Citation Nr: 21006408 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 18-14 315 DATE: February 4, 2021 ORDER The Motion to Vacate the Board of Veterans' Appeals (Board) May 2, 2019 decision on the issues of entitlement to service connection for obstructive sleep apnea and occipital neuralgia is granted. The Motion to Vacate the Board’s May 2, 2019 decision on the issues of entitlement to an increased rating in excess of 60 percent for restrictive airway disease and entitlement to service connection for an acquired psychiatric disorder is denied. Entitlement to an increased rating in excess of 60 percent for restrictive airway disease is denied. Entitlement to service connection for obstructive sleep apnea is granted. Entitlement to a total disability based on individual unemployability (TDIU) from June 16, 2017 is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for occipital neuralgia is remanded. FINDINGS OF FACT 1. On May 2, 2019, the Board issued a decision denying service connection for obstructive sleep apnea and occipital neuralgia and remanded the issues of entitlement to service connection for an acquired psychiatric disorder and an increased rating in excess of 60 percent for restrictive airway disease. 2. In August 2019, the Board received a Motion to Vacate from the Veteran’s representative disagreeing with the Board’s decision based on due process grounds, specifically arguing that the Board failed to afford the Veteran 90 days before issuing a decision as requested in March 2019 correspondence. 3. Throughout the duration of the appeal, the evidence shows the Veteran’s service-connected restrictive airway disease manifested with post-bronchodilator pulmonary function tests (PFT) with an FEV-1 (forced expiratory volume in one second) of 40 to 55 percent and/or and FEV-1/FVC (forced vital capacity) of 40 to 55 percent. 4. The Veteran’s obstructive sleep apnea is proximately due to his service-connected restrictive airway disease. 5. The evidence of record demonstrates that the Veteran’s service-connected restrictive airway disease rendered him unable to secure or follow a substantially gainful occupation from June 16, 2017. CONCLUSIONS OF LAW 1. The criteria for vacatur of the May 2, 2019 Board decision denying service connection for obstructive sleep apnea and occipital neuralgia have been met. 38 U.S.C. § 7104; 38 C.F.R. § 20.904 (a). 2. The criteria for vacatur of the May 2, 2019 Board decision remanding issues of an increased rating in excess of 60 percent for restrictive airway disease and service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. § 7104; 38 C.F.R. § 20.904 (a). 3. The criteria for entitlement to an increased rating in excess of 60 percent for restrictive airway disease have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.96, 4.97, Diagnostic Code 6602. 4. The criteria for entitlement to service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for entitlement to a TDIU from June 16, 2017 have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the Navy from July 1986 to February 1991. This matter comes before the Board on appeal from an August 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that in the May 2019 Board decision, the issues of entitlement to service connection for sleep apnea and occipital neuralgia, as well as the issue of whether new and material evidence was submitted for service connection for migraines, were denied. The issue of whether new and material evidence was submitted for an acquired psychiatric disorder was reopened. The issues of entitlement to service connection for an acquired psychiatric disorder and an increased rating in excess of 60 percent for restrictive airway disease were remanded. The Board directed the RO to obtain a VA examination to determine the nature and etiology of the Veteran’s current acquired psychiatric disorder and a contemporaneous VA examination for his service-connected restrictive airway disease. The Veteran was scheduled for and attended VA examinations in May 2019 and November 2019. Thus, the Board finds that the RO has substantially complied with the May 2019 Board remand directive. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Motion to Vacate The Board of Veterans’ Appeals may vacate an appellate decision at any time upon request of the appellant or his or her representative, or on the Board’s own motion, when an appellant has been denied due process of law or when benefits were allowed based on false or fraudulent evidence. 38 U.S.C. § 7104 (a); 38 C.F.R. § 20.904. In the present case, the Board denied the Veteran due process when a decision was entered prior to the expiration of the requested 90 days continuance. In March 2019, the Veteran, through his authorized representative, requested the Board to wait 90 days before issuing a decision as the Veteran intended to submit additional evidence. However, the Board issued a decision in May 2019 without giving the Veteran an opportunity to present additional evidence. Accordingly, the May 2019 Board decision addressing the issues of entitlement to service connection for obstructive sleep apnea and occipital neuralgia is vacated. This vacatur is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of the appeal. 38 C.F.R. § 20.1100 (b). Rather, in the present decision below, the Board will reconsider the Veteran’s claims for entitlement to service connection for obstructive sleep apnea and occipital neuralgia, as if the previous May 2019 Board decision had never been issued. See 38 C.F.R. § 20.904 (a). The Board finds that the issues of an increased rating for restrictive airway disease and service connection for an acquired psychiatric disorder are not entitled to a vacatur. In the May 2019 Board decision, these issues were remanded for further development and were not final decisions. 38 C.F.R. § 20.1100 (b). As these were not final decisions, the Board finds that the Veteran’s due process rights were not violated. Accordingly, vacatur of the issues of an increased rating for restrictive airway disease and service connection for an acquired psychiatric disorder is denied. However, the Board will continue with adjudication of these issues as the Board’s May 2019 remand directives were completed and returned to the Board. The Board also notes that the other issue in the May 2019 Board decision, the finding that new and material evidence was not received to reopen the claim of service connection for migraines, is undisturbed by the Board’s present actions. 2. Entitlement to an increased rating in excess of 60 percent for restrictive airway disease The Veteran contends that he is entitled to a higher rating for his service-connected restrictive airway disease. Disability ratings are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In rating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). 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 the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). A claim for increased rating remains in controversy when less than the maximum available benefit is awarded AB v. Brown, 6 Vet. App. 35 (1993). Reasonable doubt as to the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. The Veteran’s restrictive airway disease is currently rated as 60 percent disabling under Diagnostic Code 6602 for bronchial asthma. Diagnostic Code 6602 provides a 60 percent disability evaluation is warranted where PFTs show any of the following: FEV-1 of 40 to 55 percent predicted, FEV-1/FVC of 40 to 55 percent; or at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A 100 percent evaluation is warranted where PFTs show any of the following: FEV-1 less than 40 percent predicted, FEV-/FVC less than 40 percent; or more than one attack per week with episodes of respiratory failure, or where the use of systemic high dose corticosteroids or immunosuppressive medications are required on a daily basis. 38 C.F.R. § 4.97, Diagnostic Code 6602. The Board notes that when evaluating based on PFTs, post-bronchodilator results should be used in applying the evaluation criteria unless the post-bronchodilator results were poorer than the pre-bronchodilator results. 38 C.F.R. § 4.96 (d)(5). Additionally, when there is a disparity between the results of the different PFTs, the test result that the examiner states most accurately reflect the level of disability should be used. 38 C.F.R. § 34.96 (d)(6). The Board notes that the Veteran filed his claim for increased evaluation on August 29, 2013; the Board has considered the evidence of record since August 29, 2012 in conjunction with this decision. See 38 C.F.R. § 3.400 (o). The evidence relevant to the severity of the Veteran’s restrictive airway disease includes VA treatment records and VA examinations. The Veteran was afforded a VA examination in September 2012. The examiner found that the Veteran’s respiratory condition did not require the use of oral or parenteral corticosteroid medications. His condition did require the use of inhaled medications daily. The Veteran did not have any episodes of respiratory failure within the past 12 months although he experienced asthma attacks more than once per week. His PFT result for FEV-1 was 32 percent pre and 41 percent post and for FEV-1/FVC was 54 percent pre and 41 percent post. The examiner opined that the FEV-1/FVC test result most accurately reflected the Veteran’s pulmonary function. The Veteran was afforded another VA examination in April 2014. The examiner found that the Veteran’s respiratory condition did not require the use of oral or parenteral corticosteroid medications but did require the use of daily inhaled medications. His PFT result for FEV-1 was 17 percent pre and 41 percent post and FEV-1/FVC was 45 percent pre and 61 percent post. The examiner determined that the FVC test result most accurately reflected the Veteran’s pulmonary function; however, the Board notes that the FVC test is not used for rating purposes under Diagnostic Code 6602. The Veteran’s VA treatment records contain PFT results for May 2015, April 2016, and November 2018. His May 2015 results for FEV-1 was 34 percent pre and 41 percent post and FEV-1/FVC was 37 percent pre and 42 percent post. The PFT results for April 2016 and November 2018 only include one percentage without indication of whether the results are pre-bronchodilator or post-bronchodilator. Thus, the Board finds that the April 2016 and November 2018 PFT results are inadequate for rating purposes. 38 C.F.R. § 4.96 (d)(4) (notes that post-bronchodilator studies are required when PFTs are done for disability evaluation purposes). The Veteran was again afforded a VA examination in May 2019. The examiner found that the Veteran’s respiratory condition requires intermittent courses and bursts of oral and parenteral corticosteroids. The Veteran also uses daily inhaled medications. The Veteran had not had any asthma attacks with episodes of respiratory failure in the past 12 months. His PFT results for FEV-1 were 20 percent pre and 36 percent post. His FEV-1/FVC result was 57 percent pre and 62 percent post. The examiner determined that the FEV-1/FVC test result was the most accurate reflection of the Veteran’s pulmonary function. In November 2019, the Veteran again underwent a VA examination. The examiner found that the Veteran does not require oral or parenteral corticosteroid medications but does require daily inhaled medications. His PFT result for FEV-1 was 30 percent pre and 44 percent post; and 76 percent pre and 77 percent post for FEV-1/FVC. The examiner determined that the FVC test result most accurately reflected the Veteran’s pulmonary function; however, the Board notes that the FVC test is not used for rating purposes under Diagnostic Code 6602. The Veteran also provided a PFT report from February 2020. However, the report does not delineate between pre- and post-bronchodilator scores and does not indicate which test result more accurately reflects the Veteran’s pulmonary function. Thus, the Board finds that the report is not appropriate for rating purposes. The Board finds that based on the evidence of record, the Veteran’s asthma symptoms more nearly approximate the criteria for a 60 percent rating throughout the duration of the appeal. The Veteran’s post-bronchodilator results were between 40 to 55 percent. Additionally, the evidence shows that the Veteran did not require daily use of oral or parenteral high dose corticosteroids or immunosuppressive medications and did not have any asthma attacks with episodes of respiratory failure. The Board has considered the May 2019 VA examination where the Veteran’s FEV-1 post-bronchodilator result was 36 percent which would warrant a 100 percent rating. However, the examiner opined that the FEV-1/FVC result was the most accurate reflection of the Veteran’s pulmonary function. Therefore, the Board may not use the FEV-1 score when evaluating the severity of the Veteran’s restrictive airway disease. The Board has also considered the Veteran’s contentions that his restrictive airway disease is more severe than reflected in his current 60 percent rating. As a lay person, however, the Veteran has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Consequently, the Board gives more probative weight to the objective evidence of record. Throughout the duration of the appeal, the Veteran’s restrictive airway disease has more nearly approximated the rating criteria for a 60 percent rating. Accordingly, entitlement to an increased rating in excess of 60 percent for restrictive airway disease is denied. In reaching the above decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine does not apply. 38 C.F.R. § 4.3. 3. Entitlement to service connection for obstructive sleep apnea The Veteran contends that his obstructive sleep apnea is secondary to his service-connected restrictive airway disease. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current diagnosis of obstructive sleep apnea that is proximately due to or the result of or was aggravated beyond its natural progress by service-connected restrictive airway disease. The Veteran was diagnosed with obstructive sleep apnea in May 2009 after completing a sleep study with his local VA medical center. Thus, the Board finds that the Veteran has a current disability. In October 2019, the Veteran provided a private medical opinion completed by Dr. H.S. in May 2016. Dr. H.S. opined that it is at least as likely as not the Veteran developed sleep apnea as a direct result of his restrictive airway disease. His opinion was based on a review of the Veteran’s claims file, Social Security Administration records, and an interview with the Veteran. The rationale provided for the opinion was that the Veteran has decreased respiration that is rated as moderately severe to severe. Further, research supports that, similar to obstructive lung disease, a restrictive lung disorder interrupts the continuity of sleep and produces sleep-related mechanical restraint on ventilation. Dr. H.S. cited to and provided various medical articles supporting his opinion. The Board finds that the opinion is adequate and highly probative as it is based on an accurate medical history and provides an explanation that contains clear conclusions with supporting data. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board notes that the Veteran has not been provided with a VA examination as to whether or not his sleep apnea is proximately due to or aggravated by his service-connected restrictive airway disease. While further medical inquiry could be undertaken with a view towards further developing this claim, the Court of Appeals for Veterans’ Claims has cautioned VA against seeking an additional medical opinion where favorable evidence in the record is unrefuted (or, at worst, evenly balanced for and against the claim) and indicated that it would not be permissible to undertake further development in this circumstance if the sole purpose was to obtain evidence against an appellant’s claim. Mariano v. Principi, 17 Vet. App. 305, 312 (2003). The Board concludes that the preponderance of evidence of record is in favor of finding that the Veteran’s obstructive sleep apnea is proximately due to or the result of his service-connected restrictive airway disease. The only medical opinion of record is the May 2016 opinion provided by Dr. H.S. finding that the Veteran’s sleep apnea is at least as likely not directly related to his service-connected restrictive airway disease. Accordingly, entitlement to service connection for obstructive sleep apnea as secondary to service-connected restrictive airway disease is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to a TDIU The Veteran contends that his restrictive airway disease prevents him from engaging in substantially gainful employment. See Brief in Support of Veteran’s Claims dated October 2019. The Board notes that a claim for a TDIU is part of an increased rating claim when such a claim is raised by the record. See Rice v. Shinseki, App. 447 (2009). Here, in the October 2019 Brief in Support of Veteran’s Claims, the Veteran directly raised that his service-connected restrictive airway disease interferes with his ability to maintain employment. As the record now raises a question of whether the Veteran is unemployable due to his service-connected restrictive airway disease, a claim for a TDIU is properly before the Board. A total disability rating may be assigned when the schedular rating is less than 100 percent where a Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, that disability is rated 60 percent or more, or if there are two or more disabilities, there shall be at least one disability rated 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16. In determining whether a Veteran is unemployable for VA purposes, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Hersey v. Derwinski, 2 Vet. App. 91 (1992); Faust v. West, 13 Vet. App. 342 (2000). A Veteran need not show 100 percent unemployability in order to be entitled to a TDIU. Robertson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). Additionally, in a precedential decision issued by the United States Court of Appeals for Veterans Claims (Court), they offered guidance in defining “unable to secure and follow a substantially gainful occupation.” In Ray v. Wilkie, 31 Vet. App. 58 (2019), the Court found that 38 C.F.R. § 4.16 (b) has two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of the following: the Veteran’s history, education, skill, and training; whether the Veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the Veteran has the mental ability to perform the activities required by the occupation at issue. The Veteran has established service connection for restrictive airway disease rated as 60 percent disabling and venereal warts and status post tonsillectomy each rated as noncompensable. The Veteran’s combined rating for compensation purposes is 60 percent. 38 C.F.R. §§ 4.25, 4.26. Therefore, the Veteran meets the schedular rating criteria for a TDIU. 38 C.F.R. § 4.16 (a). The remaining inquiry is whether he was unable to secure or follow substantially gainful occupation due solely to service-connected disabilities. The evidence of record shows that the Veteran has a high school diploma and post-secondary certification in industrial maintenance. His longest tenure of employment was as an assistant plant manager with a foods company from May 1994 to September 2011. He also worked part-time in the security field from March 2013 to March 2017 according to his October 2019 Application for Increased Compensation Based on Unemployability. In an August 2020 Request for Employment Information from the Veteran’s most recent employer, indicated that the Veteran’s last date of employment was June 15, 2017 after he resigned. In a January 2019 statement by Dr. H.S., provided by the Veteran in July 2020, Dr. H.S. opined that the Veteran’s restrictive airway disease interferes with his ability to work substantially gainful employment. The doctor determined that the Veteran is not able to walk or exert himself and he can get out of breath just sitting down as well. In a May 2019 VA examination for restrictive airway disease, the VA examiner opined that the Veteran’s disability impacts his ability to work as the Veteran has difficulty walking longer than 200 feet or climbing stairs due to being short of breath. In a July 2020 statement, the Veteran contended that his restrictive airway disease affects his ability to work and help around the house. The Veteran contends that while working at the food company, he worked around fumes and chemicals that irritated his lungs and breathing. He decided to leave the job in 2011 because he was not able to perform at his best due to the problems with his breathing. He subsequently went into security which involved a lot of walking and lifting, but he was unable to walk long distances due to shortness of breath. The Veteran decided to stop working in security in 2017 due to the difficulties with his breathing. The Board also notes that the Veteran is in receipt of Social Security Disability effective September 8, 2011 for migraines and affective/mood disorders. The July 2014 Social Security Administration decision also noted restrictive airway disease as a severe impairment. However, the Board is not bound by Social Security decisions. Based on the foregoing, the Board finds that the totality of the evidence supports a finding that the Veteran’s service-connected restrictive airway disease renders him unemployable. Specifically, the evidence suggests that the Veteran last worked in security on June 15, 2017. In his July 2020 statement, the Veteran stated that he resigned from employment due to difficulty with shortness of breath and he was unable to walk long distances or lift items as necessary for his job. Prior to working in the security field, the Veteran worked as an assistant plant manager but had to resign due to difficulty breathing around the chemicals. The Board finds that the Veteran’s restrictive airway disease prevents him from physically performing the tasks necessary to engage in further employment in security or as a plant manager. The Board also finds that the Veteran’s limited training and skills prevent him from working in another field that would not result in breathing difficulties due to his restrictive airway disease. Furthermore, both Dr. H.S. and the May 2019 VA examiner opined that the Veteran’s restrictive airway disease impacts his ability to work due to shortness of breath. Therefore, the Board finds that the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected restrictive airway disease. Accordingly, entitlement to a TDIU from June 16, 2017 is granted. 38 U.S.C. § 1155; 38 C.F.R. § 4.16. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA’s duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to decide on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); Duenas v. Principi, 18 Vet. App. 512 (2004); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 1. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Veteran contends that his diagnosis of major depressive disorder is related to his active service. The Board notes that the Veteran was afforded a VA examination in May 2019. The examiner determined that the Veteran was diagnosed with both borderline personality disorder and unspecified depressive disorder. She opined that the claimed condition was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The rationale provided was that the Veteran was diagnosed with a personality disorder in the service. The examiner noted that personality disorders include pattern of instability of mood, depression, anxiety, problems with self-image, unstable relationships, fear of abandonment, history of self-mutilation or suicide attempts, and feelings of emptiness; and their difficulty in relationships and the consequences leads them to depression. The Board finds that the opinion lacks clarity and an addendum opinion is needed that more clearly and thoroughly addresses the nature and etiology of the Veteran’s major depressive disorder. The Board notes that the Veteran was diagnosed with a personality disorder in service and subsequently discharged due to this diagnosis. Pursuant to 38 C.F.R. § 3.303 (c), personality disorders are not designated as a disability for which service connection can be granted. However, disabilities resulting from a mental disorder that is “superimposed” upon a personality disorder may be service connected. 38 C.F.R. § 4.127. Therefore, the Board finds that an addendum VA medical opinion is necessary to determine whether the Veteran’s current diagnosis of major depressive disorder is “superimposed” upon his in-service diagnosis of a personality disorder. 2. Entitlement to service connection for occipital neuralgia is remanded. The Veteran contends that his diagnosis of occipital neuralgia is secondary to his service-connected restrictive airway disease and/or his now service-connected obstructive sleep apnea. See October 2019 Brief in Support of Veteran’s Claims. The Veteran’s VA treatment records indicate that the Veteran was diagnosed with occipital neuralgia in September 2012. The Veteran reported having persistent headaches since August 2010 and his doctor determined that he had a diagnosis of occipital neuralgia. However, the Board cannot make a fully-informed decision on the issue because no VA examiner has opined whether the Veteran’s occipital neuralgia is at least as likely as not proximately due to or aggravated beyond its natural progression by either his service-connected restrictive airway disease or obstructive sleep apnea. Accordingly, a remand is necessary for a VA examination. The matters are REMANDED for the following actions: 1. Obtain an addendum medical opinion from the appropriate clinician for the Veteran’s claimed major depressive disorder. The examiner must review the claims file. The examiner is asked to offer an opinion as to whether it is at least as likely as not that the Veteran’s diagnosis of major depressive disorder is “superimposed” upon his in-service diagnosis of mixed personality disorder with borderline and dependent features manifested by affective instability and self-damaging behavior. Any opinion expressed should be accompanied by a complete rationale. 2. Schedule the Veteran for a VA examination with an appropriate clinician regarding the nature and etiology of the Veteran’s diagnosis of occipital neuralgia. The examiner must review the claims file. The examiner is asked to opine as to whether the Veteran’s occipital neuralgia is at least as likely as not (1) proximately due to his service-connected restrictive airway disease and/or obstructive sleep apnea; or, (2) aggravated beyond its natural progression by his service-connected restrictive airway disease and/or obstructive sleep apnea.   Any opinion expressed should be accompanied by a complete rationale. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Hartford, 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.