Citation Nr: 21073948 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 17-50 080A DATE: December 13, 2021 REMANDED Entitlement to a compensable rating for bilateral hearing loss is remanded. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. Entitlement to service connection for degenerative arthritis of the left knee is remanded. Entitlement to service connection for degenerative arthritis of the right knee is remanded. Entitlement to service connection for degenerative arthritis of the lumbosacral spine is remanded. Entitlement to service connection for degenerative arthritis of the cervical spine is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1966 to April 1969. The Board thanks the Veteran for his service. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2015 rating decision. In March 2021, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge. The Veteran waived consideration by a Department of Veterans Affairs (VA) Regional Office (RO) for any additionally received evidence. A transcript of the hearing is associated with the claims file. Of note, the Veteran had previously had a hearing with another Veterans Law Judge in October 2019, but a transcript was unable to be produced due to technical difficulties. In December 2020, the Veteran opted to have a new virtual hearing. He was informed that, because the prior transcript was unable to be produced, a decision would be issued solely by the undersigned Veterans Law Judge, to which the Veteran agreed. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c). In May 2021, the Veteran submitted a VA medical record dated December 1998, which noted that the Veteran was seeking treatment "for entry into the VA system." However, the medical record also noted that the Veteran has a "sleep study with VA '96". The oldest CAPRI record associated with the file (other than the December 1998 record submitted by the Veteran) is dated November 1999. Thus, it appears there may be an outstanding VA sleep study and efforts should be made to associate it with the claims file. Further, the record noted prior treatment at "LLUMC" (during the hearing the Veteran indicated he was seen at "Loma Linda") but there was a provider change due to insurance reasons. Additionally, the Veteran submitted a nexus statement in May 2021, in which he explained why he believes his OSA and degenerative arthritis of the bilateral knees, lumbar spine, and cervical spine are due to a combination of excess joint wear in service and weight gain caused by his service-connected posttraumatic stress disorder (PTSD). The record shows that the Veteran is a medical doctor, and thus he is competent to provide a medical opinion in this case. However, the statement submitted by the Veteran does not adequately address the standard required for obesity to serve as an intermediate step to establish entitlement to service connection. Therefore, although the opinion invokes VA's duty to assist by obtaining an adequate medical opinion, it is inadequate to grant service connection on its own. Other individual bases for remand are discussed for each issue separately below. 1. Entitlement to a compensable rating for bilateral hearing loss The Veteran's most recent VA hearing examination was conducted in September 2017. The Veteran reported in his March 2021 Board hearing that the severity of his bilateral hearing loss had worsened since 2017. VA treatment records from February and April 2020 show that the Veteran was newly issued hearing aids for his hearing loss based on complaints of worsening hearing loss and new audiometric testing. However, the VA treatment records do not include the numeric Puretone threshold results, and the speech discrimination test scores were based on a word list other than the Maryland CNC, which is required for rating purposes. Thus, remand is required to obtain a new VA examination to evaluate the Veteran's current hearing loss. 2. Entitlement to service connection for OSA The Board cannot make a fully-informed decision on the issue of entitlement to service connection for OSA because no VA examiner has opined whether it is at least as likely as not that the Veteran's OSA was caused or aggravated by his service-connected PTSD; or, whether the Veteran's service-connected PTSD at least as likely as not caused his former obesity, whether the obesity was a substantial factor in causing OSA, and whether the OSA would not have occurred but for the obesity caused or aggravated by PTSD. 3. Entitlement to service connection for degenerative arthritis of the left knee 4. Entitlement to service connection for degenerative arthritis of the right knee In a September 2017 VA examination, the Veteran reported that his bilateral knee pain began during medical school in 1971 and has worsened over the years. A negative etiology opinion was provided, which reasoned that the diagnosed knee disabilities were less likely than not related to service because there was no documented injury in service and his knees were normal at discharge. In May 2021 the Veteran reported that his work as a tanker, platoon leader, and troop commander caused injury due to overuse or trauma as well as obesity due to PTSD. However, the Board cannot make a fully informed decision in this case because no VA examiner has addressed the Veteran's contention that his bilateral knee disability was caused by a mixture of excess wear in service (related to his duties as an armor crewman) and the strain caused by his post-service weight gain secondary to service-connected PTSD. 5. Entitlement to service connection for degenerative arthritis of the lumbosacral spine In a September 2017 VA examination, the Veteran reported that his low back symptoms began in 1968 while serving in Germany due to the heaving ammunition he had to lift as part of his duties. The VA examiner provided a negative etiology opinion, which did not consider the Veteran's report that his pain began in service and worsened following service. Rather, the examiner opined that it was less likely than not that the Veteran's degenerative arthritis was due to service because there was no documentation of injury in service, and his discharge exam was normal. A remand is necessary to obtain an addendum opinion that adequately addresses the Veteran's contention that he began experiencing low back pain in service due to his duties, and that his low back arthritis was caused a mixture of excess wear in service and the strain caused by his post-service weight gain secondary to service-connected PTSD. 6. Entitlement to service connection for degenerative arthritis of the cervical spine In a September 2017 VA examination, the Veteran reported that neck pain began in service when he fell off a tank in 1969. The VA examiner provided a negative etiology opinion, which did not consider the Veteran's report that his pain began in service and worsened following service. Rather, the examiner opined that it was less likely than not that the Veteran's degenerative arthritis was due to service because there was no documentation of injury in service, and his discharge exam was normal. A remand is necessary to obtain an addendum opinion that adequately addresses the Veteran's contention that he began experiencing neck pain in service due to an injury, and that his cervical spine arthritis was caused a mixture of excess wear in service and the strain caused by his post-service weight gain secondary to service-connected PTSD. The matters are REMANDED for the following action: 1. Attempt to associate with the record all outstanding VA treatment records, to include a sleep study in 1996. 2. Request the Veteran provide any outstanding records of treatment (or provide an authorization for VA to attempt to obtain them) for the claimed disabilities since service, including treatment from "LLUMC", "Loma Linda", or "Loma Linda University" from 1990 to 2015. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral hearing loss. 4. Schedule the Veteran for a VA examination for his diagnosed obstructive sleep apnea (OSA). Based on examination and review of the entire record, the clinician should provide an opinion that responds to the following: (a.) Is the Veteran's OSA at least as likely as not (a 50 percent or greater probability) related to service, to include the Veteran's reports of being told he snored in service. (b.) Is the Veteran's OSA at least as likely as not (a 50 percent or greater probability) caused or aggravated (any increase in disability) by service-connected PTSD? (c.) Was the Veteran's obesity (prior to gastric bypass surgeries in 2001 and 2006) at least as likely as not (a 50 percent or greater probability) caused or aggravated by service-connected PTSD? The Veteran, a medical doctor, has stated his PTSD caused his obesity in a May 2021 opinion. (d.) If the answer to (c) above is yes, was the Veteran's obesity at least as likely as not (a 50 percent or greater probability) a substantial factor in causing his OSA? (e.) If the answer to (c) and (d) above is yes, is it at least as likely as not (a 50 percent or greater probability) that the OSA would not have occurred but for obesity caused or aggravated by PTSD? Provide a rationale to support the opinion. 5. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's bilateral knee arthritis. The examiner must review the claims file. Based upon review of the entire record, the clinician should provide an opinion that responds to the following: (a.) Is the Veteran's bilateral knee arthritis at least as likely as not (a 50 percent or greater probability) related to service, to include injuries due to overuse or trauma, moving in awkward positions while working, climbing in a bent or twisted position? Please address the May 2021 medical opinion and supporting documentation prepared by the Veteran, a medical doctor, indicating "multiple foci were created for osteoarthritis performing the duties described above." (b.) Was the Veteran's obesity (prior to gastric bypass surgeries in 2001 and 2006) at least as likely as not (a 50 percent or greater probability) caused or aggravated by service-connected PTSD? (c.) If the answer to (b) above is yes, was the Veteran's obesity at least as likely as not (a 50 percent or greater probability) a substantial factor in causing his bilateral knee arthritis? (d.) If the answer to (b) and (c) above is yes, is it at least as likely as not (a 50 percent or greater probability) that the bilateral knee arthritis would not have occurred but for obesity caused or aggravated by PTSD? Provide a rationale to support the opinion. 6. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's degenerative arthritis of the lumbar spine. The examiner must review the claims file, to include the Veteran's May 2021 medical opinion and supporting documentation. The examiner should note that the Veteran is a doctor and is competent to provide a medical opinion. Based upon review of the entire record, the clinician should provide an opinion that responds to the following: a. Is the Veteran's lumbar spine arthritis at least as likely as not (a 50 percent or greater probability) related to service, to include injuries due to overuse or trauma, moving in awkward positions while working, climbing in a bent or twisted position? Please address the May 2021 medical opinion and supporting documentation prepared by the Veteran, a medical doctor, indicating "multiple foci were created for osteoarthritis performing the duties described above." b. Was the Veteran's obesity (prior to gastric bypass surgeries in 2001 and 2006) at least as likely as not (a 50 percent or greater probability) caused or aggravated by service-connected PTSD? c. If the answer to (b) above is yes, was the Veteran's obesity at least as likely as not (a 50 percent or greater probability) a substantial factor in causing his lumbar spine arthritis? d. If the answer to (b) and (c) above is yes, is it at least as likely as not (a 50 percent or greater probability) that the lumbar spine arthritis would not have occurred but for obesity caused or aggravated by PTSD? Provide a rationale to support the opinion. 7. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's degenerative arthritis of the cervical spine. The examiner must review the claims file, to include the Veteran's May 2021 medical opinion and supporting documentation. The examiner should note that the Veteran is a doctor and is competent to provide a medical opinion. Based upon review of the entire record, the clinician should provide an opinion that responds to the following: a. Is the Veteran's cervical spine arthritis at least as likely as not (a 50 percent or greater probability) related to service, to include injuries due to overuse or trauma, moving in awkward positions while working, climbing in a bent or twisted position, and/or a slip and fall while climbing into a tank? Please address the May 2021 medical opinion and supporting documentation prepared by the Veteran, a medical doctor, indicating "multiple foci were created for osteoarthritis performing the duties described above." b. Was the Veteran's obesity (prior to gastric bypass surgeries in 2001 and 2006) at least as likely as not (a 50 percent or greater probability) caused or aggravated by service-connected PTSD? c. If the answer to (b) above is yes, was the Veteran's obesity at least as likely as not (a 50 percent or greater probability) a substantial factor in causing his cervical spine arthritis? d. If the answer to (b) and (c) above is yes, is it at least as likely as not (a 50 percent or greater probability) that the cervical spine arthritis would not have occurred but for obesity caused or aggravated by PTSD? Provide a rationale to support the opinion. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Beeler, C. 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.