Citation Nr: 21007495 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 16-51 527 DATE: February 9, 2021 ORDER A rating in excess of 50 percent prior to March 20, 2020, for posttraumatic stress disorder (PTSD) is denied. A rating in excess of 70 percent from March 20, 2020, for PTSD is denied. REMANDED Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. FINDINGS OF FACT 1. Prior to March 20, 2020, the evidence does not more nearly reflect occupational and social impairment with deficiencies in most areas due to the severity, frequency, and duration of psychiatric symptoms 2. From March 20, 2020, the evidence does not more nearly reflect total occupational and social impairment due to psychiatric symptoms. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 50 percent prior to March 20, 2020, for PTSD are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 2. The criteria for an evaluation in excess of 70 percent from March 20, 2020, for PTSD are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1983 to February 2006. This appeal comes to the Board of Veterans Appeals (Board) from a May 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In November 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. In February 2020, the Board remanded the claims for further development. As to the PTSD claim, there has been substantial compliance with the Board’s prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). During remand status, a November 2020 rating decision granted service connection for residuals of kidney stones (claimed as right flank pain). As the RO granted in full the benefit sought by the Veteran in this matter, there is no remaining allegation of error of fact or law for appellate consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (noting that a grant of service connection extinguishes appeals before the Board). The RO sent to the Veteran a November 2020 supplemental statement of the case that addressed the above remaining issues on appeal. Also, during remand status, a November 2020 rating decision granted a 70 percent rating for PTSD from March 20, 2020 (date of VA examination). As the award does not represent a full grant of the benefit sought on appeal, the claim remains in appeal status. See AB v. Brown, 6 Vet. App. 35 (1993). This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.800(c). 38U.S.C. §7107(b). Evaluations Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 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 military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. A disability may require re-evaluation in accordance with changes in a veteran’s condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. 1. Entitlement to a rating in excess of 50 percent prior to March 20, 2020, for PTSD. 2. Entitlement to a rating in excess of 70 percent from March 20, 2020, for PTSD. A March 2006 rating decision granted the Veteran’s claim for service connection for PTSD and assigned a 10 percent rating effective from March 1, 2006, under 38 C.F.R. § 4.130, Diagnostic Code 9411. A December 2012 rating decision granted a 30 percent disability rating from November 18, 2011. A May 2015 rating decision granted a 50 percent rating from February 19, 2014. This appeal arises from the Veteran’s disagreement with that evaluation. See NOD (July 2015); Form 9 (October 2016). As noted above, a November 2020 rating decision granted a 70 percent rating for PTSD from March 20, 2020. Issues 1-2. The Veteran contends that a higher rating for PTSD is warranted, noting that his symptoms are worse than rated. See generally Hearing Transcript (November 2019). The question for the Board is whether the severity, frequency, and duration of psychiatric symptoms more nearly reflect occupational and social impairment with deficiencies in most areas prior to March 20, 2020, and total occupational and social impairment therefrom. The Board concludes that the preponderance of the evidence is against the claim for increase. During the appeal, the evidence reflects that PTSD was not more nearly manifested by occupational and social impairment with deficiencies in most areas prior to March 20, 2020, and total occupational and social impairment therefrom, due to the severity, frequency, and duration of psychiatric symptoms. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). During the appeal period, the Veteran’s mental disorder has been rated at 50 percent prior to March 20, 2020, and at 70 percent therefrom, under Diagnostic Code 9411. A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. Period Prior to March 20, 2020: Prior to March 20, 2020, the evidence does not more nearly reflect occupational and social impairment with deficiencies in most areas due to the severity, frequency, and duration of psychiatric symptoms. See 38 C.F.R. § 4.130, Diagnostic Code 9411. VA and private treatment records, the March 2015 VA examination, and the Veteran’s lay statements show that the Veteran’s PTSD was manifested by symptoms associated with a 50 or lower percent rating (e.g., depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, and disturbances of motivation and mood ), and symptoms associated with a 70 percent rating (e.g., near-continuous panic or depression affecting the ability to function independently, appropriately and effectively). He also had symptoms that are not listed with a specific rating, such as isolation, decreased concentration, and feelings of guilt and worthlessness. The record reflects that in 2019, the Veteran underwent group therapy sessions for anxiety and depressive symptoms; additionally, the record shows that the Veteran started group anger management treatment. The treatment notes do not show that the Veteran had hallucinations, delusions, or thought disturbance. Indeed, they show, overall, that the Veteran had a euthymic mood, with a congruent affect. His thoughts were coherent and goal oriented and, although, he shared minimally, he appeared to listen intently. At a September 2019 anger management treatment session, the Veteran expressed a need to develop self-control; he also reported attending a prior anger management class, in which, he was not open to change, however, during the current session, he “reported that he was open to change and his motivation level is high.” Prior treatment records, overall, show that the Veteran denied anxiety, depression, sleep disturbances, emotional concerns, mood swings, and changes in sleep patterns. See, e.g., Medical Treatment Record-Government Facility (June 2017) & Medical Treatment Record-Government Facility (January 2018). A March 2015 VA examination report reflects symptoms of depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. At the examination, the Veteran reported being married for 27 years; being a contract administrator since 2007; arguments with his spouse due to anger problems; and that he did not go to places where there would be a large group of people, such as the mall or outdoor festivals. The examiner noted that the Veteran was alert and oriented, eye contact inadequate at times, some teary eyed, and that he denied being suicidal. The examiner additionally annotated a flat mood; adequate insight and judgement; and that there was no evidence of thought disorder. Lastly, in the remarks section of the report, the examiner noted that the Veteran has not been in treatment for his anger problems since 2013; he has psychotropic medicine; and continues to have work-related problems. The available medical and lay evidence, prior to March 20, 2020, overall does not demonstrate the level of impairment associated with a 70 percent rating. As noted above, the Veteran’s reported symptoms were either contemplated by or more consistent with a 50 percent rating. Thus, the Board finds that the overall level of impairment caused by the Veteran’s symptoms more closely approximates the 50 percent rating. The VA examination report and counseling sessions overall indicate that the Veteran was cooperative, was appropriately dressed, had normal speech, had good hygiene, had normal attention, and fair judgment. Furthermore, his symptoms do not affect his ability to function independently, appropriately, and effectively; and although he has outburst of anger that affect his work and social relationships, the record reveals that he is motivated to change and improve his behavior by self-referring himself to group counseling therapy. Throughout the appeal period, the Veteran’s treatment notes indicate that his PTSD has been well controlled. The Board acknowledges the Veteran’s feelings of anger, detachment, isolation, decreased concentration, and avoidance of large or crowded locations. However, these symptoms are fully contemplated by the currently assigned 50 percent rating as discussed above and are not shown by either the lay or medical evidence to more nearly reflect the criteria for a 70 percent or higher disability rating. Moreover, his isolation and avoidance of crowds is similar to depression, which is also contemplated by the 30 percent rating. In summary, the severity, frequency, and/or duration of symptoms, individually or collectively, shown by the record do not more nearly reflect the type contemplated by the schedular criteria for an evaluation in excess of 50 percent for PTSD prior to March 20, 2020, which requires deficiencies in most areas due to PTSD symptoms. Period From March 20, 2020: From March 20, 2020, the evidence does not more nearly reflect total occupational and social impairment due to psychiatric symptoms. See 38 C.F.R. § 4.130, Diagnostic Code 9411. As stated above, a 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. Report of VA examination dated in March 2020 reflects that the Veteran experiences symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work like setting. The Veteran reported that he resided with his spouse of 32 years, but he noted some “ups & downs.” He additionally reported a strain in his relationship with his children due to impatience and lack of presence when they were younger. Lastly, the Veteran reported having no hobbies, friends, and social activities. The examiner noted that the Veteran was dressed and groomed appropriately, denied suicidal and homicidal thoughts, delusions, and hallucinations, and his thoughts were logical and coherent. The Veteran’s occupational and social impairment was summarized with the following: Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The March 2020 VA examination report does not show complaints or findings for symptoms of the severity, frequency, or duration to more nearly approximate the criteria for a 100 percent evaluation for PTSD. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio, 713 F.3d at 112; Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In this case, the evidence does not more nearly reflect severity, frequency, and duration of symptoms contemplated by the next higher evaluation. As noted above, the Veteran’s other remaining symptoms were either contemplated by or more consistent with a 70 percent rating. Medical evidence reflects the Veteran as maintaining a relationship with his wife; as being fully oriented and cooperative with the examination; and as having a normal rate, rhythm and tone of speech. Additionally, the Veteran has not reported suicidal or homicidal ideation. As such, the medical and lay evidence of record does not reflect: A preclusion of functioning both mentally and behaviorally on a daily basis, causing total occupational and social impairment; psychiatric symptoms productive of a danger of physical harm to the Veteran or others; gross impairment of the Veteran’s cognitive functions and behavior; the preclusion of simple activities of daily living (such as maintaining minimal personal hygiene); or a level of symptoms that reflect an increased loss of touch with reality. The Board accepts that the Veteran believes his symptoms warrant a rating in excess of 70 percent. However, whether a disability meets the schedular criteria for the assignment of a higher evaluation is a factual determination by the Board based on the Veteran’s complaints coupled with the medical evidence. Both the lay and medical evidence are probative in this case. Although the Veteran may believe that he meets the criteria for the next higher disability rating, his complaints along with the medical findings do not meet the schedular requirements for higher evaluations than now assigned, as explained and discussed above. The Board assigns greater probative value to the medical evidence, to include the March 2020 PTSD examination as it was prepared by a skilled, neutral medical professionals after evaluating the Veteran and review of the record. The Veteran has not presented a medical opinion that PTSD is productive of total occupational and social impairment to weigh in the matter. In summary, the severity, frequency, and/or duration of symptoms, individually or collectively, shown by the record do not more nearly reflect the type contemplated by the schedular criteria for an evaluation in excess of 50 percent prior to March 20, 2020, and in excess of 70 percent therefrom for PTSD. Additional staging of the PTSD rating is not warranted as the factual findings show no distinct period where the disability exhibited symptoms that would warrant higher evaluations than assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Accordingly, the claims are denied. As the evidence of record is not roughly in equipoise, there is no doubt to resolve. 38 U.S.C. § 5107(b). REASONS FOR REMAND 1. Entitlement to service connection for a left shoulder disability is remanded. 2. Entitlement to service connection for a left hip disability is remanded. Issue 1-2. The Veteran contends that symptoms of his disabilities had their onset during service. See Hearing Transcript at 10-11, 20 (November 2019). For reasons explained below, the Board finds that remand is necessary. A remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance. Stegall, 11 Vet. App. 268. As an initial matter, the Board notes that, in February 2020, the claims were remanded for, among other things, VA medical opinions. Although a VA medical opinion was obtained in March 2020, the medical opinions, are inadequate as the essential rationale for the opinions is not discernable. Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). First, VA medical opinion, for the left shoulder, reflects the conclusion that the Veteran’s left shoulder disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of the conclusion, the opinion notes that “[t]he available evidence was absent for an in-service injury and complaints of left shoulder pain. There is no evidence of chronicity of care. Therefore, a chronic shoulder condition cannot be established.” C&P Exam (March 2020). The record, however, reflects that prior to service separation, in August 2005, the Veteran reported left shoulder pain. In this regard, the Veteran stated, in a report of medical history, that his left shoulder was considerably weaker than his right shoulder; has had no prior treatment; and that pain occurs when under medium-heavy workload. See STR (August 2005). Additionally, also in August 2005, the Veteran filled out a report of medical assessment, and, once again, complained of left shoulder pain. The VA medical opinion, however, does not show a discussion or clarification on the contrary findings in the Veteran’s service treatment records; thus, the Board finds the VA medical opinion inadequate as it is not shown to be founded on an accurate factual premise with consideration of the Veteran’s prior medical history. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). Next, VA medical opinion, for the left hip, reflects the conclusion that the Veteran’s left hip disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of this conclusion, the opinion notes that the “[service treatment records] revealed complaints of right hip pain during active duty service and continued complaints are documented on the separation exam . . . . No noted complaints of left hip pain during active duty service are noted.” C&P Exam (March 2020). Here, although the opinion notes the right hip pain that is documented during service, it is inadequate because it does not reflect consideration of the Veteran’s theory that he experienced pain in both hips during service. See McKinney v. McDonald, 28 Vet. App. 15, 30-31 (2016) (“the VA examiner’s failure to consider [a veteran’s] testimony when formulating her opinion renders that opinion inadequate.”). Indeed, at the November 2019 Board hearing, the Veteran testified to experiencing pain in both hips and that the right hip was worse. See Hearing Transcript at 11-12 (November 2019). The Board found his statements of experiencing bilateral hip pain to be competent and credible. See BVA Decision (February 2020). The opinion, nevertheless, seems to have relied almost entirely on the absence of in-service documentation, without taking into consideration the Veteran’s competent and credible lay reports of experiencing bilateral hip pain. Although the clinician is not required to accept the Veteran’s theory that his military service caused his disability, or that he had symptoms associated with the disability during or following military service if this is incongruous with the record; however, the clinician is required to fully explain why he or she disagrees with the Veteran’s theory of causation, and provide a discussion of the relevant or significant medical history, clinical findings, medical knowledge or literature, etc., that support the negative medical opinion or conclusion(s). If another etiology is the more likely cause, the clinician must provide a complete explanation of his or her reasoning. Given the above, the Board finds that it may not rely upon the medical opinions in their present form and, therefore, concludes that the opinions are inadequate for adjudicative purposes. Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. 3. Entitlement to service connection for OSA is remanded. The Veteran contends that symptoms associated with his OSA started while in service. In the alternative, the Veteran also argues that his OSA is secondary to his service-connected PTSD. To ensure that VA has met its duty to assist, the claim must be remanded for further development. Barr, 21 Vet. App. 303. Here, the medical evidence of record is inadequate to decide the claim on appeal. VA medical opinion, dated in March 2020, reflects the conclusion that the Veteran’s OSA was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. VA medical opinion, dated in November 2020, reflects the conclusion that the Veteran’s OSA is less likely than not proximately due to or the result of his service-connected PTSD. In support of this conclusion, the opinion noted that there is no causal association between PTSD and OSA; OSA is a structural (narrow airway) and functional (collapse of airway due to narrowing) problem; and PTSD does not cause narrowing or functional changes to the airway. The Board finds the VA medical opinions inadequate for adjudicative purposes because they do not fully answer the Board’s questions. An adequate medical opinion must be “accurate and fully descriptive,” 38 C.F.R. § 4.1, and based on an accurate factual premise and consideration of a veteran’s prior medical history, Ardison, 6 Vet. App. at 407. In addition, the opinion “must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions.” Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (“most of the probative value of a medical opinion comes from its reasoning”). An adequate medical examination report or opinion must also “sufficiently inform the Board of a medical expert’s judgment on a medical question and the essential rationale for that opinion.” Monzingo, 26 Vet. App. at 106. In sum, although an examiner need not discuss all potentially favorable or unfavorable evidence in order to render an adequate opinion, see Monzingo, 26 Vet. App. at 105, it must be clear that the examiner was “informed of sufficient facts upon which to base an opinion relevant to the problem at hand.” Nieves-Rodriguez, 22 Vet. App. at 303. First, while the March 2020 VA medical opinion notes that the Veteran’s in-service complaint of fatigue is not a symptom used to diagnose OSA, it does not provide the Board a reasoned rationale explaining why such finding supports the negative conclusion. See Stefl, 21 Vet. App. at 124 (“a medical opinion . . . must support its conclusion with analysis that the Board can consider and weigh against contrary opinions”). Further, the opinion reveals that, in support of the conclusion, it relied on the numerous years since service separation and the Veteran’s diagnosis of OSA. However, the opinion does not provide the Board with an analysis that it can weigh against the evidence of record. Id. Second, the November 2020 VA medical opinion cites, quotes, and references medical literature showing no causal relationship between the Veteran’s OSA and PTSD, however, the opinion does not provide reflect consideration of facts specific to the Veteran vis-à-vis the medical literature that was reviewed. See Bailey v. O’Rourke, 30 Vet. App. 54, 60 (2018) (stating that a medical rationale based solely on general medical literature without discussing the specific facts pertaining to a veteran’s condition or individual circumstances is inadequate). Further, the opinion does not reflect a conclusion or reasoned medical rationale on the question of whether the Veteran’s OSA is aggravated beyond its natural progression by service-connected PTSD. See Allen v. Brown, 7 Vet. App. 439 (1995). Indeed, the bulk of the rationale provided by the opinion reflects an analysis based on causation. See Atencio v. O’Rourke, 30 Vet. App. 74, 90-91 (2018) (holding that a medical opinion was inadequate when it was unclear whether the examiner had clearly provided a rationale that dealt with causation and aggravation as independent concepts). Lastly, the Board acknowledges the private medical opinion, dated in October 2018, reflecting the conclusion that the Veteran’s OSA is at least as likely as not proximately due to or the result of his service-connected PTSD. In support of the conclusion, the clinician noted that “OSA involves intermittent and reversible closure of upper airway during one’s sleep [and] [t]he national center of PTSD mentions tight relationship between OSA and PTSD.” The Board finds the private medical opinion inadequate to support the claim. First, the opinion is inadequate because, as support for its conclusion, it relied on an association between PTSD and the Veteran’s OSA. In this regard, the opinion, in support of the conclusion, points that there is a “tight relationship between OSA and PTSD” according to the national center of PTSD. (Emphasis added). Indeed, medical literature referenced in the opinion annotates a relationship based on association rather than causation. For instance, the opinion quotes, “[w]hereas about 25% of middle age men and about 9% of middle age women have OSA, the studies in Veterans have revealed that about 70% of them are high risk for OSA.” Thus, the bulk of the rationale provided by the opinion reflects an analysis based on association rather than causation. Atencio, 30 Vet. App. at 90-91. It is noted that direct service connection and secondary service connection requires a causal relationship (not an association) between the current disability and the in-service disease or injury and/or service-connected disability. See Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); see also Allen, 7 Vet. App. 439. Second, the opinion, as noted, cited to medical literature. Although the opinion identified the medical literature, it does not reveal that facts specific to the Veteran in relation to the medical literature were discussed. Bailey, 30 Vet. App. at 60. Indeed, aside from the conclusory statements, the opinion simply referenced the study without providing the Board a reasoned medical rationale connecting the Veteran’s individual circumstances to the specific facts of the cited medical literature. As such, the Board may not rely upon it in its present form to support a grant of the Veteran’s claim and, therefore, finds the opinion is inadequate. Nevertheless, since the VA medical opinions of record are inadequate, remand is necessary. Barr, 21 Vet. App. at 311. In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. The matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from September 2020 to the Present. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s (1) left shoulder disability and (2) left hip disability. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran’s reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with any left shoulder disability and left hip disability. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. The clinician must opine on: (a) Whether any left shoulder disability at least as likely as not (1) began during active service or (2) is related to an in-service injury, event, or disease. Consider and expressly address the Veteran’s in-service complaints of left shoulder pain. Explain. (b) Whether any left hip disability at least as likely as not (1) began during active service or (2) is related to an in-service injury, event, or disease. Consider and expressly address the Veteran’s theory that he experienced pain in both hips during service. Explain. 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s OSA. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran’s reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with his OSA. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should provide an opinion, with supporting rationale, as to the following: Direct Service Connection (a) Whether the Veteran’s OSA at least as likely as not (1) had its onset in service, or (2) is otherwise related to an in-service injury, event, or disease during service. Consider whether symptoms described as tiredness and snoring started during service represent the onset of OSA in service and indicate whether such symptoms may be due to other causes. Explain. Secondary Service Connection (b) Whether the Veteran’s OSA is at least as likely as not (1) proximately due to service-connected PTSD, or (2) aggravated beyond its natural progression by service-connected PTSD. Provide a rationale that deals with causation and aggravation as independent concepts. Consider and expressly address the October 2018 private medical opinion – finding that PTSD remains a significant risk factor for noncompliance with OSA treatment. Explain. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): An adequate medical opinion may not be predicated solely on the absence of literature supporting causation or aggravation without discussing those facts specific to this Veteran. 4. Ensure that the VA medical opinion obtained include a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. (Continued on next page) 5. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Griffey, 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.