Citation Nr: 21015518 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 15-14 026 DATE: March 17, 2021 ORDER A disability rating in excess of 40 percent for a back disability is denied. A disability rating in excess of 10 percent for radiculopathy of the right lower extremity, prior to June 21, 2016, is denied. A disability rating in excess of 10 percent for radiculopathy of the left lower extremity, prior to June 21, 2016, is denied. A disability rating in excess of 40 percent for radiculopathy of the right lower extremity, from June 21, 2016, is denied. A disability rating in excess of 40 percent for radiculopathy of the left lower extremity, from June 21, 2016, is denied. REMANDED Entitlement to service connection for sleep apnea, to include as due to undiagnosed illness and medically unexplained chronic multi-symptom illnesses associated with service in the Persian Gulf is remanded. Entitlement to service connection for asthma, to include as due to undiagnosed illness and medically unexplained chronic multi-symptom illnesses associated with service in the Persian Gulf is remanded. FINDINGS OF FACT 1. The Veteran’s low back disability does not manifest by ankylosis. 2. Prior to June 21, 2016, the Veteran’s peripheral neuropathy of the right and left lower extremity most nearly approximate mild incomplete paralysis of the sciatic nerve. 3. From June 21, 2016, the Veteran’s sciatic nerve peripheral neuropathy of the right and left lower extremities manifested by no more than moderately severe incomplete paralysis of the sciatic nerve. CONCLUSIONS OF LAW 1. The criteria for an increased rating for a back disability higher than 40 percent, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5243. 2. The criteria for a rating in excess of 10 percent for peripheral neuropathy of the right lower extremity, prior to June 21, 2016, affecting the sciatic nerve, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 4.124a, Diagnostic Code 8520. 3. The criteria for a rating in excess of 10 percent for peripheral neuropathy of the left lower extremity, prior to June 21, 2016, affecting the sciatic nerve, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 4.124a, Diagnostic Code 8520. 4. The criteria for a rating in excess of 40 percent for peripheral neuropathy of the right lower extremity, from June 21, 2016, affecting the sciatic nerve, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 4.124a, Diagnostic Code 8520. 5. The criteria for a rating in excess of 40 percent for peripheral neuropathy of the left lower extremity, from June 21, 2016, affecting the sciatic nerve, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 4.124a, Diagnostic Code 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from December 1988 to October 1995. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in November 2012 and October 2013 by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston Salem, North Carolina. This appeal was previously before the Board in July 2018 and June 2019. Increased Rating VA’s percentage ratings are based on the average impairment of earning capacity as a result of service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, may not be reflected on range-of-motion testing. In addition, 38 C.F.R. § 4.45 requires consideration of less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Thus, a higher rating may be assigned if there is additional limitation of motion or functional impairment from pain or other factors during flare-ups or upon repeated use of the joint. Id. Considering these background factors as to the nature of disability, a rating for the musculoskeletal system should be assigned based on the extent to which motion is limited under 38 C.F.R. § 4.71a. Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). The most relevant information in determining the appropriate initial disability rating pertains to the severity of the disability since the effective date of service connection. Fenderson v. West, 12 Vet. App. 119 (1999). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). For both types of claims, staged ratings may be awarded if there are decreases or increases in symptomatology that meet the criteria for a different rating for a distinct period during the appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). This decision will focus on the evidence pertinent to the rating criteria and disability severity during the relevant period on appeal, but the Board has considered the entire record to have a full picture of the disability. See 38 C.F.R. §§ 4.1, 4.2, 4.41; Gonzales v. West, 218 F. 3d 1378 (Fed. Cir. 2000). 1. Entitlement to a rating in excess of 40 percent for a back disability The Veteran asserts that his current back disability is more severe than reflected by his currently assigned 40 percent rating, and that an increased rating is warranted. Here, the Board finds that considering the entirety of the Veteran’s disability picture throughout the claims period, to include several VA examinations and VA/private treatment records, the Veteran’s back disability does not present to manifest with any diagnosis of analysis. Therefore, as any higher rating in excess of 40 percent for a back disability required a finding of ankylosis, the Veteran’s claim for increased rating must be denied. The Board notes that the Veteran’s back disability has been diagnosed as denigrative arthritis of the lumbar spine and intervertebral disc syndrome (IVDS). To this end, the Veteran’s condition has been rated either under the General Rating Formula for Diseases and Injuries of the Spine, which provides for assignment of a separate rating for any associated objective neurological abnormalities, or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The method that results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25 should be used. See 38 C.F.R. § 4.71a, Diagnostic Codes 5237 & 5243, General Rating Formula & Note (1), IVDS Formula & Notes (1) & (2). Under the General Rating Formula, spinal disability will be assigned a higher rating of 50 percent requires unfavorable ankylosis of the entire thoracolumbar spine, and 100 percent requires ankylosis of the entire spine. Unfavorable ankylosis means the indicated portion of the spine is fixed in flexion or extension and the ankylosis results in certain specified impairments. See 38 C.F.R. § 4.71a, Diagnostic Codes 5237 & 5243, General Rating Formula; see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011); Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). To warrant the next higher, and maximum, rating of 60 percent under the alternative IVDS formula, there must be incapacitating episodes having a total duration of at least 6 weeks during a 12-month period. 38 C.F.R. § 4.71a, Diagnostic Codes 5243, IVDS Formula. For this purpose, an incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note (1). The Veteran was afforded several VA examinations to assess the nature and severity of his service-connected back disability in October 2011, September 2013, October 2018, and July 2019, with an addendum opinion in April 2020. A close review of all these VA examinations, along with the contemporaneous VA and private treatment records, reveal a back disability with severe limitation of motion, flare-ups, and bilateral radiculopathy. However, no medical evidence of a diagnosis of ankylosis, favorable or unfavorable, has ever been assessed during the pendency of the claim. To this end, the Board also notes that while the Veteran may suffer from severe functional loss, some movement has been noted to remain, in all directions, with regards to the Veteran’s lumbar spine. The Board will discuss these examinations in turn. An October 2011 VA examiner found no ankylosis of the spine, and the Veteran retained range of motion, albeit with pain. He had forward flexion to 80 degrees, with pain starting at 40 degrees, as well as retained motion for lateral extension and rotation, with no change after repetition. With regards to neurological examination, slight (4/5) sensory deficit was noted in both legs effecting the sciatic nerve, and some radiating pain down both lower extremities. The Veteran was also diagnosed with IVDS with no reported incapacitating episodes. A September 2013 VA examiner again found no ankylosis of the spine, and the Veteran retained range of motion with pain. He had forward flexion to 75 degrees, with pain starting at 50 degrees, as well as retained motion for lateral extension and rotation, with no change after repetition. The examiner stated that he would have additional pain on use, but no additional loss of range of motion. With regards to IVDS, the examiner again noted no evidence of any incapacitating episodes due to IVDS in the last 12 months, prior to that examination. With regards to radiculopathy, the examiner noted mild symptoms of pain, paresthesias, and numbness bilaterally that involved the sciatic nerve; and ultimately found that the affects to the sciatic nerve was considered overall mild. The Veteran was afforded another examination in October 2018. During that examination, the VA examiner again found no ankylosis, with the Veteran retaining range of motion with pain. Upon examination, the Veteran’s forward flexion was limited to 22 degrees with pain, as well as retained motion for lateral extension and rotation, albeit severely decreased, with no change after repetition. The examiner stated that he would have additional pain on use, but no additional loss of range of motion. With regards to IVDS, the examiner again noted no evidence of any incapacitating episodes in the last 12 months prior to that examination. Regarding to radiculopathy, the examiner noted moderate symptoms of pain and paresthesias, with mild numbness for the left lower extremity, and severe pain in the right lower extremity, with moderate levels of paresthesias and numbness. The examiner noted that overall, the effects to the sciatic nerve was considered moderate for the left lower extremity, and severe for the right extremity. Finally, in a July 2019 VA examination, again, no ankylosis were noted on examination; and like the prior examinations, residual range of motion remained on all plains upon testing. The Veteran’s forward flexion was noted to be limited to 10 degrees, with signed of pain. Upon repetitive testing, further reduction of range of motion were noted, to specifically include decreases in flexion to five degrees; however, again, residual movement on all range of motion plains remained. Here, upon evaluating IVDS, the examiner did acknowledge that the Veteran of having incapacitating episodes totalling a duration of 45-50 days in the last 12 months. Speaking to radiculopathy, the examiner noted moderate symptoms of pain, paresthesias, and numbness for the right lower extremity, and severe symptoms in the left lower extremity. The examiner noted that overall, the effects to the sciatic nerve was considered moderate for the right lower extremity, and severe for the left extremity. The Board notes that in April 2020, the Veteran’s claims file and medical history was reviewed by a VA examiner. The VA examiner made a finding that the Veteran’s condition had no changes from the July 2019 VA examination results, and left the examination report blank. The same examiner also made retrospective opinion regarding additional loss of range of motion between February 2011 and June 2016, and found that, essentially, an additional 5 degrees of loss of range of motion from the measured baseline was estimated. To this end, the examiner noted that with regards to incapacitating episodes, as due to IVDS, for this period, prior to June 2016, the Veteran most likely experienced four, in 12 months. The Board finds that in evaluating the medical evidence of record, the Veteran’s 40 percent rating is consistent with his demonstrated limitation of motion, including to a higher degree of limitation with increased pain. However, his spine is not fixed in flexion or extension to establish ankylosis, unfavorable or otherwise. See 38 C.F.R. § 4.71a, Diagnostic Codes 5237 & 5243, General Rating Formula. Thus, as any higher rating would require a finding of ankylosis or symptoms akin to such, which is not represented in the evidence, a rating in excess of 40 percent is not warranted on the basis of limitation of motion. Moving to a higher rating under IVDS, here the Board notes that prior to the July 2019 VA examination, there is no evidence that the Veteran’s back disability manifested to caused incapacitating episodes, much less sufficient to amount to a duration of six weeks, in the span of 12 months, which is requisite for a higher, 60 percent rating under the Diagnostic Code for IVDS. In fact, prior to July 2019 examination, there was no indication of incapacitation due to the back disability, to include prescribed bed rest or VA treatment. The VA examination prior to July 2019 explicitly noted no such episodes occurred during the period prior to the relevant examinations. A close review of the VA and private treatment records of this time period confirms no evidence of any prescribed bed rest during the claims period caused by his back disability. Even considering the April 2020 VA retrospective opinion regarding this period, the Board notes that such opinion only found four instances requiring bed rest, far short of the six weeks required under the Diagnostic Code for a higher 60 percent rating. As such, the Board must find that a higher rating under IVDS for the period prior to July 2019 is unwarranted. With regards to the July 2019 VA examination, the examiner did explicitly find that the Veteran’s IVDS caused incapacitating episodes that amounted to a duration of 45-50 days in the past 12 months. The Board finds that such finding is in fact sufficient under the Diagnostic Code for IVDS to warrant a higher 60 percent rating, with 6 weeks equaling 42 days. However, as the Formula for Rating IVDS does not provide for separate evaluations for neurological manifestations such as radiculopathy, evaluation under this Formula for incapacitating episodes would violate the VA’s prohibition against pyramiding. Here, as the Veteran is separately service connected for radiculopathy of the bilateral lower extremity, both rated at 40 percent for this period, any rating under the incapacitating provisions for IVDS would eliminate the separate rating for radiculopathy. However, a 40 percent rating for the back disability and separate 40 percent ratings for the associated left and right lower extremity radiculopathy is a greater benefit under the General Formula for Rating Diseases and Injuries of the Spine, than a singular 60 percent rating under the Formula for Rating IVDS. See 38 C.F.R. § 4.25; see also Bradley v. Peake, 22 Vet. App. 280, 294 (2008) (explaining that the Secretary is required to maximize benefits). Thus, in order to afford the Veteran the highest possible benefits, consideration of a higher rating for the back disability, under IVDS for incapacitating episodes must be precluded. Therefore, returning to limitation of motion, as there is not medical evidence of ankylosis of the spine, and as there remains residual range of motion on all planes, albeit severely decreased, the Board must find that the preponderance of evidence remains against the claim for a higher rating. As there is no reasonable doubt to be resolved, the claim must be denied. 2. Entitlement to a rating in excess of 10 percent for radiculopathy of the right lower extremity, prior to June 21, 2016. 3. Entitlement to a rating in excess of 10 percent for radiculopathy of the left lower extremity, prior to June 21, 2016. The Veteran is currently in receipt of separate ratings in regard to peripheral neuropathy of the left and right lower extremities, affecting the sciatic nerve; both associated with the Veteran’s service-connected back disability. These separate ratings have been staged, with an assigned 10 percent rating prior to June 21, 2016, for both sides, and a 40 percent rating thereafter. The Veteran’s condition is currently rated under Diagnostic Code 8520. Under Diagnostic Code 8520, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve; a 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve; a 40 percent rating is assigned for moderately severe incomplete paralysis; a 60 percent rating is assigned for severe incomplete paralysis, with marked muscular atrophy; and an 80 percent rating is assigned for complete paralysis of the sciatic nerve, where the foot dangles and drops, and there is no active movement possible of muscles below the knee, flexion of knee weakened, or very rarely, lost. The term “incomplete paralysis,” with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. See 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” Neither the Rating Schedule nor the regulations provide definitions for words such as “mild,” “moderate,” “moderately severe,” and “severe.” Rather than applying a mechanical formula, the Board must instead evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. With regards to the earlier period prior to June 21, 2016, the Board notes that the competent medical evidence prior to this date, to include two VA examination, reveal that both left and right radiculopathy has been characterized as mild, at worst. Specifically, in both VA examinations during this earlier period, in October 2011 and September 2013, which were described above, the Veteran’s radiculopathy was explicitly noted to be mild in severity, with only some mild sensory symptoms, and mild pain, numbness, and paresthesias, bilaterally. To this end, a close review of contemporaneous VA and private treatment records during this prior period, also revealed no additional evidence of complaints and/or treatments for radiculopathy symptoms for either leg that would be considered moderate or severe. Therefore, as the competent medical evidence of record does not demonstrate that the Veteran’s radiculopathy of bilateral lower extremity is manifested to a degree considered moderate, the Board must find that a rating in excess of his current 10 percent rating, for each lower extremity is warranted, for this period. As such, as the preponderance of evidence is against the claim for an increased rating, the claim for this relevant period prior to June 21, 2016, must be denied. 4. Entitlement to an increased rating in excess of 40 percent for radiculopathy of the right lower extremity, from June 21, 2016, 5. Entitlement to an increased rating in excess of 40 percent for radiculopathy of the left lower extremity, from June 21, 2016 With regards to the period after June 21, 2016, the Board notes that the Veteran’s radiculopathy has been rated at a 40 percent rating for this relevant period. As noted prior, a higher 60 percent rating is not warranted under the appropriate diagnosed code unless the condition is considered severe, with marked muscular atrophy. The Board finds that a close review of the relevant medical evidence of record, to include two VA examinations reveal no evidence of marked muscular atrophy for either side. As such, the Veteran’s claim for an increased rating in excess of 40 percent is not warranted. With regards to the VA examination, the Veteran was afforded VA examinations for his back disability, and in turn his radiculopathy in October 2018 and July 2019. In the earlier October 2018 VA examination, the Veteran’s radiculopathy was diagnosed to be an incomplete paralysis of the sciatic nerve in both the right and left lower extremities. Regarding to radiculopathy, the examiner noted moderate symptoms of pain and paresthesias, with mild numbness for the left lower extremity, and severe pain in the right lower extremity, with moderate levels of paresthesias and numbness. The examiner noted that overall, the effects to the sciatic nerve was considered moderate for the left lower extremity, and severe for the right extremity. The examiner report noted explicitly of no muscle atrophy. A July 2019 VA examination report noted similar results, to include moderate symptoms of pain, paresthesias, and numbness for the right lower extremity, and severe symptoms in the left lower extremity. The examiner noted that overall, the effects to the sciatic nerve was considered moderate for the right lower extremity, and severe for the left extremity. No muscle atrophy was noted upon testing. The Board notes that an exhaustive review of the contemporaneous VA and private medical records reveal no evidence of a more severe disability with regards to the Veteran’s bilateral lower extremities, to especially include no evidence of a diagnosis or treatment for muscle atrophy. With regards to this latter period from June 21, 2016, where the Veteran is rated at 40 percent, for a moderately-severe disability, the Board finds a higher rating is not warranted. Here, as noted above, under the appropriate Diagnostic Code, the next higher rating of 60 percent, is not warranted unless the disability is considered severe, with evidence of muscle atrophy, or a complete paralysis, for an 80 percent rating. The Board finds that the competent medical evidence of record does not demonstrate any muscle atrophy, nor complete paralysis of the sciatic nerve at any point during the claims period. Here, the Veteran was afforded several VA examinations, and a close review of all these examinations, as well as the copious amounts of VA treatment records in the claims file reveal no evidence of muscle atrophy of the right or left lower extremity, or evidence of a total paralysis of the sciatic nerve. In all the examinations, the VA examiner explicitly noted no muscle atrophy, although some decrease in strength were noted; and in all the examination reports, the examiners concluded only an incomplete paralysis of the sciatic nerve. In this regard, even if the Board considered the Veteran’s condition to be severe, as demonstrated separately by the VA examination for each lower extremity, such would still fall short of the criteria for a higher 60 percent rating, as the Code requires the finding also of ‘marked muscular atrophy’ of which there is no evidence. The Board additionally notes that the Veteran also has not alleged or asserts that he suffers from a complete paralysis of his bilateral lower extremity, as to have foot dangles/drops, or no active movement of muscles below the knee. 38 C.F.R. § 4.124a. Consequently, as there is no evidence, of any muscle atrophy, or complete paralysis, the Board must find that for the period from June 21, 2016, a higher rating in excess of 40 percent is not warranted; and as such, the Veteran’s claim for an increased rating for this period must be denied. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea, to include as due to undiagnosed illness and medically unexplained chronic multi-symptom illnesses associated with service in the Persian Gulf is remanded. 2. Entitlement to service connection for asthma, to include as due to undiagnosed illness and medically unexplained chronic multi-symptom illnesses associated with service in the Persian Gulf is remanded. With regards to both the Veteran’s service-connection claims, the Board finds that the last VA examination and opinion provided by the RO to be inadequate, and as such, remand is required for the VA to fulfill its duty to the Veteran and acquire another opinion speaking to the nature and etiology of his claimed conditions of sleep apnea and asthma. The Board notes that the VA’s statutory duty to assist the Veteran includes the duty to conduct a thorough and contemporaneous examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A (d) (West 2014); 38 C.F.R. § 3.159 (c)(4) (2016); McLendon v. Nicholson, 20 Vet. App. 79 (2006). When the medical evidence is inadequate, as it is here, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). With specific regards to the VA’s June 2019 VA addendum opinion, acquired to speak to the nature and etiology of the Veteran’s claimed sleep and respiratory disabilities, the Board finds that a close review of the conclusion and rationale of the VA examiner, reveals that the findings are internally/logically contradictory, and as such, is considered inadequate. Specifically, with the Veteran’s claim for a respiratory disability, the VA examiner found that the Veteran’s asthma was not due to any aspect of the Veteran’s active service due to the fact that no onset of symptoms was found during service. However, the examiner found wheezing to be a symptom of asthma, and related wheezing to inservice “environmental irritants”. The Board finds that logic in this examiner’s rationale flawed. Addressing the negative finding for asthma, the VA examiner’s single rationale was that there was no evidence that such condition, or symptoms of such condition arose during service; however, in contradiction of that rationale, the examiner’s very next sentence admitted that wheezing was a symptom or part of the criteria for asthma. Wheezing was explicitly noted in the Veteran’s STRs, albeit not on separation. The examiner continues by finding that such wheezing was not an undiagnosed illness or unknown etiology, as wheezing has specific risk factors such as obesity, GERD, and environmental irritants. Here again, the Veteran has repeatedly alleged he was exposed to environmental irritants during service, as part of his military occupation specialty. Therefore, as wheezing is considered a symptom or criteria of asthma which arose during service, in part due to an alleged inservice injury or incurrence, the Board must find that the ultimate negative finding and rationale to be logically contradictory, and requires further explanation. Likewise, the Board finds the VA examiner findings and rationale regarding the Veteran’s claim for sleep apnea just as curious. Here, inservice snoring and fatigue was noted by the Veteran, and such is confirmed by the examiner as symptoms of sleep apnea, although not definitive diagnoses of such condition. However, in concluding that the Veteran’s sleep apnea did not arise during service, and/or was caused by service, the examiner again, ignored these symptoms by finding that there was no reports of sleep apnea during service, and that snoring is very common among the population. The Board finds such tautology to be inadequate. Additionally, the examiner affords no rationale or medical basis for its findings, specific to the Veteran’s inservice exposure to ‘environmental irritants’. Specifically, when asked if any inservice incident to include the Veteran’s exposure as a gas turbine mechanic caused or lead to the Veteran’s sleep apnea, the examiner simply noted a finding that sleep apnea is not caused by such exposure; without providing any rationale or support based on medical findings. Likewise, in concluding that the Veteran’s inservice snoring and fatigue was not an undiagnosed illness with unknown etiology, the examiner provided no reference to what specific etiology or cause. The Board finds such lack of rationale to render the opinion incomplete and inadequate. Therefore, as such opinions are found to be inadequate, remand is required to acquire an addendum opinion so the VA can fulfill its duty to the Veteran. The matters are REMANDED for the following action: Schedule the Veteran for a VA Gulf War examination to address the nature and etiology of his claimed respiratory disabilities to include sleep apnea and asthma, claimed as due to an undiagnosed illness. The examiner must review the claims file and should note that review in the report. All appropriate tests and studies should be conducted, and any consultations deemed necessary should be accomplished. After conducting a complete examination, the examiner is asked to provide the following opinions: a) whether it is at least as likely as not (50 percent or greater probability) that the Veteran has sleep apnea and asthma, or any other respiratory condition, to include a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs and symptoms. If the Veteran does not meet the criteria for a diagnosis of these claimed condition, the examiner should explain the diagnostic criteria and what criteria the Veteran does not meet for the diagnosis. b) whether it is at least as likely as not (50 percent or greater probability) that the Veteran has objective indications of a chronic disability, to include signs and other non-medical indicators of a disability capable of independent verification, manifested by snoring, wheezing, fatigue, and/or memory issues that cannot be attributed to a known clinical diagnosis. c) whether it is at least as likely as not (50 percent or greater probability) that any such conditions are related to service, to include operations during the Persian Gulf War era, or any event, injury, or disease during service. d) Are any of the symptoms/conditions attributable to a known clinical diagnosis? Please list any and all appropriate diagnoses and a complete explanation of findings. If no diagnosis can be made based on testing and the evidence, so state. For any symptoms/conditions attributed to a known clinical diagnosis, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the known clinical diagnosis is related to service or any event, injury, or disease during service. The examiner should provide a rationale for all opinions provided. In rendering the requested opinions, the examiner should discuss the Veteran’s lay statements regarding the history and continuity of symptomatology, and his exposure to any environmental hazards as part of his MOS during service as a gas turbine engineer. The examiner should record all noted signs and reported symptoms, document clinical findings, and provide a diagnosis where possible. All opinions are to be supported with citation to evidence in the record and to medically accepted knowledge. JEREMY J. OLSEN Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ziheng Zhu, 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.