Citation Nr: 21070391 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 16-37 801 DATE: November 23, 2021 REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a skin disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1989 to July 1993, including service in the Southwest Asia theater of operations from October 1991 to June 1992. His awards and decorations include the Combat Medical Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). A hearing was held before the undersigned Veterans Law Judge (VLJ) in June 2019. A transcript has been associated with the claims file. The Board remanded the case for further development in October 2019. The case has since been returned to the Board for appellate review. Upon review, the Board finds that additional development is needed prior to adjudication of the issues on appeal. The Veteran was afforded a VA examination in September 2020 in connection with his claim for service connection for sleep apnea. The examiner opined that the disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. He noted that a February 2007 sleep study found severe sleep apnea and that an August 2012 sleep study noted morbid obesity with a body mass index (BMI) rising from 33.3 to 50.2 since 2007. The examiner stated that it is more likely that the Veteran's severe sleep apnea is a direct result of morbid obesity as opposed to being involved in an exposure event. He noted that the Veteran's BMI had since decreased to 33.7 and that he still has obstructive sleep apnea, which was more likely than not induced by excessive weight gain after military service. In addition, the examiner stated that the Veteran's current sleep apnea is not due to environmental hazards related to service in Southwest Asia. Nevertheless, the Board notes that the September 2020 VA examiner did not address the lay statements regarding the reported symptoms in service and whether they could have been early manifestations of sleep apnea, as directed in the prior remand. He also did not provide rationale for his statement that the Veteran's sleep apnea is not due to environmental hazards in Southwest Asia. Therefore, the Board finds that an additional VA medical opinion is needed. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). The Veteran was also afforded a VA examination in September 2020 in connection with his claim for service connection for a skin disorder. The examiner diagnosed him with intertrigo, but opined that the disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. He explained that intertrigo (intertriginous dermatitis) is an inflammatory condition of the skin folds, which is induced or aggravated by heat, moisture, maceration, friction, and the lack of air circulation. He commented that intertrigo is frequently worsened by infection, which most commonly occurs with the Candida species. The examiner noted that the Veteran's service treatment records do not document complaints, treatment, or diagnosis of this condition. He also stated that the current skin condition is not due to environmental hazards related to service in Southwest Asia. However, the examiner did not address the lay statements regarding the reported symptoms in service, as directed in the prior remand. Nor did he provide rationale for his statement that the disorder is not due to environmental hazards in Southwest Asia. Therefore, the Board finds that an additional VA medical opinion is needed. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for sleep apnea and a skin disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. Any outstanding VA medical records should also be obtained and associated with the claims file. 2. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of his sleep apnea. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should state whether it is at least as likely as not that the Veteran has sleep apnea that manifested in or is otherwise related to his military service, including any symptomatology and environmental hazards therein. The Veteran has claimed that he had environmental exposures while deployed to Southwest Asia from October 1991 to June 1992, including smoke from oil well fires. He has also reported that he had symptoms in service. The examiner should specifically address the lay evidence, including the Veteran's June 2019 hearing testimony and December 2015 lay statements from E.A., B.B., and S.R. (initials used to protect privacy). (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of any current skin disorder, including intertrigo. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify any skin disorders that have been present during the appeal period, to include intertrigo. If any previously diagnosed skin disorder is not found on examination, the examiner should address whether the disorder was misdiagnosed or has resolved For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise related to the Veteran's military service, including any symptomatology or environmental exposures therein. In rendering this opinion, the examiner should consider the Veteran's June 2019 hearing testimony and the December 2015 lay statements from E.A. and S.R., who indicated that he had rashes on his body during a deployment to the Persian Gulf. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. After completing these actions, the AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.S. Chilcote 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.