Citation Nr: 21074657 Decision Date: 12/16/21 Archive Date: 12/15/21 DOCKET NO. 17-63 078 DATE: December 16, 2021 REMANDED Entitlement to service connection for sleep apnea, to include as due to asbestos exposure, or secondary to the Veteran's service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1962 to December 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claim in July 2019, March 2021, and July 2021, for further development. Unfortunately, another remand is required. 1. Entitlement to service connection for sleep apnea, to include as due to asbestos exposure, or secondary to the Veteran's service-connected disabilities, is remanded. The Veteran contends that his sleep apnea is related to asbestos exposure during service, or secondary to his service-connected disabilities. Service connection is in effect for restrictive lung disease, coronary artery disease (CAD), diabetes mellitus, type 2 (DM II), chronic obstructive pulmonary disease (COPD), and peripheral neuropathy. The Veteran is service connected for bilateral lower extremity peripheral neuropathy to include meralgia paresthetica. In a March 2017 VA examination report, the examiner referenced a study that meralgia paresthetica represents a symptom complex relating to the femoral cutaneous nerve, and as such is merely a manifestation of the diabetic neuropathy. The examiner noted that the most frequent associated conditions are obesity, diabetes mellitus, and older age. The mean body mass index of patients with meralgia was significantly greater than that of matched controls. The record reflects that the Veteran has been described as obese, and shows treatment for weight loss that includes exercise, which the Veteran has attempted. The Veteran maintains that he cannot exercise for long periods due to fatigue, stable angina, and shortness of breath which limits sitting, standing, and walking. The Veteran noted that an August 2021 VA examiner opined that the most common and recognized risk factor for obstructive sleep apnea is obesity. VAOPGCPREC 1-2017 concludes that obesity per se is not a disease or injury for purposes of 38 U.S.C. §§ 1110 and 1131 and therefore may not be service connected on a direct or secondary basis. VAOPGCPREC 1-2017, however, also recognizes that obesity may act 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). Additionally, in Walsh v. Wilkie, 32 Vet. App. 300 (2020), the Court held that aggravation must be addressed as well. Thus, the Board finds an addendum opinion is necessary that addresses the specific questions set forth in the General Counsel's opinion for determining if obesity is 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). The matter is REMANDED for the following action: 1. Obtain an addendum opinion for the Veteran's claimed sleep apnea. The claims file must be made available to and reviewed by the examiner. A note that such review was completed should be provided in the examiner's report. The examiner should offer comments and an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that: (a) the Veteran's sleep apnea is caused or aggravated (beyond a natural progression) by his service-connected restrictive lung disease, CAD, DM II, COPD, and peripheral neuropathy conditions. In so opining, please address the following: *Did the Veteran's restrictive lung disease, CAD, DM II, COPD, and peripheral neuropathy conditions cause the Veteran to become obese/gain weight or aggravated the Veteran's obesity/weight gain, to include as due to pain and functional impairment? The examiner should consider the March 2017 VA examination report's reference to a study on meralgia paresthetica. *If yes, was the obesity/weight gain because of the restrictive lung disease, CAD, DM II, COPD, and peripheral neuropathy conditions a substantial factor in causing sleep apnea? *Would the sleep apnea have not occurred but for the obesity/weight gain caused or aggravated by the restrictive lung disease, CAD, DM II, COPD, and peripheral neuropathy conditions? All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Edwin B. Esmenda, 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.