Citation Nr: 21022507 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 17-42 906 DATE: April 16, 2021 REMANDED Entitlement to service connection for circadian rhythm sleep-wake disorder, to include as secondary to service-connected adjustment disorder with anxiety and/or irritable bowel syndrome, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from July 1997 to November 2000. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2020, the Veteran testified before the undersigned Veterans Law Judge at a video conference hearing. A transcript of the hearing is of record. In March 2020, the Board remanded this matter for further development. At that time, the Board also remanded a claim for service connection for an acquired psychiatric disorder, to include adjustment disorder with anxiety; however, the RO granted that claim in an August 2020 rating decision. As the grant of service connection represents a full grant of the benefit sought, that issue is no longer on appeal before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Unfortunately, as explained below, the Board is not satisfied that there was substantial compliance with its prior remand as to the issue remaining on appeal; therefore, the appeal must be remanded once again. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for circadian rhythm sleep-wake disorder, to include as secondary to service-connected adjustment disorder with anxiety and/or irritable bowel syndrome, is remanded. The Veteran seeks entitlement to service connection for a sleep disorder, diagnosed as circadian rhythm sleep-wake disorder, which he contends was incurred in service. The Veteran asserts that he began having trouble sleeping during service due to the high-stress nature of his military occupational specialty (MOS) of security forces journeyman, which required him to work overnight shifts. Alternatively, the Veteran has also claimed that his sleep disorder may be proximately due to or caused by his service-connected adjustment disorder with anxiety. The Veteran was diagnosed with circadian rhythm sleep-wake disorder by a VA examiner in March 2015, who, upon testing and interview of the Veteran, found that he met the diagnostic criteria for this specific diagnosis as set forth by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Moreover, at a January 2017 VA behavioral health evaluation, the Veteran was diagnosed with an unspecified sleep-wake disorder. In the March 2020 remand, the Board found that the evidence of record did not contain an adequate medical opinion addressing the Veteran’s claim, to include whether he is entitled to secondary service connection. As such, the Board directed the RO to obtain an addendum medical opinion from a VA examiner that adequately addresses the nature and etiology of the Veteran’s sleep disorder. The Veteran underwent a VA mental disorders examination in May 2020. The VA examiner indicated on the examination report that the Veteran denied any current symptoms of sleep disturbance. Therefore, the examiner determined that the Veteran does not currently meet the DSM-5 criteria for any sleep disorder, to include circadian rhythm sleep-wake disorder. The examiner further stated that at the time of his last VA examination in 2015, his reported sleep disturbance appeared to be a symptom of adjustment disorder with anxiety and should not have been considered a separately-diagnosable condition. In an October 2020 statement, the Veteran disputed the May 2020 VA examiner’s findings and described experiencing current symptoms of sleep disturbance. In this statement, the Veteran also raised the additional theory that his current sleep disorder may be secondary to his service-connected irritable bowel syndrome, which he stated interferes with his ability to sleep. See Szemraj v. Principi, 357 F.3d 1370, 1375-76 (Fed. Cir. 2004). The Board finds the May 2020 VA medical opinion to be inadequate. First, even if the examiner determined that the Veteran does not currently meet the diagnostic criteria for a sleep disorder, the examiner should have provided responses to the Board’s examination directives for the sleep disorder diagnosed during the pendency of the appeal. The examiner did not do this. Moreover, the examiner’s conclusion that the sleep disturbance noted at the March 2015 VA examination “should not have been considered a separately-diagnosable condition” was not accompanied by a supporting medical rationale. The Board can find no reason to dispute the findings of the VA psychologist who, upon testing and interview of the Veteran, determined that he met the DSM-5 criteria for a diagnosed sleep disorder at that time. In light of the above, the Board finds that the record still does not contain a medical opinion that is sufficient to fairly decide the Veteran’s service connection claim. As such, the claim must be remanded once again because the RO did not comply with the Board’s prior remand directives to obtain an adequate medical opinion on the Veteran’s behalf.  See Stegall, 11 Vet. App. at 268.  On remand, a medical opinion must be obtained that is adequate for the Board to make an informed decision on the Veteran’s claim.  See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Douglas v. Shinseki, 23 Vet. App. 19, 26 (2009). In this regard, the Board notes that any sleep disorder diagnosed during the pendency of the claim must be addressed, even if not currently present on examination or deemed resolved, prior to VA’s adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013).   Accordingly, the matter is REMANDED for the following action: Schedule the Veteran for a VA examination with a medical professional of appropriate expertise to determine the nature and etiology of any currently-diagnosed sleep disorder, to include circadian rhythm sleep-wake disorder. The entire claims file, to include a copy of this REMAND, must be provided to the examiner and reviewed in full. A complete history of symptoms should be elicited from the Veteran. Thereafter, the VA examiner is asked to provide a fully-articulated medical opinion addressing the following: (a) Identify all sleep disorders diagnosed during the pendency of this appeal, including those that have since resolved. In this regard, the record reflects that the Veteran has been diagnosed with circadian rhythm sleep-wake disorder and unspecified sleep-wake disorder during the pendency of this appeal. (b) If, upon thorough examination and interview of the Veteran, including performing any necessary psychological testing, the examiner determines that the Veteran does not currently meet the diagnostic criteria under the DSM-5 for a sleep disorder, this finding must be supported by a fully-articulated medical rationale. If the examiner finds that the Veteran’s current symptoms of sleep disturbance are solely a symptom of his adjustment disorder with anxiety, as opposed to a separately-diagnosed condition, such a finding also needs to be accompanied by a fully-articulated medical rationale. (c) For any sleep disorder diagnosed during the pendency of the claim, even if currently resolved, opine whether it is at least as likely as not (50 percent or greater probability) that the condition was incurred in or caused by any in-service disease, event, or injury. (d) For any sleep disorder diagnosed during the pendency of the claim, even if currently resolved, opine whether it is at least as likely as not (50 percent or greater probability) that the condition is caused by the Veteran’s service-connected adjustment disorder with anxiety and/or irritable bowel syndrome. (e) For any sleep disorder diagnosed during the pendency of the claim, even if currently resolved, opine whether it is at least as likely as not (50 percent or greater probability) that the condition is aggravated by (increased in severity beyond its natural progression) the Veteran’s service-connected adjustment disorder with anxiety and/or irritable bowel syndrome. Separate responses must be provided for questions (d) and (e). In providing the requested opinion(s), the examiner must specifically consider and address: (i) the Veteran’s lay statements and hearing testimony as to the in-service onset of symptoms of a sleep disorder due to the stress of his MOS duties; (ii) his October 2020 statement that his symptoms of irritable bowel syndrome interfere with his ability to sleep; and (iii) a January 2013 American Academy of Sleep Medicine article submitted by the Veteran titled, “Active Duty Military Personnel Prone to Sleep Disorders and Short Sleep Duration.” The examiner is advised that the Veteran is competent to report his medical history, including the onset of symptoms, and such reports must be acknowledged and considered in formulating any opinion. The Veteran’s lay contentions must be considered and weighed in making the determination as to whether a nexus exists between the claimed disability and military service. The examiner must provide a complete rationale for any opinion offered, citing to the examiner’s own expertise, medical principals, and/or evidence in the Veteran’s claims file, when necessary, to support the conclusion reached.  If the requested opinion cannot be rendered without resorting to speculation, the examiner must fully explain why that is so.   The examiner is reminded that failure to comply with the directives outlined herein will render the opinion inadequate and will result in further remand of the Veteran’s claim. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Melissa Barbee, 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.