Citation Nr: 21015601 Decision Date: 03/18/21 Archive Date: 03/17/21 DOCKET NO. 16-56 283 DATE: March 18, 2021 ORDER Service connection for right knee arthritis is granted. REMANDED Service connection for a right wrist disability. Service connection for a left wrist disability. Service connection for a right hip disability. Service connection for a right leg disability. Service connection for sciatica. Service connection for a chronic headache disability. Service connection for sleep apnea. FINDING OF FACT Right knee arthritis was shown in active service and there have been subsequent manifestations of this chronic disease. CONCLUSION OF LAW The criteria for service connection for right knee arthritis have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.309(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1975 to November 1975 (referenced on the relevant DD 214 as “ADT” service), from February 1983 to June 1983 (referenced on the relevant DD 214 as “FTTD” service), from July 1988 to December 1988 (referenced on the relevant DD 214 as “FTTD” service) and from March 1990 to November 1997. The record also reflected that the Veteran had various additional periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). The case is on appeal from July 2015, September 2015 and October 2016 rating decisions. In July 2019, the Board denied all of the claims noted above as being on appeal, as well as service connection for left foot hammer toe. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In a September 2020 Order, the Court granted an August 2020 joint motion for partial remand (JMPR) that addressed the issues noted above and remanded these issues for action consistent with the JMPR. The Court’s September 2020 Order noted that the appeal of the remaining issue, the left foot hammer toe claim, was dismissed. Right knee arthritis Legal Criteria 38 C.F.R. § 3.303(b) states that: With chronic disease shown as such in service…so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain…in service will permit service connection of arthritis…first shown as a clearcut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” When the disease identity is established…there is no requirement of evidentiary showing of continuity.  Arthritis is considered a chronic disease for purposes of 38 C.F.R. § 3.303(b). See 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013) (“properly interpreted…§ 3.303(b) is constrained by § 3.309(a)…in that the regulation is only available to establish service connection for the specific chronic diseases listed in § 3.309(a)”). Analysis Upon review, and resolving reasonable doubt in the Veteran’s favor, the Board finds that service connection is warranted for right knee arthritis. The Veteran’s service treatment records (STRs) included various notes related to the right knee. A May 3, 1997 Report of Medical Examination was signed, under the heading of “typed or printed name of physician,” by D.S. and thus this form indicated that D.S. was a doctor. Under the section of the form related to defects and diagnoses, “bilat[eral] knee pain” was noted. The Veteran’s physical profile was noted as “3T” under the “L” item of the PULHES rating system. See Horn v. Shinseki, 25 Vet. App. 231, 233 n.1 (2012) (“PULHES is a rating system widely employed by armed services physicians in examination reports for induction and separation…the ‘L’ [stands for] for ‘lower extremities’…A rating of ‘1’ in any of the six categories, the highest rating, means that the inductee’s condition in that category should not result in any limitations in military assignments…Ratings from ‘2’ to ‘4’ indicate the existence of physical conditions that will result in progressively more severe restrictions on the assignments that the inductee may be given”). On a May 4, 1997 Report of Medical History form, the Veteran stated “knee problems are hindering my running.” He reported having had or having now swollen or painful joints, and he reported being treated for “both knees – arthritic condition VA – 1997.” A section of the form completed by a medical professional, specifically D.S., stated “knee swelling (bad in am).” A May 4, 1997 Physical Profile form, also completed and signed by D.S., noted a medical condition of “bilat[eral] knee pain (osteoarthritis[)]” and noted “3T” under the “L” item of the PULHES rating system. An October 5, 1997 Physical Profile form, also completed and signed by D.S., noted a medical condition of “bilat[eral] chronic knee pain osteoarthritis” and noted “3T” under the “L” item of the PULHES rating system. A separate October 5, 1997 STR, also signed by D.S., stated “renewal temporary profile for chronic bilat[eral] osteoarthritis.” Upon review of the Veteran’s STRs, and resolving reasonable doubt in the Veteran’s favor, the Board finds that a chronic disease of right knee arthritis was shown during active service. As outlined, three STRs (May 4, 1997 and October 5, 1997 Physical Profile forms and a separate October 5, 1997 STR) contained findings that referenced right knee arthritis. These forms were completed and signed by D.S., who as noted above was indicated to be a doctor by way of the May 3, 1997 Report of Medical Examination. Based on the multiple 1997 STRs and resolving reasonable doubt in the Veteran’s favor, the Board finds that the chronic disease of right knee arthritis was shown in service. See 38 C.F.R. § 3.303(b) (“For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time”); Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013) (38 C.F.R. § 3.303(b) “equates ‘shown in service’ with a reliable diagnosis of the chronic disease while in service…To be ‘shown in service,’ the disease identity must be established and the diagnosis not be subject to legitimate question”). The Board also notes that in the August 2020 JMPR, the Physical Profile forms were discussed, and it was stated that “[a]s the November 2016 VA examiner did not consider these in-service symptoms and diagnoses of right knee osteoarthritis, it is inadequate.” In essence, the JMPR contained a finding that right knee osteoarthritis was diagnosed in service, which further supports the finding that right knee arthritis was shown in service for purposes of 38 C.F.R. § 3.303(b). Pursuant to 38 C.F.R. § 3.303(b), “[w]ith chronic disease shown as such in service…subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes.” See Walker v. Shinseki, 708 F.3d 1331, 1335-36 (Fed. Cir. 2013) (“if a veteran can prove a chronic disease ‘shown in service,’ and there are no intercurrent causes, the manifestation of the chronic disease present at the time the veteran seeks benefits establishes service connection for the chronic disease”). In this case, as noted, the Board has found that the chronic disease of right knee arthritis was shown in service. The Board also finds that evidence of record indicated that there have been subsequent manifestations of right knee arthritis. In this regard, the Veteran was afforded a November 2016 VA examination and a Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ) was completed. The DBQ noted a diagnosis of right degenerative arthritis and also noted that degenerative or traumatic arthritis of the right knee was documented by imaging studies. The Board accordingly finds that there have been subsequent manifestations of right knee arthritis. The Board acknowledges that of record is a negative November 2016 VA direct service connection nexus opinion. Initially, as referenced above, this opinion was found to be inadequate by the August 2020 JMPR. Moreover, based on the application of 38 C.F.R. § 3.303(b), a nexus is not required in this case. See Walker v. Shinseki, 708 F.3d 1331, 1336 (Fed. Cir. 2013) (“By treating all subsequent manifestations as service connected, the veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability compensation is sought. In short, there is no ‘nexus’ requirement for compensation for a chronic disease which was shown in service”). In sum, the Board finds that right knee arthritis was shown in active service and that there have been subsequent manifestations of this chronic disease. This is particularly so when reasonable doubt is resolved in the Veteran’s favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, the Board concludes that the criteria for service connection for right knee arthritis have been met and, in this regard, the Veteran’s claim is therefore granted. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.309(a). REASONS FOR REMAND 1. Right wrist disability 2. Left wrist disability Upon review, the Board finds that remand is required for these claims. The Veteran filed claims in August 2015 for “[l]eft [and] [r]ight [w]rist conditions.” He was afforded a VA examination in September 2015 and a Wrist Conditions DBQ was completed. The DBQ only noted a diagnosis of bilateral ganglion cysts. The DBQ noted that the Veteran “states he has had ganglion cysts surgical[l]y removed…while on active duty…the right was removed in 1997 and the left in 1991.” The DBQ also noted that the Veteran “says since the surgery he has lost feeling on top of both hands after surgery bilaterally and he says he has lost some flex[i]bility in the wrists” and that “the problems with mobility started in 1997 for the left wrist and in 1991 for the right wrist following surgery. He says he could not do any push ups after that. [H]e says he also experi[en]ced loss of sensation of the back of both hands following surgery.” The examiner provided a negative direct service connection nexus opinion. In July 2019, the Board denied these claims, essentially finding that while there were current bilateral wrist disabilities and in-service treatment for bilateral wrist ganglion cysts, there was no nexus to service. In the August 2020 JMPR, it was stated that “the Board denied [Veteran’s] right and left wrist disabilities by relying on a September 2015 VA examination report.” The JMPR stated that the Veteran “has reported experiencing wrist symptomatology continuously since service” and quoted the September 2015 DBQ discussed above. The JMPR further stated that “the September 2015 VA wrist conditions opinion is inadequate as it failed to address [Veteran’s] competent and credible lay statements of continuity of symptomatology” and that “the parties agree that the duty to assist has not been satisfied and remand is warranted for the Board to ensure that VA obtains an adequate medical opinion with respect to [the Veteran’s] right and left wrist claims.” In light of the JMPR, the Board finds that remand is accordingly required to obtain a new VA examination and opinion, as outlined further in the remand directives below. While on remand, outstanding VA treatment records must also be obtained (the most recent records of record are from January 2018). 3. Right hip disability 4. Right leg disability 5. Sciatica Upon review, the Board finds that remand is required for these claims. These issues are being discussed together because of the overlap in symptoms, contentions and evidence, as will be outlined below. In March 2015, the Veteran filed claims for “[r]ight [h]ip [c]ondition,” “[s]ciatica condition sec[ondary] to [l]ower [b]ack” and “[r]ight leg condition sec[ondary] to hip [and] back.” The Board denied these three claims in July 2019, finding that the Veteran did not have a right hip disability, a right leg disability or sciatica. With respect to the right hip disability claim, the August 2020 JMPR referenced the Veteran’s “reports of both symptomatology and functional impairment in a November 2016 VA hip and thigh conditions examination report.” The JMPR then stated that “‘pain alone, without an accompanying diagnosis or identifiable condition,’ can constitute a current disability, provided the pain ‘reaches the level of a functional impairment of earning capacity.’ Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018)” and that “[t]he Board did not explain why [the Veteran’s] pain and functional impairment did not qualify as a disability for VA purposes under Saunders.” The August 2020 JMPR discussed the right leg disability and sciatica claims together. The JMPR referenced the Board’s findings of a lack of a diagnosis of a right leg disability and sciatica and stated that “the Board failed to address multiple medical records that show right leg symptoms which are relevant for both claims.” Records cited by the JMPR included a July 5, 2017 VA primary care treatment note that stated that the Veteran was “still having some sciatic nerve pain,” noted an assessment of right piriformis syndrome and noted a referral to a chiropractor. An assessment was also noted of restless leg syndrome. The Board notes that earlier VA primary care notes also included assessments of right piriformis syndrome and restless leg syndrome. See December 2016 VA Primary Care Treatment Note (noting assessments of both); June 2016 VA Primary Care Treatment Note (noting an assessment of restless leg syndrome). Additional records cited in the JMPR included July 6, 2017 VA and August 16, 2017 VA chiropractor notes, which were substantively similar, that noted a chief complaint of right hip pain and that the Veteran was consulted “for treatment of [h]ip pain [with] radiation down to knee.” Diagnosis were noted of hip pain, myospasm right piriformis and chronic pain. The Veteran submitted in September 2020 “additional legal arguments,” which was a document written by the Veteran’s representative before the Court. In this document, while discussing the right hip disability, reference was made to the December 2016 VA primary care treatment note that included an assessment of right piriformis syndrome. The Board notes that piriformis syndrome is defined as a “neuromuscular disorder that occurs when the piriformis muscle compresses or irritates the sciatic nerve…The piriformis muscle is a narrow muscle located in the buttocks. Compression of the sciatic nerve causes pain-frequently described as tingling or numbness-in the buttocks and along the nerve, often down to the leg.” See Piriformis Syndrome Information Page, National Institute of Neurological Disorders and Stroke, https://www.ninds.nih.gov/Disorders/All-Disorders/Piriformis-Syndrome-Information-Page (last visited March 10, 2021). The Board observes that piriformis syndrome involves the sciatic nerve and seemingly could result in pain or other symptoms in the hip or leg. As such, this diagnosis is relevant to all three claims. It appears that the earliest diagnosis of record of this disability was in the December 2016 VA primary care treatment note, which was dated after the Veteran was afforded various VA examinations in November 2016 (as relevant, a Back Conditions DBQ, Knee and Lower Leg Conditions DBQ and Hip and Thigh Conditions DBQs were completed). In light of this new diagnosis that was noted subsequent to the prior examinations, the Board finds that remand is required for a new VA examination and opinion as to direct service connection, as outlined further in the remand directives below. In addition, this opinion must also address restless leg syndrome, as no opinion is of record addressing this disability. Further, the Veteran explicitly raised the theory of secondary service connection as to his service-connected low back disability (specifically degenerative arthritis of the thoracolumbar spine) and there is evidence indicating that lower leg symptomatology may be related to the service-connected low back disability. See March 2015 VA Form 21-526 (claiming disabilities of “[s]ciatica condition sec[ondary] to [l]ower [b]ack” and “[r]ight leg condition sec[ondary] to hip [and] back”); November 2016 Hip and Thigh Conditions DBQ (“[The Veteran] says that he has r[ight]t restless leg problems and the leg movement is worse when he has the increase in pain on the right hip and back”); November 2016 Back DBQ (“[The Veteran complains of] r[ight]t sided low back pain and r[ight]t hip pain that radiates into the upper thigh”). The Board finds that the requirements to obtain a VA opinion as to secondary service connection were met in this case and such will also be requested on remand, as outlined further in the remand directives below. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Also, the November 2016 Hip and Thigh Conditions DBQ stated “[i]n addition to the VA he sees Dr[.] H[.]…off and on” and a January 2017 VA physical therapy (PT) evaluation consult note contained a diagnosis of right piriformis syndrome and stated “consult was placed for community based PT.” As such, while on remand, the Veteran must be given the opportunity to either provide any outstanding relevant private treatment records, to include any records from Dr. H. or physical therapy, or complete a release for such providers; if any releases are returned, VA must attempt to obtain the identified records. See 38 C.F.R. § 3.159(e)(2) (“If VA becomes aware of the existence of relevant records before deciding the claim, VA will notify the claimant of the records and request that the claimant provide a release for the records”). 6. Chronic headache disability Upon review, the Board finds that remand is required for this claim. The July 2019 Board decision denied service connection for a chronic headache disability. The August 2020 JMPR stated that “the Board addressed [the Veteran’s] headache claim exclusively based on direct service connection…However, [the Veteran] explicitly raised the theory that his headaches are secondary to a neck disability.” The JMPR cited the Veteran’s March 2015 claim that stated “[h]eadaches sec[ondary] to Neck.” The Veteran was granted service connection for a cervical spine disability (specifically degenerative arthritis) in a November 2016 rating decision. The Veteran was afforded a VA examination in June 2016 and a Headaches DBQ was completed. The DBQ stated that the Veteran “reports headaches start with the neck pain.” The examiner provided a negative direct service connection nexus opinion, but did not provide an opinion as to the issue of secondary service connection. The Board finds that the requirements to obtain a VA opinion as to secondary service connection were met in this case. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). As such, remand is required to afford the Veteran a VA examination and obtain a secondary service connection opinion, as outlined further in the remand directives below. 7. Sleep apnea Upon review, the Board finds that remand is required for this claim. The July 2019 Board decision denied service connection for sleep apnea. The Board stated in part that “post-service evidence does not reflect complaints of sleep apnea for many years following separation from service.” The August 2020 JMPR quoted this language and stated “the Board failed to address an August 13, 1999, VA mental health note in which [the Veteran] reported experiencing ‘[s]leep disturbance – unable to sleep more than 6 hours, restless,’” which the JMPR noted was “dated less than two years after [the Veteran’s] separation from service.” The JMPR also stated that “the Board failed to address a March 24, 2016 VA primary care outpatient note in which [the Veteran] reported experiencing sleep symptoms ‘for the last 15 years’ including ‘apneic episodes.’” The JMPR continued that “[a]s the Board denied [the Veteran’s] sleep apnea claim based on the lack of evidence of complaints of sleep apnea for many years following separation from service, the Board was required to address this evidence that [the Veteran] complained of relevant symptoms less than two years after separation from service.” Based on the records cited in the JMPR, the Board finds that the requirements to obtain a VA examination and opinion (which were not previously performed or obtained for this claim) have been met and that remand is therefore required for such, as outlined further in the remand directives below. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, an April 11, 2016 VA sleep medicine note stated that the Veteran “stated that 3 years ago he had a sleep study at Iowa Sleep Disorder Center and they told him that he had severe [obstructive sleep apnea].” An addendum to this note stated “received fax from Iowa Sleep Disorder Center dated 12/15/2013” and “[s]leep study records for Iowa Sleep Disorder Center sent to scanning.” The referenced sleep study records are not currently of record (i.e., associated with the Veteran’s electronic claims file). In review, potentially relevant private medical records appear to be in VA’s possession, but such records are not currently of record. As such, while on remand, the referenced scanned sleep study records for Iowa Sleep Disorder Center must be obtained, if available. The matters are REMANDED for the following action: 1. Obtain outstanding VA treatment records from January 2018 to present. 2. Associate with the Veteran’s electronic claims file, if available, scanned sleep study records for Iowa Sleep Disorder Center referenced in April 11, 2016 VA sleep medicine notes. 3. Contact the Veteran and request that he either provides any outstanding relevant private treatment records, to include any records from Dr. H. or physical therapy, or completes a release for such providers; if any releases are returned, attempt to obtain the identified records. 4. Afford the Veteran a VA examination with respect to his right and left wrist disability claims. The examiner must provide an opinion addressing the following: Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any right or left wrist disability had its onset during service or is otherwise related to service. The examiner’s attention is invited to: (a.) The Veteran’s report of experiencing wrist symptomatology continuously since service. See September 2015 Wrist Conditions DBQ (“says since the surgery he has lost feeling on top of both hands after surgery bilaterally and he says he has lost some flex[i]bility in the wrists” and that “the problems with mobility started in 1997 for the left wrist and in 1991 for the right wrist following surgery. He says he could not do any push ups. after that. [H]e says he also experi[en]ced loss of sensation of the back of both hands following surgery”). (b.) An August 1992 STR, which stated “[decreased] sensation dorsum wrist from previous surg[ery].” (c.) A February 1997 Documentation of Informed Consent form, which was related to excision of a right dorsal wrist ganglion and which listed multiple risks that included “pain, numbness, weakness, stiffness.” For all opinions provided, the examiner must include the underlying reasons for any conclusions reached. 5. Afford the Veteran a VA examination with respect to his right hip disability, right leg disability and sciatica claims. The examiner must provide an opinion addressing the following: (a.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any (1) right hip disability, (2) right leg disability (to include restless leg syndrome) or (3) sciatica (to include piriformis syndrome) had its onset during service or is otherwise related to service. (b.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any (1) right hip disability, (2) right leg disability (to include restless leg syndrome) or (3) sciatica (to include piriformis syndrome) is due to or caused by the Veteran’s service-connected degenerative arthritis of the thoracolumbar spine. (c.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any (1) right hip disability, (2) right leg disability (to include restless leg syndrome) or (3) sciatica (to include piriformis syndrome) has been aggravated (i.e., increased in severity) by the Veteran’s service-connected degenerative arthritis of the thoracolumbar spine. The examiner’s attention is invited to: (a.) Medical records indicating right hip and lower extremity symptoms during active service: i. September 1988 STR (noting a chief complaint of “numbness in legs” for four weeks). ii. February 17, 1993 Authorization for Emergency Medical Care (noting that the Veteran “slipped and fell on ice covered driveway” and an initial diagnosis of “neck and hip problem”) and February 17, 1993 VA Medical Certificate (“slipped and fell on ice…[complains of]…hip pain” and “[complains of] lower back pain [with] numbness [right] lat[eral] thigh”). iii. May 1997 Report of Medical History form (with the Veteran reporting ever having or having now “cramps in your legs” and in the section completed by a medical professional a notation of “[l]eg cramps”). iv. September 1997 Dr. D.H. Private Medical Record (noting the Veteran was seen for “bursitis [right] gluteal [and] hamstrings”). v. May 1998 Annual Medical Certificate (with the Veteran reporting a current medical problem or injury and stating “injury to…right hip from Sept[ember] [19]97”). vi. June 2000 VA Primary Care Treatment Note (noting an assessment of “twitching/jerking r[ight] leg 2-3 y[ear]s”). (b.) The Veteran’s lay statements as to the onset and duration of his right hip and lower extremity symptoms: i. June 2015 Hip and Thigh Conditions DBQ (“The veteran reports ‘pain in the right hip pain started in 1980’s was a minor type of pain, then over the years increase in the pain of the right hip, thinks pain is secondary to walking, running through out the years of active duty service. The [Veteran] reports pain has gradu[]ally increased over the years”). ii. November 2016 Hip and Thigh Conditions DBQ (“Veteran says he has…r[igh]t hip problems that started in the 1980’s in the military when heavy shelving fell on him giving him a concussion and neck injury and back injury and r[ight]t hip problems. Also, he says his training in the military required him to run in combat boots and this aggr[a]vated his hip condition. Since then he has had chronic pain in r[igh]t hip”). iii. January 2017 VA Physical Therapy Evaluation Consult Note (noting a diagnosis of right piriformis syndrome and stating regarding the right buttock “onset approximately 20 years ago from a combination of repeated running and a bookcase that fell on him”). iv. July 6, 2017 VA and August 16, 2017 VA Chiropractor Notes (noting a chief complaint of right hip pain, with an onset noted of “20 years ago”). (c.) As to secondary service connection and items “b” and “c” above: i. November 2016 Hip and Thigh Conditions DBQ (“[The Veteran] says that he has r[ight]t restless leg problems and the leg movement is worse when he has the increase in pain on the right hip and back”). ii. November 2016 Back DBQ (“[The Veteran complains of] r[ight]t sided low back pain and r[ight]t hip pain that radiates into the upper thigh”). For all opinions provided, the examiner must include the underlying reasons for any conclusions reached. 6. Afford the Veteran a VA examination with respect to his chronic headache disability claim. The examiner must provide an opinion addressing the following: (a.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any headache disability is due to or caused by the Veteran’s service-connected degenerative arthritis of the cervical spine. (b.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any headache disability has been aggravated (i.e., increased in severity) by the Veteran’s service-connected degenerative arthritis of the cervical spine. The examiner’s attention is invited to: A June 2016 Headaches DBQ, which stated that the Veteran “reports headaches start with the neck pain.” For all opinions provided, the examiner must include the underlying reasons for any conclusions reached. 7. Afford the Veteran a VA examination with respect to his sleep apnea claim. The examiner must provide an opinion addressing the following: Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that sleep apnea had its onset during service or is otherwise related to service. The examiner’s attention is invited to: (a.) An August 13, 1999 VA mental health note stating “[s]leep disturbance-unable to sleep more than 6 hours, restless.” This note was less than two years after the Veteran’s separation from active service in November 1997. (b.) A March 24, 2016 VA primary care outpatient note stating that the Veteran “reports that he has been having alot of problems with sleeping. He reports that he snores and wife reports that he has apneic episodes…[symptoms] for the last 15 years.” For all opinions provided, the examiner must include the underlying reasons for any conclusions reached. KANISHA R. LAFFITTE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Hoopengardner, 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.