Citation Nr: 21021538 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 17-04 480 DATE: April 13, 2021 REMANDED Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for sleep apnea, to include as secondary to the acquired psychiatric disorder or due to an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI), is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety disorder, not otherwise specified (NOS), attention deficit hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), chronic insomnia, and adjustment disorder, is remanded. REASONS FOR REMAND The Veteran had active military service from March 1986 to March 1992, to include service in Southwest Asia during the Persian Gulf War. These issues are on appeal from a December 2015 rating decision. In January 2019, the Board of Veterans’ Appeals (Board) denied these claims, along with the claims of service connection for a personality disorder and alcohol abuse disorder. The Board also dismissed two other claims. The Veteran appealed the sleep apnea, tinnitus, and acquired psychiatric disorder denials to the U.S. Court of Appeals for Veterans Claims (Court). A June 2020 Court Memorandum Decision set aside the January 2019 Board decision regarding the sleep apnea, tinnitus, and acquired psychiatric disorder denials and remanded these issues to the Board for further consideration consistent with the Memorandum Decision. The Court deemed the dismissals, personality disorder, and alcohol abuse disorder claims to be abandoned by the Veteran. 1. Entitlement to service connection for tinnitus is remanded. The Board cannot make a fully-informed decision on the tinnitus issue because the November 2015 VA examiner provided inadequate rationale to support his conclusion that the Veteran’s tinnitus was not related to in-service noise exposure. His rationale focused specifically on whether the Veteran had tinnitus since service but did not address whether in-service noise exposure could have resulted in a later diagnosis of tinnitus. Upon remand, an adequate VA medical opinion must be obtained. 2. Entitlement to service connection for sleep apnea, to include as secondary to the acquired psychiatric disorder or due to an undiagnosed illness or a MUCMI, is remanded. The Board cannot make a fully-informed decision on the sleep apnea issue because no VA examiner has opined whether the Veteran’s currently diagnosed sleep apnea is a MUCMI. 38 C.F.R. § 3.317(a)(2)(ii). A MUCMI is a “diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities.” Id. An etiology opinion is not of record for the diagnosed sleep apnea, and the Veteran has not been afforded a VA examination and medical opinion for this claim. Due to his current diagnosis and his Persian Gulf War service, the Board finds that, upon remand, an adequate VA medical opinion must be obtained. 3. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety disorder, NOS, ADHD, PTSD, chronic insomnia, and adjustment disorder, is remanded. The Board cannot make a fully-informed decision on the acquired psychiatric disorder issue because the June 2017 VA examiner overlooked the Veteran’s reports of in-service events, including SCUD missile attacks, searching for bombs, and witnessing a fatal car accident. The examiner also failed to discuss whether such events caused or were in some way related to the Veteran’s current psychiatric symptoms. Instead, the examiner relied on the absence of psychiatric symptoms in service and provided an inadequate rationale for the opinion rendered. Upon remand, an adequate VA medical opinion must be obtained. The matters are REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s currently diagnosed tinnitus. The examiner is asked to provide a response to the following: a) Is the Veteran’s currently diagnosed tinnitus at least as likely as not related to service, including his in-service noise exposure from working as a military policeman? b) Is it at least as likely as not that the Veteran’s currently diagnosed tinnitus (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? In providing the requested opinions, consider the Veteran’s description of his in-service noise exposure as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? The examiner must review the claims file. Provide a rationale to support the opinions. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s currently diagnosed sleep apnea. The examiner is asked to provide a response to the following: a) Is the Veteran’s currently diagnosed sleep apnea at least as likely as not related to service, including the environmental hazards from his service in the Persian Gulf War? b) Is the etiology of the Veteran's current sleep apnea completely or partially understood? c) Is the pathophysiology of the Veteran's current sleep apnea completely or partially understood? For the purposes of this opinion, the examiner is advised that "pathophysiology" is defined as "the physiology of abnormal states; spec[ifically]: the functional changes that accompany a particular syndrome or disease." Webster's Third New International Dictionary of the English Language Unabridged 1655 (1966); Stewart v. Wilkie, 30 Vet. App. 383, 392 (2018). 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s currently diagnosed acquired psychiatric disorder, to include anxiety disorder, NOS, ADHD, PTSD, chronic insomnia, and adjustment disorder. The examiner is asked to provide a response to the following: a) Does the Veteran have a current diagnosis of PTSD? If so, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. In this regard, the examiner must discuss the November 2019 private nurse practitioner opinion that diagnoses the Veteran with PTSD. b) Is the Veteran’s acquired psychiatric disorder at least as likely as not related to service, to include the Veteran’s reports of in-service events? In forming this opinion, the examiner must address the Veteran’s reports of in-service events, including SCUD missile attacks, searching for bombs, and witnessing a fatal car accident. c) Is it at least as likely as not that the current acquired psychiatric disorder (not including any diagnosed PTSD) (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? In providing the requested opinions, consider the Veteran’s description of the in-service events and his symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported events and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? The examiner must review the claims file. Provide a rationale to support the opinions. 4. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefits sought are not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Shauna M. Watkins, 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.