Citation Nr: A21017367 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 200514-84773 DATE: October 27, 2021 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD, is remanded. Entitlement to service connection for right lower extremity limb movement disability, to include periodic limb movement disorder and restless leg syndrome, is remanded. Entitlement to service connection for left lower extremity limb movement disability, to include periodic limb movement disorder and restless leg syndrome, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1990 to May 1991. In April 2020, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of an April 2019 decision. In April 2020, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the prior April 2019 decision. In the May 2020 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of initial rating decision. Evidence was added to the claims file during a period of time when new evidence was not allowed. As the Board is remanding the claims for further development, this additional evidence will be considered by the RO in the adjudication of those claims. The Veteran contends that his sleep apnea and bilateral lower extremity limb movement disorder are related to his active-duty service. Alternatively, he contends that they are secondary to his service-connected PTSD, noting that "the PTSD drives the apnea" and "the sleepness nights drive the restlessness." In a March 2019 VA examination, the Veteran was diagnosed with periodic limb movement disorder, a central nervous system (CNS) condition. The examiner opined that "[t]here is no current medical evidence supporting a causal relationship and/or direct relationship between the veteran's claimed condition of periodic limb movement disorder and the veteran's environmental exposure event in Southwest Asia." The examiner did not provide any rationale. In a March 2019 VA examination report for sleep apnea, the examiner noted diagnoses of obstructive sleep apnea and restless leg syndrome. The examiner opined that the Veteran's restless leg syndrome and his sleep apnea were less likely as not (less than 50/50 probability) proximately due to or the result of PTSD as there is no nexus with which to connect the conditions. For the sleep apnea, the examiner further noted that while there are studies that show possible associations between PTSD and obstructive sleep apnea, this relationship has not yet been determined to be causal and therefore PTSD is not a widely accepted risk factor for development of obstructive sleep apnea. The examiner suggests that the Veteran's sleep apnea was more likely related to his weight, neck circumference, age, and gender than his PTSD. With respect to the lower extremity limb movement disability, the examiner did not provide adequate rationale for the direct service connection opinion. The examiner also did not provide adequate rationale for the causation opinion and did not address aggravation. With respect to the sleep apnea disability, the examiner did not provide a direct service connection opinion for the sleep apnea and did not address aggravation. The Board finds that additional VA examiner opinions must be provided on remand. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate.) When the Board identifies a pre-decisional duty to assist error in an AMA appeal, under Pub. L. No. 115-55, section 2(d)(2); 38 C.F.R. §§ 3.159(c), 20.802(a) (2019), the Board will remand the appeal back to the Agency of Original Jurisdiction (AOJ) with instructions to correct the error. Following correction of the error, the AOJ must readjudicate the issue. Pub. L. No. 115-55, § 2(d)(2); 38 C.F.R. § 3.2502 (2019). Therefore, the issues on appeal are remanded to obtain addendum medical opinions with an adequate rationale and in consideration of all the theories of entitlement. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the following: (a.) Whether the Veteran's sleep apnea is at least as likely as not (a 50 percent or greater probability) due to service. (b.) Whether the Veteran's sleep apnea is at least as likely as not (a 50 percent or greater probability) aggravated beyond its natural progression by his service-connected PTSD. 2. Schedule the Veteran for a VA examination to address the nature and etiology of any diagnosed lower extremity limb movement disability, to include restless leg syndrome and periodic limb movement disorder. A complete and detailed rationale should be given for all opinions and conclusions expressed. The examiner should review the claims file and note that review in the examination report. The examiner should specifically opine as to: (a.) Whether any diagnosed lower extremity limb movement disability, to include restless leg syndrome and periodic limb movement disorder, is at least as likely as not (a 50 percent or greater probability) due to service, to include any environmental exposures in Southwest Asia. (b.) Whether any diagnosed lower extremity limb movement disability, to include restless leg syndrome and periodic limb movement disorder, is at least as likely as not (50 percent or greater probability) (a) proximately due to or (b) aggravated beyond its natural progression by his service-connected PTSD. JENNA BRANT Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Romero-Sanchez, 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.