Citation Nr: 21014384 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 16-44 522 DATE: March 12, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. Entitlement to special monthly compensation based on the need for aid and attendance or housebound status is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from March 1966 to December 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from September 2016 and May 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). This appeal has been advanced on docket pursuant to 38 C.F.R. § 20.900 (c); 38 U.S.C. § 7107 (a)(2). The Veteran’s claims were previously remanded by the Board in a December 2020. The Board finds that the RO has substantially complied with the December 2020 Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. There are conflicting opinions of record as to the etiology of the Veteran’s OSA. In March 2017, the Veteran submitted a private opinion from H.S., M.D., regarding the nature and etiology of his OSA. Dr. H.S. opined that it is as likely as not that the Veteran’s depressive disorder and diabetes mellitus aided in the development of and permanently aggravates his severe OSA. Dr. H.S. cited multiple research studies showing a positive association between patients with diabetes mellitus type 2 and psychiatric disorders with developing OSA. Dr. H.S. further noted that due to his mental disorders, the Veteran finds the treatment for OSA to be overwhelming. Dr. H.S. indicated the Veteran’s inability to use his CPAP every night greatly aggravates the effects of his sleep apnea. In September 2020, a VA examiner opined that the Veteran’s OSA is not aggravated by his sleep issues or diabetes. The examiner made overly broad conclusions without citations to medical evidence or research. Further, the examiner did not consider or discuss the articles cited by Dr. H.S. The Board also observes that the examiner placed the blame for the Veteran’s condition solely on his obesity. The Board further notes that the Veteran is service connected for bilateral upper and lower extremity peripheral neuropathy. A treatment record from December 2020 indicated that the Veteran requires an assistive device to ambulate inside the home part of the time and requires a four wheeled walker for sit-stand transfers. The Veteran was noted to have changes in his balance, ability to stand, ability to drive, and motor and sensor functioning. Given his limitations in ambulation due to his service-connected bilateral upper and lower extremity peripheral neuropathy, it is reasonable to conclude that these limitations have prevented him from exercising, which may have resulted in his obesity. The September 2020 VA examiner noted significant weight gain over the last few years. Obesity may act as an “intermediate step” between a service-connected disability and a current disability. VAOPGCPREC 1-2017 (Jan. 6, 2017). In light of this, a new VA examination is necessary in order to resolve the discrepancy between the March 2017 Private opinion and the September 2020 VA examiner’s opinion as well as address whether the Veteran’s other service-connected disabilities, primarily his bilateral upper and lower extremity peripheral neuropathy and mental disorders, resulted in his obesity, which in turn caused or aggravated his sleep apnea. As such, the issue must be remanded for a new examination. 2. Entitlement to special monthly compensation based on the need for aid and attendance or housebound status is remanded. The Veteran was afforded an examination for housebound status or permanent need for regular aid and attendance in April 2017. While the examiner noted that the Veteran was able to feed himself, prepare his own meals, and did not need assistance in bathing and tending to other hygiene needs; the examiner did note the Veteran was obese with poor balance, had trouble with fine movements of hands, experiences weakness and numbness of both legs and feet, only left the house once a week with his wife, and used an assistive device if walking over 500 feet. Since that time, the Veteran has become service-connected for diabetic nephropathy, and diabetic peripheral neuropathy of the bilateral upper and lower extremities. The Board further notes that treatment notes from November 2020 indicate that the Veteran is repeatedly dropping his silverware due to the absence of sensation and impaired motor control with his hands bilaterally. Thus, the Board finds that a new examination is required to determine the Veteran’s current need for aid and attendance. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s sleep apnea. The examiner should answer the following: (a.) Is it at least as likely as not (a fifty percent probability or greater) that the Veteran’s service-connected disabilities, including but not limited to peripheral neuropathy or unspecified depressive disorder, including medication therefor, resulted in the Veteran becoming obese? (b.) Is it at least as likely as not (a fifty percent probability or greater) that sleep apnea was caused by: 1. Peripheral neuropathy, to include obesity resulting therefrom? 2. Unspecified depressive disorder, to include obesity resulting therefrom? (c.) If not, is it at least as likely as not (a fifty percent probability or greater) that sleep apnea was aggravated (worsened) by: 1. Bilateral upper and lower extremity peripheral neuropathy, to include obesity resulting therefrom? 2. PTSD, to include obesity resulting therefrom? A detailed rationale for the opinion must be provided. Attention is invited to the March 2017 opinion indicating that the Veteran’s bilateral upper and lower extremity peripheral neuropathy and mental conditions are associated with his sleep apnea. 2. Afford the Veteran a VA examination to determine whether, due to his service connected disabilities, he is in   need of aid and attendance or is in housebound status. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.D. Taylor, 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.