Citation Nr: 21026239 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 14-07 943 DATE: April 30, 2021 REMANDED The issue of entitlement to service connection for a condition of extreme cough, to include as due to an undiagnosed illness, is remanded. The issue of entitlement to service connection for a sleep disorder, to include sleep apnea, is remanded. REASONS FOR REMAND The Veteran served on active duty during Peacetime and the Gulf War from December 1984 to December 1987 and from July 1989 to January 1992. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a January 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board and remanded for additional development in November 2017. Unfortunately, the completed development does not substantially comply with the remand directives and an additional remand is warranted. Dyment v. West, 13 Vet. App. 141, 14647 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. The condition of extreme cough due to oil fires, to include as due to an undiagnosed illness is remanded. The Veteran contends that he has developed an extreme cough due to exposure to oil fires during the Gulf War. January 29, 2011, Statement in Support of Claim. In an October 2011 lay statement, the Veteran’s wife explains that the Veteran has not been able to stop coughing since he returned from the Gulf War and started to cough up dark mucous in the past five years. October 9, 2011, Statement in Support of Claim. A new VA examination was obtained in August 2018. The examiner determined that the Veteran did not now have or has ever been diagnosed with a respiratory condition. August 11, 2018, VA Examination. The examiner opined that the claimed condition, extreme cough, was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. August 11, 2018, Medical Opinion. The examiner acknowledged that the Veteran was exposed to oil fires during his service in the Persian Gulf but reasoned that there was no supporting evidence of a diagnosis of a chronic respiratory condition resulting from the exposure. Although the Veteran was afforded an additional VA examination, the medical opinion is not adequate for adjudication purposes. The examiner failed to address whether the Veteran’s report of respiratory symptoms represent an objective indication of a chronic disability attributable to an undiagnosed illness or a medically unexplained chronic multi-symptom illness related to the Veteran’s Gulf War service. 38 C.F.R. § 3.317. A remand is necessary to obtain an addendum opinion. Once VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311. 2. A sleep disorder, to include sleep apnea is remanded. The Veteran contends that he has developed sleep apnea from the Gulf War. January 29, 2011, Statement in Support of Claim. The Veteran has a confirmed diagnosis of sleep apnea. June 21, 2018, Medical Treatment Record – Non-Government. The Veteran also endorses difficulty sleeping and insomnia. August 11, 2018, VA Examination. The Veteran’s wife notes that the Veteran cannot sleep without medication and he wasn’t that way before he was deployed to the Persian Gulf. See October 9, 2011, Statement in Support of Claim. The Veteran was afforded a new VA examination in August 2018. The examiner rendered a negative nexus opinion, noting that respiratory conditions are not exclusive causes of sleep impairment disorders and physical conditions are usually more related. August 11, 2018, Medical Opinion. The examiner explained that physical examination of the Veteran revealed weight issues, large tonsils and tongue with narrow pharynx were more related to the cause of the Veteran’s sleep condition than any respiratory condition at this time. It is not clear whether the examiner considered the Veteran’s contention that exposure to oil fires, and not a respiratory condition, caused him to develop sleep apnea in formulating his opinion. An addendum opinion is warranted. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (a medical opinion is inadequate if it does not take into account the Veteran’s reports of symptoms and history). Additionally, in light of the examiner’s opinion and the Veteran’s service-connected disabilities of bunionectomy with residual scar and decreased mobility and posttraumatic stress disorder (PTSD), the theory of secondary service connection with obesity as an intermediate step is reasonably raised. 38 C.F.R. § 3.310(a); VAOPGCPREC 1-2017 (Jan. 6, 2017). The record reveals that the Veteran was granted service connection for residuals of a right foot bunionectomy with an effective date of October 2000 in an April 2002 rating decision. April 24, 2002, Rating Decision. During a March 2002 VA examination, the Veteran reported pain and weakness when standing and walking and weighed 255 pounds with a reported height of 75 inches. March 8, 2002, VA Examination. During an October 2003 examination, the examiner noted increased worsening of pain associated with residuals of right foot bunionectomy and the Veteran’s weight had increased to 272 pounds. October 29, 2003, Medical Treatment Record -Government. By February 2011, the Veteran weighed 294 pounds and an examiner opined that the effect of the Veteran’s residuals of right foot bunionectomy on his usual occupation and daily activities was moderate due to extreme pain when walking and standing. June 2, 2011, VA Examination. An addendum opinion is warranted to address this theory of entitlement. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the appropriate clinician to determine the nature and etiology of the Veteran’s extreme cough due to oil fires, to include as due to an undiagnosed illness. If the clinician states than an examination of the Veteran would be appropriate, schedule one. The clinician should review the virtual file and address the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) the Veteran’s report of extreme cough represents an objective indication of a chronic disability attributable to an undiagnosed illness or a medically unexplained chronic multi-symptom illness related to the Veteran’s Gulf War service. The examiner should acknowledge and address the lay statements of the Veteran and his wife concerning the onset and persistent nature of the cough. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for doing so. 2. Obtain an addendum opinion from the appropriate clinician to determine the etiology of the Veteran’s sleep apnea. If the clinician states than an examination of the Veteran would be appropriate, schedule one. The clinician should review the virtual file and address the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s current sleep apnea was incurred in or is otherwise related to the Veteran’s period of active service, to specifically include exposure to oil fires. (b.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s service-connected disabilities caused or aggravated (i.e., worsened beyond the normal progression) the Veteran’s obesity. If the answer to (b.) is yes, then the examiner should proceed and address the following: (c.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s obesity was a substantial factor in causing or aggravating non-service-connected sleep apnea. (Continued on the next page)   (d.) Whether it is at least as likely as not (50 percent or greater probability) that non-service-connected sleep apnea would not have occurred but for obesity caused by service-connected disabilities. 3. A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Monica Ball Jackson, 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.