Citation Nr: 21073113 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 12-07 806 DATE: December 7, 2021 ORDER Entitlement to service connection for a back disability is denied. Entitlement to service connection for bilateral shoulder disability is denied. Entitlement to an initial increased disability rating in excess of 10 percent for diabetes mellitus prior to July 20, 2011 and in excess of 20 percent thereafter is denied. Entitlement to an initial increased disability rating in excess of 20 percent for right upper extremity peripheral neuropathy is denied. Entitlement to an initial increased disability rating in excess of 30 percent for left upper extremity peripheral neuropathy is denied. Entitlement to an initial increased disability rating in excess of 20 percent for right lower extremity peripheral neuropathy is denied. Entitlement to an initial increased disability rating in excess of 20 percent for left lower extremity peripheral neuropathy is denied. Entitlement to an effective date of June 15, 2010 for service connection for right upper extremity peripheral neuropathy is granted. Entitlement to an effective date of June 15, 2010 for service connection for left upper extremity peripheral neuropathy is granted. Entitlement to an effective date of June 15, 2010 for service connection for right lower extremity peripheral neuropathy is granted. Entitlement to an effective date of June 15, 2010 for service connection for left lower extremity peripheral neuropathy is granted. Entitlement to special monthly compensation (SMC) based on housebound criteria is granted from June 15, 2010. REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for bilateral knee disability is remanded. FINDINGS OF FACT 1. The evidence does not show the Veteran's back disability is related to an in-service injury, event or disease. 2. The evidence does not show the Veteran's bilateral shoulder disability is related to an in-service injury, event or disease 3. Prior to July 20, 2011, the Veteran's diabetes was managed by restricted diet only. 4. At no time during the period on appeal did the Veteran's diabetes require prescribed regulation of activities. 5. The Veteran's right upper extremity diabetic peripheral neuropathy of the median nerve is manifested by moderate incomplete paralysis. 6. The Veteran's left upper extremity diabetic peripheral neuropathy of the median nerve is manifested by moderate incomplete paralysis. 7. The Veteran's right lower extremity diabetic peripheral neuropathy of the sciatic nerve is manifested by moderate incomplete paralysis. 8. The Veteran's left lower extremity diabetic peripheral neuropathy of the sciatic nerve is manifested by moderate incomplete paralysis. 9. The evidence shows that the Veteran had current disabilities of diabetes mellitus and bilateral peripheral neuropathy of the upper and lower extremities from June 15, 2010. 10. The Veteran is entitled to special monthly compensation (SMC) at the housebound level from June 15, 2010. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a back disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for a bilateral shoulder disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for an initial increased disability rating in excess of 10 percent for diabetes mellitus prior to July 20, 2011 and in excess of 20 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.119, Diagnostic Code 7913. 4. The criteria for an initial disability rating in excess of 20 percent for right upper extremity diabetic peripheral neuropathy of the median nerve have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.124a, Diagnostic Code 8515. 5. The criteria for an initial disability rating in excess of 30 percent for left upper extremity diabetic peripheral neuropathy of the median nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.124a, Diagnostic Code 8515. 6. The criteria for an initial disability rating in excess of 20 percent for right lower extremity diabetic peripheral neuropathy of the sciatic nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.124a, Diagnostic Code 8520. 7. The criteria for an initial disability rating in excess of 20 percent for left lower extremity diabetic peripheral neuropathy of the sciatic nerve have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.124a, Diagnostic Code 8520. 8. The criteria for an assignment of an effective date of June 15, 2010 for the grant of service connection for peripheral neuropathy of the bilateral upper and lower extremities have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 9. The criteria are met for SMC from June 15, 2010. 38 U.S.C. § 1114 (s); 38 C.F.R. § 3.350 (i). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from January 1971 to December 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a May 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). This case was previously remanded by the Board in December 2017. In March 2017, the Veteran testified during a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. The Board is cognizant of the ruling of the United States Court of Appeals for Veterans Claims (Court) in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on individual unemployability (TDIU) due to service-connected disability, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this matter, the Veteran is already in receipt of TDIU throughout the duration of the appeal. Service Connection Service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish service connection for a disability, the Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 1. Back Disability 2. Bilateral Shoulder Disability The Veteran seeks service connection for a back and bilateral shoulder disability. The Veteran testified during the March 2017 Board hearing that he did not hurt his back or bilateral shoulders in-service but indicated that he participated in heavy lifting during service and began experiencing back pain and shoulder problems shortly after service which has continued ever since. The evidence of record shows that the Veteran was diagnosed with degenerative arthritis of the spine and bilateral shoulder strains. Therefore, there is evidence of current disabilities. As to an in-service event, injury or disease the Veteran's service treatment records do not reflect complaints related to his back or shoulders. The Veteran has testified he engaged in significant heavy lifting during service. The Board notes that lifting items is generally consistent with the conditions of the Veteran's service, as reflected in his DD Form 214 and the service records. See 38 U.S.C. § 1154 (a)(1). In addition, the Veteran is competent to report symptoms, such as pain, that he experienced shortly after service. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). As such, the Board finds there is evidence of an in-service event of lifting heavy objects. Therefore, the question remaining for consideration is whether there is a causal relationship between the in-service lifting and the Veteran's current back and bilateral shoulder disability. The Veteran denied recurrent back pain but reported swollen or painful joints in a July 1972 Report of Medical History. A November 1972 medical examination showed normal upper extremities and spine and other musculoskeletal. The Veteran attended a VA back examination in November 2020. A diagnosis of degenerative arthritis of the spine was noted. The Veteran reported an onset in 1971 or 1972. The November 2020 VA examiner stated the Veteran's back disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the service treatment records were silent for a back condition in service. Furthermore, the Veteran reports he did not have a back injury while on active-duty service and was never seen for a back complaint or condition while in service. He reported there was some heavy lifting at times, but not more than 50 pounds. He reported he mostly stood around with a weapon and guarded the ship. It is my medical opinion the veterans less than two years of active-duty service did not cause a back condition related to heavy lifting while in service and is more likely caused by the Veteran's reports of 40 plus years of working in plumbing post service. It is less likely as not the Veteran's back condition was caused by heavy lifting while in service and is not related to service. A nexus has not been established. The Veteran attended a VA examination in May 2012 for his shoulders. The Veteran reported onset of shoulder pain in the 1980s. No bilateral shoulder diagnosis was established, but decreased strength and pain was noted. The examiner stated the shoulder condition was less likely than not incurred in service. The examiner reasoned the Veteran did not have any visits for treatment or complaints during service relating to his shoulders. No further treatment until 2003 and imaging studies of shoulders are negative. The Veteran underwent a VA shoulder examination in January 2018. The Veteran reported the onset of shoulder pain in 2007. A diagnosis of bilateral shoulder strain was rendered. The January 2018 VA examiner stated the Veteran's bilateral shoulder disability was less likely than not incurred in or caused by the claimed in-service injury. The examiner noted that the Veteran was active-duty November 1971 to December 1972. Per the Veteran's lay statement, he has "pains in shoulder and arm." His statement also indicates he was a plumber and maintenance mechanic within the last 15 years, and he completed schooling for welding in 1982. Per his statement when he was a maintenance mechanic, his "tools had to be taken from truck to apt., such as sewer machines, pipe, radiators, and other equipment such as ladders and more." There was no statement from service about issues with heavy lifting, and his complaint from this exam are simply that he has shoulder pain. A note from May 2008 indicated the Veteran has a lipoma of the left shoulder. Surgery note dated July 2009 states: "pathology shows lesion was a lipoma. No e/o wound complications". Veteran's lipoma was removed, per a Surgery Consult dated August 17, 2011. Veteran was seen for bilateral shoulder pain in May 2012, and it appears this is a chronic condition lasting many years; however, it is not related or due to his time in service. It would seem any current issues are from issues with his jobs after service. Therefore, the Veteran's claimed bilateral shoulder condition, are less likely than not (less than 50 percent probability) began in or otherwise related to service, to include descriptions of in-service heavy lifting. With respect to a nexus between the current back and bilateral shoulder disabilities and in-service event, the only competent medical opinions of record are the January 2018 and November 2020 VA opinions, which weigh against the Veteran's claims. The January 2018 and the November 2020 opinions considered the Veteran's circumstances of service (lifting heavy objects) and contain thorough rationales. For these reasons the Board affords significant probative weight to the January 2018 and the November 2020 VA opinions stating that the Veteran's current back disability and bilateral shoulder disability are not related to his service, to include lifting heavy objects during service. The only evidence indicating an association between the current back disability and bilateral shoulder disability and service are the Veteran's own assertions. It is well established that a layperson without medical training is not qualified to render a medical opinion regarding the diagnosis or etiology of certain disorders and disabilities. See 38 C.F.R. § 3.159 (a)(1). In certain instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). However, as the origin or cause of a back disability and a bilateral shoulder disability are not simple questions that can be determined based on personal observation by a lay person, the Veteran's lay testimony is not competent to establish medical etiology or nexus. Id. The Board has also considered whether the Veteran is entitled to service connection for arthritis of the back as a "chronic disease." See 38 C.F.R. § 3.303 (b). Arthritis is included in the list of "chronic" diseases under 38 C.F.R. § 3.309 (a). However, the Veteran has not argued, and the record does not show, that he was diagnosed with degenerative arthritis of the spine or any other "chronic" disease listed under 38 C.F.R. § 3.309 (a) during service or within one year of separation from service. Therefore, service connection is not warranted on a presumptive basis under the provisions of 38 C.F.R. §§ 3.303 (b), 3.307, and 3.309. In light of the above, the preponderance of the evidence is against the claims and the benefit-of-the-doubt doctrine is not for application. The claims therefore must be denied. 38 U.S.C. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," in all claims for increased ratings. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). 1. Diabetes The Veteran seeks a higher initial rating for his service-connected diabetes. The Veteran's service-connected diabetes is rated as 10 percent disabling from June 15, 2010 to July 20, 2011 and 20 percent disabling thereafter. The applicable rating period is from June 15, 2010, the effective date for the award of service connection through the present. See 38 C.F.R. § 3.400. Under Diagnostic Code 7913, diabetes mellitus which is manageable by restricted diet only is rated at 10 percent. Diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet, is rated at 20 percent. Diabetes mellitus requiring insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) is rated at 40 percent. Diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year, or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately rated, is rated at 60 percent. Diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately rated, is rated at 100 percent. "Regulation of activities" is defined in Diagnostic Code 7913 as "avoidance of strenuous occupational and recreational activities." Medical evidence is required to support the "regulation of activities" criterion. See Camacho v. Nicholson, 21 Vet. App. 360, 364 (2007); 38 C.F.R. § 4.119, Diagnostic Code 7913. The evidence shows that the Veteran's diabetes mellitus was not manifested by requiring one or more daily injection of insulin and restricted diet, or oral hypoglycemic agent and restricted diet prior to July 20, 2011. At the March 2017 Board hearing the Veteran's prior representative stated the Veteran should have been prescribed medication sooner because his diabetes was so poorly controlled with sugar off the charts prior to being prescribed Metformin in July 2011. However, a February 2011 VA treatment note reports the Veteran's diabetes is diet controlled at goal with A1C less than seven. On July 20, 2011 VA treatment note stated A1C was good at 6.5, but it was going up with diet, and the Veteran should implement diet changes the best that he can. The Veteran was prescribed to start Metformin. This shows the Veteran's diabetes mellitus required an oral hypoglycemic agent and restricted diet beginning July 20, 2011, thus, a disability rating in excess of 10 percent prior to July 20, 2011 is not warranted. The records reflect that the Veteran is treated for his diabetes with a prescribed oral hypoglycemic agent and restriction of diet; however, there is no indication that his treatment regimen includes regulation of activities. In his January 2018 and November 2020 VA examinations, the examiners indicated that the Veteran's activities were not restricted. In fact, several of the treatment records expressly encourage the Veteran to be more active. In a May 2021 VA treatment record, the Veteran is encouraged to engage in regular exercise. Thus, given that a restriction of activities is required for a disability rating in excess of 20 percent, the Veteran's claim must be denied. Since the Veteran is currently rated under Diagnostic Code 7913, any diabetic complications associated with his service-connected diabetes, to include diabetic neuropathy, are part and parcel of an increased rating claim for service-connected diabetes. See 38 C.F.R. § 4.119, Diagnostic Code 7913, Note (1). 2. Diabetic Peripheral Neuropathy Diseases of the peripheral nerves are evaluated under 38 C.F.R. § 4.124a of the Rating Schedule. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The words 'slight,' 'moderate,' 'moderately severe,' and 'severe,' as used in the various Diagnostic Codes, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are 'equitable and just.' 38 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. Bilateral Upper and Lower Extremities The Veteran's right and left upper extremity peripheral neuropathy of the median nerve is currently rated as 20 and 30 percent disabling, respectively, under Diagnostic Code 8515 of the Rating Schedule. See 38 C.F.R. § 4.124a. The Veteran's left and right lower extremity peripheral neuropathy are each currently rated as 20 percent disabling under Diagnostic Code 8520 of the Rating Schedule. Pursuant to Diagnostic Code 8515 (paralysis of the median nerve), a 10 percent rating is warranted for mild incomplete paralysis, bilaterally. 38 C.F.R. § 4.124a. Moderate incomplete paralysis is rated as 30 percent disabling for the major extremity and 20 percent disabling for the minor extremity. Severe incomplete paralysis is rated as 50 percent disabling for the major extremity and 40 percent disabling for the minor extremity. Complete paralysis is rated as 70 percent disabling for the major extremity and 60 percent disabling for the minor extremity. Pursuant to Diagnostic Code 8520 (paralysis of the sciatic nerve), a 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. A 20 percent rating is warranted for moderate incomplete paralysis of the sciatic nerve. A 40 percent rating is warranted for moderately severe incomplete paralysis of the sciatic nerve. A 60 percent rating is warranted for severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. An 80 percent rating is warranted for complete paralysis of the sciatic nerve, where the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. A November 2010 VA treatment note shows the Veteran was being treated with gabapentin for diabetic neuropathy. A November 2012 VA diabetic peripheral neuropathy examination diagnosed the Veteran with mild diabetic peripheral neuropathy of the bilateral upper and lower extremities. The Veteran reported paresthesias in bilateral legs for one year with random shooting pains. Veteran reported paresthesias in bilateral upper extremities for two year with stabbing pain. The Veteran's left hand is his dominant hand. The Veteran had severe intermittent pain and severe paresthesias and/or dysesthesias in the bilateral upper and lower extremities. Strength all normal except the right-hand grip and pinch which were less than normal. Light touch testing revealed decreased sensation in bilateral forearms, bilateral hands/fingers, bilateral ankle/lower leg, and bilateral foot and toes. The examiner noted that the Veteran has bilateral sensory diabetic peripheral neuropathy involving all four extremities. This is judged mild based on only sensory complaints and the specific nerves involved cannot be identified based on the distribution of sensory changes. The Veteran does have right hand weakness which based on today's evaluation is secondary to his cervical spine condition and not to a peripheral neuropathy. The Veteran underwent a VA diabetic peripheral neuropathy examination in November 2020. The Veteran had mild constant pain and mild paresthesias and/or dysesthesias of the bilateral lower extremities, mild constant pain and mild paresthesias and/or dysesthesias of right upper extremity, and moderate constant pain and moderate paresthesias and/or dysesthesias of left upper extremity. The Veteran had severe numbness in left upper extremity and moderate numbness in the remaining extremities. Strength testing was normal except the bilateral pinch which was less than normal strength. Deep tendon reflexes were all normal. Light touch testing all normal except being decreased in bilateral hand/fingers and the left foot/toes. Position sense, vibration sensation, and cold sensation were decreased in all extremities. No muscle atrophy or trophic changes noted. The examiner found mild incomplete paralysis of the right upper extremity and moderate incomplete paralysis of the left upper extremity of the radial, median, and ulnar nerves. The examiner found mild incomplete paralysis of the right lower extremity and moderate incomplete paralysis of the left lower extremity of the sciatic nerve. The examiner found mild incomplete paralysis of the right lower extremity and mild incomplete paralysis of the left lower extremity of the femoral nerve. The Veteran underwent a VA diabetic peripheral neuropathy examination in May 2021. The Veteran had mild constant pain of all extremities. Mild paresthesias and/or dysesthesias of all extremities. Mild numbness of all extremities. Strength testing was all normal. Deep tendon reflexes were all normal. Light touch testing all normal except being decreased in bilateral hand/fingers and the bilateral foot/toes. Position sense was normal. Vibration sensation decreased in all extremities. No muscle atrophy or trophic changes noted. The examiner found mild incomplete paralysis of the bilateral upper extremities of the radial nerve. The examiner found mild incomplete paralysis of the bilateral lower extremities of the sciatic nerve. Regarding the dominant left upper extremity, a disability rating in excess of 30 percent is not warranted as the evidence does not more nearly approximate severe incomplete paralysis of the median nerve. Similarly, for the non-dominant right upper extremity, a disability rating in excess of 20 percent is not warranted as the evidence does not more nearly approximate severe incomplete paralysis of the median nerve. Though pain, numbness, and dysesthesias and/or paresthesias were noted to be severe at times, testing has not revealed that any sensory facet was absent. Further, there is little evidence of trophic changes of the upper extremities. Moreover, and as noted above, motor functioning is not so impaired as to warrant a severe rating. Examination reports reveal that his ability to grip, and wrist flexion/extension exhibited normal strength. At worst, his pinch was less than normal strength. Additionally, examiners have found the bilateral upper extremities to exhibit mild incomplete paralysis, which is strong evidence the bilateral upper extremities do not nearly approximate severe incomplete paralysis. For these reasons, the Veteran's left upper extremity is more nearly approximated by a 30 percent disability rating and the right upper extremity is more nearly approximated by a 20 percent disability rating. A review of the record indicates that the Veteran's bilateral lower extremity peripheral neuropathy is manifested by moderate incomplete paralysis. Specifically, impairment due to incomplete paralysis of the sciatic nerve is primarily sensory in nature. A rating higher than 20 percent is not warranted as the Veteran's peripheral neuropathy is not more closely approximated by moderately severe incomplete paralysis. As noted above, the impairment of the sciatic nerve appears to be primarily sensory in nature. There is no indication of any muscular atrophy in examinations or treatment records. Further, there is little to no evidence of impaired motor functioning attributable to bilateral peripheral neuropathy of the sciatic nerve. Muscle strength testing was normal during the examinations. Additionally, testing revealed normal muscle strength with knee extension, knee flexion, ankle plantar flexion, and ankle dorsiflexion bilaterally. As such, a disability rating higher than 20 percent disabling is not warranted for either left or right lower extremity peripheral neuropathy. 3. Entitlement to effective date of June 15, 2010 for grant of service connection for bilateral upper and lower extremity neuropathy The assignment of effective dates of awards is generally governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award of compensation based on an original claim shall be fixed in accordance with facts found but shall not be earlier than the date of receipt of application therefor. See 38 U.S.C. § 5110 (a). The implementing VA regulation provides that the effective date of an award of compensation based on an original claim will be the date of receipt of the claim or the date entitlement arose, whichever is later. See 38 C.F.R. § 3.400 (a). The effective date for an award of service connection for a disability shall be the day following separation from active service or date entitlement arose if the claim was received within one year after separation from service; otherwise, the effective date shall be date of receipt of claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400 (b)(2)(i). In this case, the RO awarded the Veteran an effective date of June 15, 2010 (date of receipt of claim) for the Veteran's service connection for diabetes mellitus. A review of the Veteran's treatment records shows that the Veteran did have secondary bilateral peripheral neuropathy earlier than the currently awarded service connection date of July 13, 2011. A November 2010 VA treatment note shows the Veteran was being treated with gabapentin for diabetic neuropathy. Further the November 2012 VA diabetic peripheral neuropathy examination shows the Veteran reported paresthesias in bilateral legs for one year with random shooting pains, and the Veteran reported paresthesias in bilateral upper extremities for two year with stabbing pain. Resolving reasonable doubt in the Veteran's favor, entitlement to effective dates of June 15, 2010 for entitlement to service connection for the secondary peripheral neuropathy in the bilateral upper and lower extremities is granted. 38 C.F.R. § 3.400 (a). Special Monthly Compensation The Veteran is currently in receipt of SMC based on housebound criteria being met from July 13, 2011. Entitlement to statutory housebound benefits was granted because entitlement to individual unemployability based solely on the Veteran's service-connected posttraumatic stress disorder has been established and the Veteran has additional disabilities (diabetes mellitus and bilateral upper and lower extremity peripheral neuropathy) rated at 60 percent or more. As such the requirements for statutory housebound benefits are met. 38 C.F.R. § 3.350. As the effective date for service connection for the Veteran's bilateral upper and lower extremity was awarded herein from June 15, 2010, entitlement to statutory housebound benefits is granted effective June 15, 2010. REASONS FOR REMAND 1. Sleep apnea The Veteran seeks entitlement to service connection for sleep apnea. The Veteran was provided VA opinions as to his sleep apnea in January 2018, and January and July 2020. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The January and July 2020 VA examiners stated there is no relationship between PTSD and sleep apnea. The examiner's failed to provide a reasoned rationale explaining why there is no relationship between PTSD and sleep apnea, especially in light of the fact the Veteran's representative has submitted a number of articles suggesting an association between PTSD and sleep disorders, including sleep apnea. As the opinions are not adequate for decision-making purposes, the Veteran must be provided a new VA opinion to address whether the Veteran's sleep apnea is caused or aggravated by his service-connected PTSD Further, the Veteran's representative asserts that the Veteran has gained weight since he was diagnosed with PTSD. They argue that the Veteran entered service with a body mass index (BMI) of 21.7 but was discharged with a BMI of 24 after his psychiatric problems manifested in service. The Veteran continued to receive psychiatric treatment post-service and his BMI had increased to 30.5 by 2005. Also, the July 2020 VA examiner indicated the Veteran's sleep apnea was most likely due to his obesity, along with physiologic senescence, and inverted papilloma of the left maxillary. The Veteran's representative submitted articles on associations between PTSD and obesity, as well as articles on associations between obesity and sleep apnea. While obesity cannot be service-connected on a direct basis, and obesity cannot qualify as an in-service event for service connection purposes, obesity may serve as an "intermediate step" between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310 (a). In such a case, the evidence would need to reflect that (1) a service-connected disability or disabilities caused the Veteran to become obese, (2) the obesity was a substantial factor in causing another disability, and (3) the disability would not have occurred but for the obesity caused by the Veteran's service-connected disability or disabilities. 2. Bilateral Knee Disability In its December 2017 remand, the Board directed the AOJ to provide the Veteran a VA opinion to answer whether the Veteran's bilateral knee disability was at least as likely as not related to service. In rendering an opinion, the December 2017 remand stated the examiner should consider the Veteran's lay statements regarding bilateral symptomatology since service and any other pertinent evidence in the claims file, to include the March 1973 VA examination report of the knees showing, what appears to be, a diagnosis of clouding supra and retra patellar spur, moderate on right side, meniscal on left side as well as a March 1999 X-ray of the left knee showing an assessment of degenerative joint disease. While the January 2018 addendum opinion addressed the 1999 assessment of arthritis, the examiner failed to address the March 1973 VA examiner report of the knees showing, what appears to be, a diagnosis of clouding supra and retra patellar spur, moderate on right side, meniscal on left side. Accordingly, the January 2018 VA addendum opinion is inadequate for decision making purposes and does not substantially comply with the Board's December 2017 remand directives. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Board remand). On remand the VA examiner must provide an addendum opinion regarding the Veteran's bilateral knee disability which addresses all the relevant evidence of record. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the etiology of the Veteran's sleep apnea. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. The examiner should provide an opinion as to whether it is at least as likely as not that his sleep apnea is caused and/or aggravated by the Veteran's service-connected PTSD. The examiner should discuss the articles submitted by Veteran suggesting an association between PTSD and sleep apnea. The examiner should address whether the Veteran's service-connected PTSD caused the Veteran to become obese, to include medications taken for the disability; whether the obesity was a substantial factor in causing sleep apnea; and, whether sleep apnea would not have occurred but for the obesity caused by the Veteran's service-connected PTSD. 2. Obtain an addendum opinion regarding the etiology of the Veteran's bilateral knee disability. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. The examiner should address whether it is at least as likely as not that the Veteran's bilateral knee disability was incurred in or is otherwise related to service. The examiner should consider the Veteran's lay statements regarding bilateral symptomatology since service and any other pertinent evidence in the claims file, to include April 1971 service treatment record showing right knee giving out, the March 1973 VA examination report of the knees showing, what appears, to be a diagnosis of clouding supra and retra patellar spur, moderate on right side, meniscal on left side as well as a March 1999 X-ray of the left knee showing an assessment of degenerative joint disease. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. St. Laurent, 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.