Citation Nr: 21026223 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 19-07 112 DATE: April 30, 2021 REMANDED Entitlement to service connection for a skin disorder, to include as secondary to service-connected hypertension and service-connected posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected PTSD is remanded. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected PTSD is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from November 1965 until November 1967. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.902 (c). This appeal was most recently before the Board in January 2021 when it was remanded for further development. Unfortunately, there has not been substantial compliance with the prior remand directives and another remand is required. Stegall v. West, 11 Vet. App. 268 (1998). The Veteran’s representative argues that the February 2021 VA opinions are inadequate as to all three claims. The Board agrees; the claims must be remanded for adequate opinions. The secondary aggravation opinions considered an incorrect standard. The correct standard for aggravation of a nonservice-connected disability by a service-connected disability is any increase in disability. 38 C.F.R. § 3.310 (b). 1. Entitlement to service connection for a skin disorder, to include as secondary to service-connected hypertension and PTSD is remanded. The Veteran asserts that his skin disorder is proximately due to or aggravated by his service-connected hypertension to include the medication prescribed to treat his hypertension and his service-connected PTSD. The opinion on remand must include the correct standard of aggravation and consider the recently raised theory that the Veteran’s skin condition is secondary to his PTSD. The Veteran’s representative submitted specific articles suggesting a connection. 2. Entitlement to service connection for GERD, to include as secondary to service-connected PTSD is remanded. The Veteran asserts that his GERD is proximately due to or aggravated by his service-connected PTSD. The opinion on remand must include the correct standard of aggravation and must also address the recent assertion that the Veteran’s GERD is caused by obesity which itself is caused by his PTSD. Obesity may be an intermediate step between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310 (a). See VAOPGCPREC 1-2017 (Jan. 6. 2017). 3. Entitlement to service connection for OSA, to include as secondary to service-connected PTSD is remanded. The Veteran asserts that his sleep apnea is proximately due to or aggravated by his service-connected PTSD. The VA opinion provider noted that the Veteran has a history of obesity. The Veteran has recently presented argument that his obesity is due to his service-connected PTSD. The opinion on remand must consider the appropriate standard of aggravation whether the Veteran’s OSA and PTSD are related through the intermediate step of obesity. The Veteran has submitted numerous articles regarding the relationship between sleep apnea and PTSD since the last VA examination. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s skin disorder. The opinion provider should be provided with all pertinent documents, including a copy of this remand. If the examiner determines that a requested opinion cannot be made without examination of the Veteran, one should be scheduled. After a review of pertinent records and examination of the Veteran, if necessary, the opinion provider is asked to answer the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s skin disorder is proximately due to/caused by his service-connected hypertension, to include medications used to treat his hypertension? (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s skin disorder is aggravated by (any increase in disability) his service-connected hypertension, to include medications used to treat his hypertension? (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s skin disorder is proximately due to/caused by his service-connected PTSD? (d) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s skin disorder is aggravated by (any increase in disability) his service-connected PTSD? In answering these questions, the examiner must specifically discuss the studies referenced in the representative’s April 2021 submission related to medical evidence linking hypertension and seborrheic keratosis. See Gupta A, K, Madzia S, E, Batra R.: Etiology and Managements of Seborrheic Dermatitis. Dermatology 2004; 208:89-93doi:10.1159/000076478. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge; the examiner’s own expertise, or; whether additional facts are required and note what, if any, additional evidence would permit such an opinion to be made. 2. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s GERD. The opinion provider should be provided with all pertinent documents, including a copy of this remand. If the examiner determines that a requested opinion cannot be made without examination of the Veteran, one should be scheduled. After a review of pertinent records and examination of the Veteran, if necessary, the opinion provider is asked to answer the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s GERD is proximately due to his service-connected PTSD? (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s GERD is aggravated by (any increase in disability) his service-connected PTSD? In answering these questions, the examiner must specifically address the following: (i) whether the Veteran’s service-connected PTSD caused the Veteran to become obese; (2) if so, whether the obesity as a result of his PTSD was a substantial factor in causing the Veteran’s GERD; and (3) whether the GERD would not have occurred but for obesity caused by his PTSD disability? The opinion provider must consider, and discuss as appropriate, the article submitted by the Veteran in April 2021 regarding gastrointestinal issues in Veterans. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge; the examiner’s own expertise, or; whether additional facts are required and note what, if any, additional evidence would permit such an opinion to be made. 3. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s sleep apnea. The opinion provider should be provided with all pertinent documents, including a copy of this remand. If the examiner determines that a requested opinion cannot be made without examination of the Veteran, one should be scheduled. After a review of pertinent records and examination of the Veteran, if necessary, the opinion provider is asked to answer the following: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea is proximately due to his service-connected PTSD? (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea is aggravated by (any increase in disability) his service-connected PTSD? In answering these questions, the examiner must specifically address the following: (i) whether the Veteran’s service-connected PTSD caused the Veteran to become obese; (2) if so, whether the obesity as a result of his PTSD was a substantial factor in causing the sleep apnea; and (3) whether the sleep apnea would not have occurred but for obesity caused by his PTSD disability? The opinion provider must consider, and discuss as appropriate, the numerous articles submitted by the Veteran in April 2021 regarding sleep apnea and its relation to PTSD. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge; the examiner’s own expertise, or; whether additional facts are required and note what, if any, additional evidence would permit such an opinion to be made. 4. Confirm that the VA medical opinions provided comport with this remand. Specifically, ensure that the standard for secondary aggravation opinions is any increase in disability, not the standard of “beyond the natural progression” as noted on the examination form itself. If the incorrect standard is applied, obtain an addendum opinion prior to readjudication of the claim. M.E. Larkin Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.D. Collins, 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.