Citation Nr: 21010814 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 15-21 832 DATE: February 25, 2021 REMANDED Entitlement to service connection for a sleep disorder, to include claimed as secondary to another service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from December 1969 through October 1972, to include service in the reserves. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a November 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in July 2018, when it was first remanded for a VA examination. The issue was returned to the Board in July 2019 however a VA examination had not been completed and it was again remanded. Unfortunately, there has still not been substantial compliance with the Board’s previous remand directives regarding the issue of a sleep disorder and whether it is a separate and distinct disability from any psychiatric disabilities. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for a sleep disorder, to include claimed as secondary to another service-connected disability, is remanded. The Veteran contends that he suffers from a sleep disorder as a result of his active duty service, to include as secondary to service-connected disabilities, such as tinnitus or his service-connected major depressive disorder (MDD). Although the Board regrets an additional delay, a remand is necessary to ensure there is a complete record upon which to decide the appellant’s claim and to afford him every possible consideration. The record is currently unclear as to whether the Veteran truly has a uniquely separate sleep disorder or whether his sleep disturbances are merely a manifestation of his already service-connected MDD. In particular, the Veteran was diagnosed with insomnia in 2014. This diagnosis, however, appears intertwined with treatment and diagnosis related to his service-connected MDD, also diagnosed in 2014. In July 2013, the Veteran stated that he has not slept since leaving Vietnam in 1972, and that his sleep issues are linked to the fear and depression associated with his service there as well. A January 2020 VA examination opinion notes the Veteran has “severe depression insomnia,” and also notes that depression can cause sleep disorders. Again, this opinion leaves the question ambiguous as to whether the Veteran truly has a uniquely separate sleep disorder or whether his sleep disturbances are merely a manifestation of his already service-connected depression. Thus, the Board finds a clarifying addendum opinion necessary as the evidence of record is insufficient for a decision at this time. The matters are REMANDED for the following action: 1. Obtain any additional treatment records from the VA or private medical centers, to include records from September 2020 to the present. 2. Ask the appropriate examiner to review the Veteran’s file. The necessity of an in-person examination, with any appropriate testing, is left to the discretion of the examiner. The examiner is asked to opine first on whether the Veteran’s insomnia is a separate disability in and of itself, or if it is merely a symptom/manifestation of the Veteran’s service-connected major depressive disorder (MDD). Once that distinction has been established, and IF (and only if) the examiner determines that the Veteran’s insomnia is a separate disability, then the examiner should additionally opine as follows: (a.) whether the Veteran’s insomnia was at least as likely as not (a probability of 50% or greater) incurred in or is otherwise related to active duty in light of the Veteran’s statements that nightmares and sleep issues began during service as well as in-service treatment records showing treatment for sleep issues and complaints of nightmares. The examiner is also directed to consider the Veteran’s lay statements and medical treatment records during and since service. (b.) whether the diagnosis is at least as likely as not caused or aggravated by a service-connected disability, to include tinnitus or MDD. Note that aggravation means any incremental increase in disability in non service-connected disabilities (i.e. any additional impairment of earning capacity) resulting from a service-connected condition. A complete rationale detailing both causation and aggravation should accompany any opinion provided. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Boivin, 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.