Citation Nr: 21007192 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 17-25 710 DATE: February 8, 2021 REMANDED Entitlement to service connection for a sleep disorder is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty for training in the United States Army Reserves and/or the Army National Guard between May 1982 and October 1999. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a March 2015 Department of Veterans Affairs (VA) rating decision. In October 2018, a videoconference hearing was held before the undersigned; a transcript is in the record. In January 2019, April 2020, and August 2020, the matter was remanded for additional development. The appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). The Board is aware this matter was remanded three times before (and regrets the delay in final adjudication inherent with yet another remand). However, the response to prior remands received did not adequately comply with instructions in the previous remand, and corrective action is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The April 2020 and August 2020 Board remands sought an addendum medical advisory opinion regarding the nature and etiology of the sleep disturbances that have been related to the Veteran’s service-connected shoulder disability. Notably, the providers were asked to opine whether the sleep disturbances constitute a separate disability (from either obstructive sleep apnea (OSA) or her service-connected shoulder disability) or are merely manifestations of either disability. In an October 2020 VA addendum medical opinion, a consulting physician assistant (other than the November 2019 or May 2020 examiners) addressed the etiology of OSA (in essence both indicating that based on anatomical features, an [orthopedic] shoulder disability would not contribute to cause or increase the severity of OSA). However, the examiner again did not respond to the request for clarification whether the sleep disturbances (which a November 2019 examiner found was secondary to a service-connected shoulder disability) constituted a (meaning any) disability entity separate from the shoulder disability (so as to warrant an award of secondary service connection) or are merely manifestations of the shoulder disability (such as pain), and thus not warranting a separate grant of service connection, but for consideration in rating the shoulder. In a November 2020 addendum opinion (requested by the Agency of Originating Jurisdiction because the October 2020 opinion failed address the Board’s remand instruction seeking clarification of the nature of the sleep disturbances), the provider stated that no change to her opinion was warranted and failed to address the nature of the sleep disturbances (provide the additional information sought). Considering the foregoing, the Board has no recourse but to remand the matter again to ensure there is compliance with its remand instructions. See Stegall, 22 Vet. App. at 271. The matters are REMANDED for the following: Arrange for the Veteran’s claims file to be forwarded to an appropriate (experienced in diagnosis/treatment of sleep problems/disorders) clinician (for review and an addendum medical advisory opinion regarding the nature and etiology of the sleep disturbances that have been related to her service-connected shoulder disability, other than OSA. [If examination of the Veteran is deemed necessary, such should be arranged).] [A repeat opinion addressing whether a shoulder disability caused or aggravated OSA is not needed, and not sought.] Upon review of the record, the consulting provider should: (a.) Regarding the sleep disturbances that have been opined to be due to the Veteran’s service-connected shoulder disability, indicate whether they constitute a separate (from the service-connected shoulder) disability entity or whether they are merely manifestations of the shoulder disability (considered in rating the shoulder disability). (b.) If the sleep disturbances are a separate disability entity, identify the disability entity by diagnosis (and discuss its nature and related impairment of function). Include complete rationale with all opinions, citing to clinical findings and medical principles supporting the conclusions. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Naumovich, 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.