss is Denied. The Veteran contends that he is entitled to service connection for bilateral hearing loss that was proximately caused by his active military service, to include his exposure to hazardous military noise during service. After review of the lay and medical evidence of record, the Board finds that service connection for bilateral hearing loss is not warranted. Service connection is warranted where the evidence of record demonstrates that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty during active military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection for a disability requires competent and credible evidence of the following: (1) the existence of a current disability; (2) the existence of the disease or injury in service; and (3) a relationship or nexus between the current disability and any injury or disease during service. See Hickson v. West, 12 Vet. App. 247, 252 (1999). A presumption of service connection attaches to certain diseases enumerated in 38 C.F.R. § 3.309(a). In this case, sensorineural hearing loss is categorized as an organic disease of the nervous system under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258, 271 (2015). Where a veteran has served for at least ninety days during a period of war or after December 31, 1946 and develops an enumerated chronic disease to a compensable degree within one year from the date of separation from service, such disease shall be presumed to have been incurred or aggravated in service even though there is no evidence of such disease during the period of service. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In order to establish a chronic disease in service, a veteran must show a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." See 38 C.F.R. § 3.303(b). When the disease identity is established, there is no requirement of an evidentiary showing of continuity. See id. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. See id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. See id. Continuity of symptomatology is only applicable to those diseases recognized as "chronic" for VA purposes. See Walker v. Shinseki, 708 F.3d 1331, 1338-1339 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.309(a). Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified puretone and speech recognition criteria. Audiometric testing measures puretone threshold hearing levels (in decibels) over a range of frequencies (in Hertz). See Hensley v. Brown, 5 Vet. App. 155, 158 (1993). The determination of whether a veteran has a hearing loss disability is governed by 38 C.F.R. § 3.385, which provides that, for the purposes of applying the laws administered by VA, impaired hearing will be considered a disability only where one of the following is established: (1) the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; (2) the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 hertz are 26 decibels or greater; or (3) speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385. The threshold for normal hearing ranges between zero to 20 decibels and higher threshold levels indicate some degree of hearing loss. See Hensley, 5 Vet. App. at 157. A veteran may establish direct service connection for a hearing disability that initially manifests several years after separation if the evidence of record demonstrates a causal relationship between the veteran's current hearing disability and the injury or disease suffered in service. See id. at 164; 38 C.F.R. § 3.303(d). After careful review of the evidence of record, the Board finds that the Veteran currently does not suffer from bilateral hearing loss to an extent recognized as a disability for VA purposes. In September 2014 and October 2020, the Veteran was afforded VA audiological examinations which both reflected bilateral hearing thresholds of 25 decibels or lower in all frequencies from 500 Hertz to 4000 Hertz. Speech recognition measured as 98 percent bilaterally in September 2014 and 96 percent bilaterally in October 2020. All of these measurements fall short of the VA criteria for a hearing disability as set forth above. See 38 C.F.R. § 3.385. Further, the October 2020 VA examiner thoroughly reviewed the service treatment records and concluded the Veteran had normal hearing throughout service. Specifically, the VA examiner showed June 2001 and March 2012 military audiological testing revealed normal hearing. The examiner also looked at a March 1, 2012 hearing examination that appeared to show a shift in hearing, but noted that on March 9, 2012, the Veteran underwent a full audio evaluation that showed there was no in-service shift in the Veteran's hearing. In summary, there is no competent medical evidence that indicates that the Veteran has a current hearing loss disability in either ear that meets VA disability criteria. The Veteran is competent to report symptoms of hearing loss that he may experience as a layperson. However, the Veteran is not competent to diagnose a bilateral hearing loss disability because hearing loss is identified by objective and specific audiometric and speech recognition testing. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he has personal knowledge); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). As such, the Board finds that the preponderance of the evidence is against the claim for a hearing loss disability of either ear. Consequently, because a preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. Service connection for a bilateral hearing loss disability is denied. See 38 C.F.R. §§ 3.102, 3.303. REASONS FOR REMAND 1. Service Connection for OSA is Remanded. The Veteran contends the currently diagnosed sleep apnea began during or is the result of his active military service. After review of the medical and lay evidence of record, the Board finds that a remand is necessary to make a fully informed decision. On his pre-discharge compensation claim, the Veteran filed for service connection for sleep apnea. In September 2014, the Veteran underwent a VA examination to determine the nature and etiology of any sleep disorders. The Veteran reported that he had not been diagnosed with OSA yet but was scheduled for a sleep study in a few months. He denied any daytime hypersomnolence. Under abnormal physical findings, the VA examiner checked the box indicating the Veteran was obese but indicated there was insufficient evidence to diagnose OSA at that time. A September 2014 rating decision denied service connection for OSA. The Veteran filed a timely notice of disagreement and this appeal followed. In January 2015, the Veteran submitted a personal statement and multiple buddy statements. The Veteran indicated his service-connected disabilities caused him to gain 45 pounds. The Veteran's wife indicated that he experienced sleep issues during service. In January 2017, the Veteran submitted a claim for OSA, claimed as secondary to service-connected posttraumatic stress disorder. A May 2019 sleep study showed severe sleep apnea. In September 2020, a VA examiner reviewed the record and opined the current OSA was less likely than not incurred during the Veteran's active military service in part based on OSA risk factors including obesity, neck circumference, and medical conditions. However, the examiner failed to address that obesity was checked on the September 2014 VA examination and the Veteran's lay reports, including buddy statements. Further, the examiner failed to address whether the OSA was caused or aggravated by any service-connected disabilities, including PTSD. Given the deficiencies in the record, a remand is necessary. Barr v. Nicholson, 21 Vet. App. 303 (2007). The matters are REMANDED for the following action: 1. Associate any VA treatment records since October 2020 with the electronic claims file. 2. After completion of the above-specified development. Schedule the Veteran for a VA examination to determine the nature and etiology of the currently diagnosed obstructive sleep apnea. The examiner must have the appropriate expertise and be provided access to the electronic claims file. The examiner must indicate review of the claims file in the examination report. The examiner is asked to provide the following opinions: a) Is it at least as likely as not (50 percent or greater probability) that any current obstructive sleep apnea had its onset in service? b) Is it at least as likely as not (50 percent probability or greater) that the current sleep apnea is caused by the Veteran's service-connected disabilities, including PTSD, to include any obesity/weight gain caused by such conditions? c) If not caused by the service-connected disabilities, is it at least as likely as not (50 percent probability or greater) that the sleep apnea is aggravated (worsened in severity beyond the natural progression of the disease) by the Veteran's service-connected disabilities, including PTSD to include any obesity/weight gain caused by such conditions? If the VA examiner opines that the sleep apnea is aggravated by the PTSD, he/she should indicate the degree of disability before aggravation and the current degree of disability. The VA examiner must comment on the Veteran's September 2014 VA examination documenting obesity, as well as, lay reports of in-service sleep problems. A rationale should be given for all opinions and conclusions rendered. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Teague, 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.