Citation Nr: 21071818 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 14-25 487A DATE: December 1, 2021 ORDER Entitlement to service connection for insomnia, as due to an undiagnosed illness and/or as secondary to service-connected disabilities is denied. REMANDED Entitlement to service connection for reflex sympathetic dystrophy (RSD), to include as secondary to fibromyalgia, is remanded. FINDING OF FACT The Veteran's symptom of insomnia is contemplated by the evaluation of his service-connected posttraumatic stress disorder (PTSD); the probative evidence of record is against a finding that the Veteran has a separately diagnosed sleep disorder. CONCLUSION OF LAW The criteria for entitlement to service connection for insomnia have not been met. 38 U.S.C. §§ 1110; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1986 to June 1991. He testified at a videoconference hearing before the undersigned in January 2019. A transcript of the hearing is of record. These claims were previously before the Board in May 2020 and May 2021, at which time they were remanded for further development. They have now been returned for further appellate review. Entitlement to service connection for insomnia, as due to an undiagnosed illness and/or as secondary to service-connected disabilities. The Veteran seeks entitlement to service connection for insomnia, to include as due to an undiagnosed illness and/or as secondary to his service-connected disabilities. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In this case, the Veteran has indicated that his insomnia is either due to his service-connected posttraumatic stress disorder (PTSD) and major depressive disorder or, in the alternative, due to an undiagnosed illness related to his service in SW Asia. See January 2019 hearing transcript. In a July 1997 VA service treatment record, the Veteran endorsed insomnia and noted improved sleep with prescribed medication. See July 1997 VA Psychiatry consult note. In October 1997, a VA physician noted that the Veteran's insomnia was a symptom of his diagnosed depressive disorder and chronic PTSD. Additionally, various VA treatment records indicate insomnia as a symptom of the Veteran's mental health disabilities. See May 2000 VA Physician Progress Note; October 2014 Psychiatry Note. Upon VA examination in March 1999 for PTSD, the Veteran reported no problem with sleep while deployed but indicated current sleep problems with the main issue being the ability to fall asleep. Under the "Signs and Symptoms" heading, the VA examiner recorded that the Veteran had difficulty falling asleep, but that once asleep, he slept well. Prescribed medication helped the Veteran fall asleep. Upon VA examination in October 2010, the VA examiner noted that the Veteran's sleeping problems had onset in 1991, approximately three to four months after returning from Southwest Asia. The Veteran experienced the inability to sleep with sometimes only sleeping one hour in a 24-hour period. He was evaluated by several doctors and prescribed various sleep aids with varying results. Upon examination in January 2015, January 2021, and June 2021, the examiners noted that the Veteran's insomnia was subsumed under the Veteran's mental health disabilities and was not a stand-alone diagnosis but rather a symptom of those mental health disabilities. Additionally, upon the June 2021 examination, the examiner also opined that no evidence of record suggested or supported that the Veteran has a diagnosed insomnia disorder that is related to his service in Southwest Asia. Although the Veteran is competent to report observable symptoms related to his sleep disturbances, he has not been shown to have the qualifications to offer medical diagnoses. See 38 C.F.R. § 3.159. That stated, during his January 2019 Board hearing, the Veteran suggested that his sleep issues may be part and parcel of his PTSD and was a symptom of that disability. The competent medical evidence of record confirms that the Veteran's insomnia is a symptom of his service-connected PTSD, and not a stand-alone separate disability. The Board adds that the Veteran's chronic sleep impairment, including insomnia, is contemplated in the evaluation of his service-connected PTSD. There are no positive medical opinions of record demonstrating that the Veteran's insomnia is a separate and distinct disability. Accordingly, the Board finds entitlement to service connection for insomnia is not warranted, and the Veteran's claim is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for RSD, to include as secondary to fibromyalgia, is remanded. In its May 2021 remand, the Board directed the agency of original jurisdiction (AOJ) to obtain an addendum opinion assessing the nature and etiology of the of the Veteran's RSD. Specifically, the examiner was asked to opine whether the Veteran's RSD had onset in, or was otherwise related to his active-duty service, including his service in Southwest Asia. If the Veteran's RSD was determined to be a manifestation of an undiagnosed illness, a chronic multisymptom disability of unknown etiology, or a chronic multi-symptom illness with a partially explained etiology, the examiner was to provide an explanation as to how the conclusion was reached. Additionally, the examiner was asked to opine whether the Veteran's RSD was caused or aggravated by his service-connected fibromyalgia. In July 2021, an examiner provided an addendum opinion based upon review of the Veteran's record. The examiner opined that the Veteran's RSD was a diagnosable condition with partially explained etiology and that it was neither caused or aggravated by his service-connected fibromyalgia. Although the VA examiner provided a negative nexus opinion addressing direct service connection, he based his opinion largely upon a lack of documented in-service complaints and delayed diagnosis in 1997. The examiner also noted that the peripheral nerve examination performed in June 2020 was not the correct examination to fully assess the Veteran's RSD condition. And, because the Veteran had been diagnosed with chronic fatigue syndrome, RSD, fibromyalgia, and mental health conditions, the examiner stated that it was virtually impossible to delineate findings between the conditions, and to do so would be speculative without a focused neurology examination. A neurology examination was not ordered by the AOJ and the claims file was subsequently returned to the Board. Once VA undertakes an examination, an adequate one must be produced. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Based upon the findings of the July 2021 VA examination, the Board finds that additional development must be conducted prior to adjudication. On remand, the AOJ should obtain an addendum opinion from a qualified medical professional and any necessary testing should be performed. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from a qualified professional assessing the nature and etiology of the of the Veteran's reflex sympathetic dystrophy (RSD). It is left to the discretion of the examiner as to whether an in-person examination is necessary to provide informed responses to the questions below, and if so, what type of examination. The Veteran's electronic claims file must be made available to and reviewed by the examiner and any necessary testing should be performed. Upon review of the record, the examiner should respond to the following: Is it at least as likely as not that the Veteran's RSD had onset in, or is otherwise related to his active-duty service, to include his service in Southwest Asia? If the Veteran's RSD is a manifestation of an undiagnosed illness, a chronic multisymptom disability of unknown etiology, or a chronic multi-symptom illness with a partially explained etiology this should be made clear, with an explanation as to how the conclusion was reached. All opinions should be supported with a medical explanation or rationale. 2. Then, readjudicate the issue on appeal. If the benefits sought remain denied, in whole or in part, send the Veteran and his attorney a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Bristow Williams, 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.