Citation Nr: 21023170 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 10-08 365 DATE: April 20, 2021 REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1967 to April 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2009 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). The Board provided detailed historical recitations in its previous remand orders. Given the extremely lengthy historical nature of this case, they are incorporated by reference at this time. In December 2020, the Board remanded the Veteran’s claims for service connection for sleep apnea, back, and left shoulder disabilities for additional development, to include obtaining adequate medical opinions. The matter has returned to the Board for further appellate review.   1. Entitlement to service connection for sleep apnea is remanded. Unfortunately, the Board regrets further delay but cannot make a fully informed decision on this matter because the January 2021 VA medical opinions are inadequate. The Veteran has contended that his sleep apnea is related to his active duty service, to include as secondary to his service-connected diabetes mellitus. Pursuant to the Board’s October 2020 remand directives, an aggravation opinion was sought in January 2021. The examiner opined that, regarding obstructive sleep apnea (OSA) being due to or the result of the service-connected diabetes, there was absolutely no correlation. The rationale was that OSA, as the name implied, was due to airway obstruction, mostly, upper airway, as in a person with chronic sinusitis/rhinitis. They noted that diabetes is an endocrine disorder manifested by high blood sugars, which at times may require use of hypoglycemic agents, or at its worst, use of insulin. The examiner concluded it was less likely as not that the Veteran's OSA was due to or the result of his service-connected diabetes. They further opined that, along the same lines, OSA was not aggravated by diabetes. See January 2021 C&P Examination. The Board finds the January 2021 medical opinion inadequate because the examiner mostly described what sleep apnea is on one hand and what diabetes is on the other hand without providing further details. Although the opinion inferred that there is no causal relationship between the two disabilities, the opinion failed to specifically discuss the effect of the Veteran’s diabetes on his sleep apnea. For instance, whether or not the Veteran’s diabetes medications have any impact on the development or progression of his sleep apnea. Based on the above, a remand is warranted for another VA opinion to determine the nature and etiology of the Veteran’s sleep apnea. When VA undertakes to obtain an examination or opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).   2. Entitlement to service connection for a left shoulder disability is remanded. The Veteran claims that his left shoulder disability is related to his active duty service to include as due to a service-connected disability or disabilities. Following the Board’s December 2020 remand directives, the agency of original jurisdiction (AOJ) obtained an opinion regarding the Veteran’s left shoulder disability in January 2021. The examiner opined that it was less likely as not the result of service-connected disability or disabilities listed. They noted that the Veteran was service-connected for coronary artery disease, diabetes mellitus, peripheral vascular disease of the bilateral lower extremities, adjustment disorder, bilateral hearing loss, tinnitus, kidney stones, and skin melanoma. The examiner opined that all of them had nothing to do with the left shoulder disability. The examiner further opined that the question of aggravation was also a moot point, i.e., none of the service-connected disabilities contributed to or caused the left shoulder dysfunction. See January 2021 C&P Examination. The Board finds the January 2021 examination inadequate because while the examiner noted that the service-connected disabilities have “nothing to do with the left shoulder disability,” this statement is vague, lacks sufficient detail, and too conclusory to understand why the examiner reached this opinion. An adequate medical examination must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions and must provide sufficient detail for the Board to make a fully informed evaluation of whether service connection is warranted. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); See also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). For this reason, a new medical opinion must be obtained upon remand. 3. Entitlement to service connection for a back disability is remanded. The Veteran contends that his back disability was incurred in service. A medical opinion determining the etiology of the back disability was sought in January 2021. The examiner opined that it was less likely as not that the diagnosis of any disability of the spine was due to or the result of an in-service disease, injury, or other incident involving the back. The rationale was that the Veteran enlisted on July 11, 1967, and was discharged on April 30, 1971. The examiner noted that review of the service treatment records (STRs) failed to disclose any documentation of any back injury having occurred while on active duty. The examiner noted that the Veteran's claims file did disclose he fell off a ladder in 1999 and injured his back, years after having been discharged. See January 2021 C&P Examination. The Board finds the January 2021 opinion inadequate for adjudicative purposes, because even though the examiner noted that there was no documentation of a back condition in the Veteran’s STRs, the records reveal that in January 1969, the Veteran sought treatment for back pain of three days duration and was diagnosed with a possible viral myositis. A medical opinion based on an inaccurate factual premise has no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012). As such, a new opinion is required. The matters are REMANDED for the following action: 1. Obtain all outstanding VA and private medical records and associate them with the claims file. 2. After the development ordered in Step 1 above has been performed to the extent possible, obtain a medical opinion regarding the etiology of the Veteran’s sleep apnea. The claims file must be made available to the examiner. The Veteran need not be personally examined unless such examination is found necessary by the reviewer. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the examiner must opine as to: (a) whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's sleep apnea had its onset in or is related to service. The examiner must consider all risk factors as narrated by the Veteran. (b) whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's sleep apnea is caused by OR aggravated by his service-connected diabetes mellitus. A complete rationale must be provided. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. 3. After the development ordered in Step 1 above has been performed to the extent possible, obtain a medical opinion regarding the etiology of the Veteran’s left shoulder disability. The claims file must be made available to the examiner. The Veteran need not be personally examined unless such examination is found necessary by the reviewer. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the examiner must opine as to: (a) whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's left shoulder disability had its onset in or is related to service. (b) whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's left shoulder disability is caused by OR aggravated by any of his service-connected disabilities (coronary artery disease, diabetes mellitus, peripheral vascular disease of the bilateral lower extremities, adjustment disorder, bilateral hearing loss, tinnitus, kidney stones, and skin melanoma). The examiner must discuss the specific factors that contributed to the Veteran’s current left shoulder disability in providing the opinion. A complete rationale must be provided. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. 4. After the development ordered in Step 1 above has been performed to the extent possible, obtain an opinion from an appropriate clinician regarding the etiology of the Veteran’s back disability. The claims file must be made available to the examiner. The Veteran need not be personally examined unless such examination is found necessary by the reviewer. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner must opine as to: (a) whether it is at least as likely as not (a 50 percent probability or greater) that the back disability began during service or is otherwise related to an in-service injury, event, or disease. (b) whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's back disability is caused by OR aggravated by any of his service-connected disabilities. The examiner must discuss the specific factors that contributed to the Veteran’s current back disability in providing the opinion. A complete rationale must be provided. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. 5. Thereafter, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period should be allowed for response. L. BARSTOW Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. M. Rogers, 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.