Citation Nr: 21071211 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 18-39 377 DATE: November 30, 2021 REMANDED Entitlement to service connection for carpal tunnel syndrome is remanded. Entitlement to service connection for sleep apnea is remanded. REASONS FOR REMAND The Veteran had active service from May 1989 to August 1989, January 1991 to July 1991, November 2001 to March 2002, and January 2003 to February 2004, to include Southwest Asia service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for carpal tunnel syndrome, sleep apnea, and irritable bowel syndrome (IBS). The Veteran filed a Notice of Disagreement regarding the claims for carpal tunnel syndrome and sleep apnea in January 2016. A separate Notice of Disagreement was filed regarding IBS. A July 2018 Statement of the Case addressed service connection for sleep apnea and carpal tunnel syndrome. The Veteran subsequently filed a Form 9 in July 2018 regarding those claims. However, the Veteran did not appeal his claim for IBS to the Board at that time. A Statement of the Case regarding IBS was issued in December 2019. The Veteran filed a Decision Review Request: Board Appeal (VA Form 10182) in May 2020, requesting to appeal IBS, sleep apnea, hypertension, and tinnitus. The Veteran was informed via a Board letter in August 2020 that VA had not made a decision in the modernized system for the issues of IBS, sleep apnea, and hypertension. As such, an appeal to the Board for IBS has not been perfected. In February 2021, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the proceeding has been associated with the claims file. As a preliminary matter, the Board notes that the Veteran's hearing testimony focused on entitlement to service connection for irritable bowel syndrome (IBS). However, as noted above, that matter is not properly before the Board at this time. 1. Entitlement to service connection for carpal tunnel syndrome The Veteran contends that symptoms of his carpal tunnel syndrome had their onset during service. A January 2004 post-deployment health assessment notes that the Veteran complained of numbness and tingling in his hands. He indicated that he was experiencing numbness and tingling again in a Report of Medical History in December 2006, and a medical readiness record review in January 2010 also noted bilateral tingling in his hands. The Veteran was afforded a VA examination for his bilateral carpal tunnel syndrome in May 2015. The examiner opined that the carpal tunnel symptoms had their onset after military service, and that there was insufficient evidence to correlate the Veteran's bilateral carpal tunnel syndrome with service in Southwest Asia. However, the examiner did not comment on the Veteran's earlier symptoms. As such, another opinion should be obtained that addresses the Veteran's in-service symptoms. 2. Entitlement to service connection for sleep apnea The Veteran contends that his obstructive sleep apnea had its onset during service, or alternatively that his service-connected disabilities, including posttraumatic stress disorder (PTSD) and left knee strain, have caused him to become obese, thus predisposing him to obstructive sleep apnea. The Veteran is currently diagnosed with sleep apnea. Relevant to this appeal, obesity can constitute an "intermediate step" between a service-connected disability and a disability that may be service connected on a secondary basis. See Walsh v. Wilkie, 32 Vet. App. 300 (2020); General Counsel Precedent Opinion 1-2017. The record reveals a private medical opinion regarding the Veteran's sleep apnea was provided in February 2020. The private examiner opined that the Veteran's weight gain has predisposed him to sleep apnea, and that his comorbidities of PTSD and orthopedic disability have contributed to his obesity. While the examiner noted that the Veteran's PTSD and knee disability contributed to his obesity, the examiner did not provide a clear conclusion that indicated whether the Veteran's obesity would not have occurred but for his service-connected disabilities. The Veteran was afforded a VA examination in June 2018. The examiner opined that the Veteran was not diagnosed with sleep apnea until 10 years post-service and that there was no indication that the Veteran's condition began during service. However, the examiner did not explain why the lay evidence of record, including a statement from the Veteran's spouse as to the onset of possible symptoms of sleep apnea, did not indicate the condition began during service. As such, another opinion should be obtained that fully explains the basis for the conclusion expressed, as well as provides an opinion as to whether the Veteran's sleep apnea was caused or aggravated by a service-connected disability, including as due to lack of exercise and obesity as an intermediate step. The matters are REMANDED for the following action: 1. Provide the Veteran's entire claims file to an appropriate clinician and obtain an addendum opinion regarding the Veteran's bilateral carpal tunnel syndrome. (a.) The examiner should provide an opinion that addresses whether the Veteran is diagnosed to have carpal tunnel syndrome of the upper extremities. If it is necessary to examine the Veteran, that should be arranged. (b.) If a diagnosis is made, the examiner should state whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's conditions are attributable to his active service. In offering the opinion, the examiner should address the Veteran's reported history of symptoms, to include any lay statements of record, as well as the reports of numbness and tingling in his hands in January 2004 and December 2006 service treatment records. A rationale should be provided for any opinion expressed. 2. Provide the Veteran's entire claims file to an appropriate clinician and obtain an addendum opinion that addresses the following: (a.) Whether the Veteran's service-connected disabilities, including PTSD and left knee disability, caused the Veteran to become obese; and if so, whether obesity as a result of the service-connected disability/ies was a substantial factor in causing obstructive sleep apnea, and whether obstructive sleep apnea would not have occurred but for the obesity caused by service-connected PTSD and left knee disability. (b.) Whether the Veteran's service-connected PTSD and/or left knee disability caused the Veteran's obesity to be worse than it otherwise would have been; and if so, whether this increase in severity of the obesity as a result of the service- connected disability/ies was a substantial factor in causing the obstructive sleep apnea, and whether obstructive sleep apnea would not have occurred but for the aggravation of obesity caused by service connected disability/ies. A complete rationale must be provided for all opinions presented. The examiner should connect all opinions made to the evidence of record and any medical literature referenced. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should provide an explanation stating why that is the case. The examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or whether the examiner has exhausted the limits of current medical knowledge. 3. After completing the above actions, to include any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V. Geer, 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.