Citation Nr: 21076232 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 18-51 482 DATE: December 22, 2021 ORDER The issue of entitlement to service connection for bilateral dry eye syndrome is granted. REMANDED The issue of entitlement to service connection for a deviated septum is remanded. FINDING OF FACT The Veteran's bilateral dry eye syndrome is aggravated by treatment for his service-connected obstructive sleep apnea. CONCLUSION OF LAW The criteria for service connection for bilateral dry eye syndrome are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran Served on active duty in the United States Air Force from August 2001 to September 2008. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2017 and March 2018 rating decisions by a Department of Veterans Affairs (VA) regional office. In furtherance of the issues on appeal, there was a February 2021 Board hearing before the undersigned Veterans Law Judge, and the transcript is of record. The matters were previously before the Board in May 2021 at which time they were remanded for further development. Now, the Board finds the Veteran entitled to service connection for his bilateral dry eye syndrome. Generally, to establish service connection, a showing of competent medical, or in certain circumstances, lay evidence must confirm (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 116667 (Fed. Cir 2004). Service connection may also be granted where a disability is proximately due to or aggravated by an already service-connected disability. 38 C.F.R. § 3.310. To establish secondary service connection for a disability there must be (1) a current disability (for which secondary service connection is sought); (2) an existing service-connected disability; and (3) evidence that the current disability for which service connection is sought was either (a) caused or (b) aggravated by the service-connected disability. 38 C.F.R. § 3.310. See Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). In this case, the Veteran has been recently diagnosed with bilateral dry eye syndrome and is service connected for obstructive sleep apnea (OSA). See 3/7/2018 C&P Examination (diagnosing dry eye syndrome); Rating Decision (granting service connection for obstructive sleep apnea). Moreover, two VA examinations have associated the Veteran's dry eye syndrome to his use of a continuous positive airway pressure (CPAP) machine to treat his OSA. While the March 2018 VA examiner opined that the Veteran's use of a CPAP machine for OSA most likely contributed to his dry eye syndrome, the Veteran was not service connected for OSA at that time, and the opinion was ultimately found inadequate for failure to consider all of the evidence of record. See 3/7/2018 C&P Examination; 5/18/2021 Remand BVA. Nonetheless, the August 2021 examiner also opined that the Veteran's bilateral dry eye syndrome was aggravated by CPAP use because "aggravation of dry eye is a documented and known complication." See 8/16/2021 C&P Examination. The Board finds that opinion adequate. Accordingly, service connection for bilateral dry eye syndrome, secondary to service connected OSA, is granted. The Board notes that the August 2021 examiner provided two other, ultimately inadequate, VA opinions, opining that the Veteran's bilateral dry eye syndrome was not directly related to his active-duty service, nor was it related to his service-connected dyspepsia. However, out of respect for the Veteran's time, in the interest of judicial economy, and because this opinion ultimately awards the Veteran service connection (so he is not prejudiced), the Board has decided not to remand for updated VA opinions related to this issue. In addition, the Board acknowledges a November 18, 2021 correspondence in which the Veteran's representative contended that neither Dr. J.S., who authored the optometry examination opinion, nor Nurse Practitioner S.S., who authored the deviated septum examination opinion, were qualified to provide opinions because the physicians were not listed in VA's Office of Disability and Medical Assessment (DMA). According to the Veteran's representative, VHA Directive 1603 requires completion of certain training courses for certification to conduct C&P examinations, and upon completion the examiner is listed under the DMA Clinician Lookup tool. When medical examiner competency is challenged, the Board must make a factual finding as to whether the medical examiner is competent and provide reasons and bases explaining that decision. Francway v. Wilkie, 940 F.3d 1304, 1307-08 (Fed. Cir. 2019). Despite the Veteran's representative's contentions, the Board finds that both Dr. J.S. and Nurse Practitioner S.S. are competent to provide opinions in this case. First, VHA Directive 1603 does not have the force of law. Second, while the DMA's database lists examiners who provide compensation and pension examinations and have presumably completed the required training to provide such examinations, not being listed does not inherently mean that the provider is incompetent to provide an opinion. To be competent to provide an opinion, an individual must simply have sufficient knowledge, training, or expertise to provide such an opinion. Jandreau v. Nicholson, 492 F.3d. 1372, 1377 n.4 (Fed. Cir. 2007). A review of the record shows that both Dr. J.S. and Nurse Practitioner S.S are competent to provide an etiology opinion in this case. Dr. J.S. is an optometrist licensed in New York and Tennessee and was so at the time of the opinion in question, and Nurse Practitioner S.S. is a general practice nurse practitioner licensed in Indiana and was so at the time of the opinion. The Board views the examiners' credentials as a proxy for their knowledge, training, and expertise, and finds them competent to provide etiology opinions despite not being listed in the DMA database. REASONS FOR REMAND Nonetheless, the Board finds the opinion regarding the Veteran's deviated septum inadequate for adjudicative purposes. All medical examinations ordered by the VA must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007. A medical opinion is adequate "where it is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Additionally, a thorough and adequate examination must consider all other relevant evidence of record, including lay statements. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). An adequate medical opinion does not contain only data and conclusions, "but also a reasoned medical explanation connecting the two." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Ultimately, if an examination report does not contain sufficient detail, "it is incumbent upon the rating board to return the report as inadequate for evaluation purposes." 38 C.F.R. § 4.2; see Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return inadequate examination reports); Hicks v. Brown, 8 Vet. App. 417, 421 (1995) (inadequate medical evaluation frustrates judicial review). In the single VA examination conducted in furtherance of the Veteran's claim for entitlement to service connection for a deviated septum, the examiner noted that the Veteran denied a history of trauma to the nose and had problems with frequent nosebleeds prior to service. See 9/3/20021 C&P Examination. The examiner also noted that people with deviated septum tend to experience frequent nosebleeds because the irregularity of the nostril size tends to dry out one side of the nose. Id. However, the examiner did not explicitly connect the Veteran's nosebleeds to his deviated septum, nor did she explain whether nosebleeds prior to service were indicative of congenital, as opposed to traumatic, origins. Additionally, the examiner did not discuss the June 2008 medical report that established a diagnosis of acquired deviated septum or whether acquired is synonymous with trauma induced and required by the Remand directives. Thus, the Board finds that those directives were not substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, remand for an addendum opinion is warranted. The matter is REMANDED for the following action: Return the claims file to the VA examiner who conducted the September 3, 2021 C&P Examination, if available. If that examiner is not available, send the claims file to another appropriate examiner. If, and only if, the examiner determines that an examination should be conducted to determine whether the Veteran's deviated septum is congenital or trauma induced, one should be scheduled. Thereafter, the examiner should address the following: Is it at least as likely as not (50 percent probability or greater) that the Veteran's deviated septum had its onset during the Veteran's active service or is otherwise related to active service? In addressing this question, please discuss (1) the June 2008 medical report establishing acquired deviated septum, and (2) whether acquired is synonymous with trauma induced. Please also address whether the Veteran's recurrent pre-service nosebleeds are indicative of a congenital deviated septum. A complete rationale for the examiner's opinions should be provided, citing to specific evidence of record, as necessary. Citation to relevant peer reviewed medical literature reviewed in rendering the opinion would be of considerable assistance to the Board. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Z. Sloley, 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.