Citation Nr: 21072947 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 17-08 381 DATE: December 7, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1999 to June 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2019, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. By way of background, this matter was initially before the Board in February 2020, when it was remanded for further development. See February 2020 BVA Decision. Thereafter, in a January 2021 decision, the Board denied the Veteran's claim of entitlement to service connection for OSA, and the Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). See January 2021 BVA Decision. In August 2021, the Court granted the parties' Joint Motion for Remand (JMR), which vacated the Board's January 2021 decision and remanded the matter for additional development and readjudication. See August 2021 CAVC Decision. Entitlement to service connection for OSA, to include as secondary to service-connected disabilities, is remanded. In the August 2021 JMR, the Court found the July 2020 VA medical opinion inadequate pursuant to Garner v Tran, 33 Vet. App. 241, 251-52 (2021) and Walsh v. Wilkie, 32 Vet. App. 300, 307 (2020). See August 2021 CAVC Decision. In the July 2020 VA medical opinion, the examiner, in pertinent part, opined that it was less likely than not that the Veteran's service-connected disabilities were causative for or related to his obesity. In support of his opinion, the examiner referenced an article published by the Mayo Clinic, which states that obesity is a complex problem that is caused by a variety of factors, to include genetic, behavioral, metabolic, and hormonal influences, but is principally due to an energy imbalance between calories consumed in the diet and energy expended with physical activity and basal metabolism. In this regard, the examiner indicated that the complexity of the problem made it impossible to identify a single underlying cause of obesity. However, the examiner also noted that, while a sedentary lifestyle decreases energy expenditure, it is much easier to cause an energy imbalance leading to obesity by consuming excess calories than it is to burn the calories off with physical exercise regardless of whether or not a chronic musculoskeletal disorder exists. To this end, the examiner stated that there are other forms of physical activity that do not require weight-bearing that the Veteran would likely be able to perform, and which could replace the calorie burn that the Veteran was not able to do through weight-bearing activities due his service-connected disabilities. As such, the examiner opined that it was not possible to create a nexus between the Veteran's obesity condition and his service-connected disabilities. See July 2020 C&P examination. Thus, the July 2020 VA examiner focused only on the question of causation and did not address whether the Veteran's service-connected disabilities aggravated his obesity, which the examiner acknowledged was the proximate cause thereof. Based on the foregoing, the Board finds that a remand is necessary to obtain an addendum medical opinion to evaluate whether the Veteran's service-connected disabilities aggravated his obesity as a possible intermittent step between his service-connected disabilities and his diagnosed OSA. The matter is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. After completion of the above development, obtain an addendum opinion by an appropriate examiner to determine the nature and etiology of the Veteran's diagnosed OSA. It is up to the discretion of the examiner as to whether an in-person examination is necessary. The examiner should provide the following opinion: Is it at least as likely as not (50 percent or greater probability) that the Veteran's service-connected disabilities, to include posttraumatic stress disorder (PTSD) with unspecified depressive disorder, bilateral pes planus, right knee patellofemoral syndrome status-post partial lateral meniscectomy, and right knee surgical scar, aggravated his obesity, to include as due to any lack of exercise resulting from service-connected disabilities? Please explain why or why not. 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. The examiner should review pertinent documents in the Veteran's claims file in connection with the addendum medical opinion, including this Remand. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.