Citation Nr: 21010318 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 11-14 833 DATE: February 24, 2021 REMANDED Entitlement to service connection for sleep apnea, including as secondary to service-connected Reiter’s syndrome and/or service-connected gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for diabetes mellitus, type II, including as secondary to sleep apnea and/or service-connected vitamin D deficiency associated with Reiter’s disease is remanded. REASONS FOR REMAND The Veteran had active military service from September 1973 to November 1987. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. An August 2012 videoconference hearing was held before the undersigned. A transcript of that hearing is of record. Initially, the Board acknowledges that the Veteran submitted a Rapid Appeals Modernization Program (RAMP) opt-in election form, which VA received in December 2018. However, the service connection claims for sleep apnea and diabetes mellitus, type II, had already been activated at the Board and were therefore no longer eligible for the RAMP program. Accordingly, the appeals will continue under the Legacy appeals procedures. The Board regrets the delay associated with this remand, especially considering that this matter was the subject of previous remands. However, for reasons explained further below another remand is necessary to ensure that the Veteran is accorded full compliance with the statutory duty to assist. In November 2017, the Board remanded the claims for new medical opinions addressing whether medications taken for GERD and Reiter’s syndrome caused or aggravated sleep apnea and whether the standard, high fat and carbohydrate diet provided during service was related to the Veteran’s eventual diagnosis of diabetes mellitus, type II. The requested medical opinions were obtained in May 2018. Unfortunately, after a review of the medical opinions, the Board finds that another remand is required to ensure compliance with the Board’s previous remand directives. Stegall v. West, 11 Vet. App. 268 (1998). In this regard, the May 2018 VA examiner opined that the Veteran’s sleep apnea was less likely than not related to his Reiter’s Syndrome because there are no medications known to cause a congenital anomaly that affects the tracheolaryngeal area to be occluded. The examiner also indicated that there is no evidence that the Veteran’s sleep apnea has been aggravated beyond its natural progression due to his Reiter’s syndrome medications. He was diagnosed with Reiter’s Syndrome during active duty, and his treatment started over 15 years prior to his diagnosis of sleep apnea. He has had one sleep study in 2009. He has not had any further testing due to stability with his CPAP machine. The examiner further opined that the Veteran’s sleep apnea was less likely than not due to or the result of taking medications for GERD, reasoning that Proton Pump Inhibitors (PPIs) are used to treat GERD. Side effects from PPIs are rare, and there is no discussion regarding PPI’s causing sleep apnea. Additionally, the May 2018 VA examiner opined that the Veteran’s sleep apnea was less than likely as not aggravated by taking medications for GERD. The examiner again noted that PPIs are used to treat GERD, and side effects from PPIs are rare; there is no discussion regarding PPIs causing sleep apnea. Here, regarding the aggravation opinion pertaining to the medications for his service-connected GERD, the Board notes that the rationale does not support the conclusion as it addresses causation. Thus, on remand, an opinion should be obtained that addresses the question of whether sleep apnea was aggravated by the medications taken for GERD. With regard to the Veteran’s service connection claim for diabetes mellitus, type II, as the Veteran has also claimed that diabetes mellitus, type II, is secondarily related to sleep apnea, these two claims are inextricably intertwined. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a “significant impact” upon another, and that impact in turn could render any appellate review meaningless and a waste of judicial resources, the two claims are inextricably intertwined). Thus, adjudication of this claim would be premature prior to adjudication of the claim of entitlement to service connection for sleep apnea. Accordingly, the case is REMANDED for the following action: Arrange for a qualified medical professional to review the claims folder, to include a copy of this Remand, and provide an addendum opinion that fully addresses the question below. If the examiner is unavailable, the file should be referred to another similarly qualified medical professional. The examiner must note on the examination report that review of the electronic record was accomplished. If necessary, the Veteran should be scheduled for another VA examination. (a.) The examiner is asked to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s sleep apnea has been aggravated (increased in severity beyond the natural progress of the disorder) by the medications taken for his service-connected GERD. (b.) If aggravation is found, identify the baseline level of disability prior to any such aggravation, to the extent possible, based on the available evidence. An explanation of all opinions expressed must be provided, with consideration given to all evidence of record. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should indicate such and provide a supporting rationale as to why the opinion cannot be made without resorting to speculation. M. MAC Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Hite, 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.