Citation Nr: 21028353 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 08-17 953 DATE: May 11, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected intervertebral disc syndrome (IVDS) with degenerative arthritis of the lumbosacral spine, and right thumb sprain and osteoarthritis, is denied. REMANDED Entitlement to service connection for a bilateral ear disability other than hearing loss and tinnitus is remanded. Entitlement to service connection for a sleep disorder other than OSA, to include insomnia, and as secondary to service-connected IVDS with degenerative arthritis of the lumbosacral spine, and right thumb sprain and osteoarthritis, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran's bilateral hearing loss disability was incurred in, or is otherwise related to, his active duty service. 2. The preponderance of the evidence is against a finding that the Veteran's tinnitus was incurred in, or is otherwise related to, his period of active duty service. 3. The competent and probative evidence of record demonstrates that the Veteran's currently diagnosed OSA is not related to his military service, to include as secondary to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.309(a), 3.385. 2. The criteria for service connection for tinnitus are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309(a). 3. The criteria for service connection for OSA are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1973 to November 1984. The matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision. These matters were previously remanded for further development in April 2012, March 2016, March 2017, May 2019, January 2020, and most recently in July 2020. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.304. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be awarded on a secondary basis for disability which is caused or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310(a). Additionally, for Veterans who have served 90 days or more of active service during a period of war or after December 31, 1946, certain chronic disabilities, including tinnitus and sensorineural hearing loss, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing a continuity of symptomatology after service. 38 C.F.R. § 3.303 (b). The use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Sensorineural hearing loss and tinnitus are considered organic diseases of the nervous system for the purposes of 38 C.F.R. § 3.309(a). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for bilateral hearing loss is denied. 2. Entitlement to service connection for tinnitus is denied. The Veteran filed his service-connection claim for a sleep disorder, hearing loss, and an inner ear condition in April 2006. See April 2006 VA Form 21-526. The Veteran contends that his in-service exposure to acoustic trauma is related to his current conditions. See February 2011 VA Form 646. The record indicates that the Veteran has tinnitus. See March 2009 Emergency Department records; see also May 2009 private treatment records. Additionally, the Veteran has been diagnosed with bilateral hearing loss. See October 2014 VA examination report; see also July 2019 VA examination report. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. At the Veteran's October 2014 audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 15 15 20 LEFT 15 5 20 15 20 The Veteran's speech discrimination scores were 88% in the right ear and 90% in the left ear. The VA examiner opined that the Veteran's bilateral hearing loss was not at least as likely as not (50 percent probability or greater) caused by or a result of an event in military service. The examiner explained that the service medical records in the Veteran's claims file show one pure tone hearing test which was performed at enlistment and the test shows normal hearing levels in both ears. The examiner noted that the test is documented in two places; one record is a graph and the other is a chart, but they show the same test results; so, although the graph is not dated, it appears that it is the source of the test results that were recorded on the enlistment physical (some of the levels from the graph were not recorded on the enlistment physical, however). The VA examiner explained that the Veteran's hearing levels during the October 2014 exam were also normal, with the exception of mild bilateral high frequency hearing loss at 8KHz in both ears, and the current hearing loss is not considered a disability. See October 2014 VA examination report. During the Veteran's October 2014 VA examination, the VA examiner noted the Veteran reported recurrent tinnitus as well as the Veteran's reports that he first noticed it in 2006 and it was documented by a private physician at that time. The VA examiner opined that the Veteran's tinnitus is less likely than not (less than 50 percent probability) caused by or a result of military noise exposure. She explained that the onset of tinnitus was many years after military service and there is no record of a tinnitus complaint in any of the service treatment records, including the notes from medical clinic appointments for ear pain related to cold air, and visits related to dizziness. The examiner noted that, although the lack of evidence is not evidence, because tinnitus is subjective, the lack of a report of tinnitus at other visits for ear problems suggests that the tinnitus onset was not during service. The VA examiner noted that, on questioning that day, the Veteran related that he first noticed tinnitus about 20 years ago, and first reported it to the private physician that he saw in Virginia in 2006, a record of which is in the claims file. She explained that it is also not likely that the tinnitus is caused by the Veteran's reported noise exposure and hearing problems in service, or the documented ear pain in service, or the result of a disease or injury in service. She noted that there is no evidence that the current hearing loss occurred in service, and as such there is no evidence of acoustic trauma to the ears from noise in service. The examiner explained that, while middle ear abnormalities may cause tinnitus, there is no evidence that any ear pain or otitis media that occurred in service continues now; testing today reveals normal middle ear and ear drums bilaterally. She stated that she sees no evidence of a disease or injury in service that would cause tinnitus many years later, including ear pain and dizziness. The examiner noted that the Veteran reported loud noise exposure from a tank in Germany, and a bleeding right ear while in Germany in 1982 or 1983, but there is no residual injury on examination today such as perforated ear drums, and there is no record of the bleeding ears in the service medical records. The examiner noted that the Veteran reported he has diabetes and high blood pressure, and either or both of these conditions may lead to tinnitus onset. See October 2014 VA examination report. In its March 2016 decision, the Board found the October 2014 medical opinion to be inadequate as the VA examiner incorrectly stated the Veteran's current hearing loss was not considered a disability; this assessment was incorrect based on the Veteran's speech recognition ability of 88 percent in the right ear and 90 percent in the left ear, which meets the criteria for a diagnosis of hearing loss per VA regulations. The Board remanded the issue for an addendum opinion regarding the etiology of the Veteran's bilateral hearing loss. The record includes a May 2016 VA opinion in which the VA examiner noted that she had reviewed the claims file and there are several medical notes showing ear pain was reported when running in cold weather, and a profile for not running outside in cold air was completed. On one note, the ENT recommended discontinuation of Q-tips to reduce the ear pain. On two of these notes regarding ear pain from cold weather, with different dates, it is noted that the Veteran denied hearing loss. In addition, the claims file contains a 1982 Report of Medical History form from 1982, that is completed by the servicemember, on which the servicemember indicated "No" to the questions of "hearing loss" and "ENT trouble." In addition, the examiner noted that the Veteran's MOS had a low risk of hazardous noise exposure. The examiner also noted that there was record of reports of vertigo in the service medical records; those care notes indicate that the vertigo episodes were related to gastroenteritis. Given all of the above, especially the noted report of no hearing loss found on two different care notes in the service medical record, and the 1982 Report of Medical History on which the servicemember noted no hearing loss or ENT trouble, it was her opinion that the hearing loss found on word recognition testing at the October 2014 C&P examination is less likely as not caused by or a result of any in-service disease, event, or injury, to include the documented in-service complaints related to his ears beginning in September 1974, to include being put on profile in February 1975. See May 2016 VA examination report. The Board remanded in May 2019 for an addendum opinion to include consideration of the Veteran's report of a history of hearing loss in his Report of Medical History at the time of separation from service as well as his contentions that all his ear trouble started while in service and that he was still having trouble with severe earaches. The Veteran was afforded another VA hearing loss and tinnitus examination in July 2019. At his July 2019 audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 10 10 LEFT 20 5 10 15 20 The Veteran's speech discrimination scores were 96% in the right ear and 90% in the left ear. Based on review of the Veteran's file as well as the in-person examination, the July 2019 VA examiner opined that it was not at least as likely as not (50 percent probability or greater) that the Veteran's right or left ear hearing loss was caused by or a result of an event in military service. They explained that there is no evidence of significant worsening of hearing in service in either ear, and hearing is within normal limits today except at 8000 Hz in both ears. The report of "hearing loss" on the Report of Medical History form completed for ETS appears to be an outlier; other notes show no hearing loss was reported, years after release from active duty. Hearing loss in the right ear did not exist prior to service and, though hearing loss existed in the left ear prior to service, it was not aggravated beyond normal progression in military service; the mild left ear haring loss was found on the audiometer tracing from enlistment, and that hearing loss at one frequency is no worse on examination today. See July 2019 VA examination report. With respect to tinnitus, during the July 2019 VA examination, the Veteran reported recurrent tinnitus and that he has had ear pain from injury to his ear from an incident in service. When asked specifically about tinnitus, the Veteran was not sure when it began or if it was ever documented. The July 2019 VA examiner opined that the Veteran's tinnitus was less likely than not (less than 50 percent probability) caused by or a result of military noise exposure. The VA examiner explained that the claims file contains the Veteran's verbal report that the tinnitus onset timing was about 20 years from to the 2014 VA examination, which corresponds with the 2009 private treatment notes. Later private treatment notes show no tinnitus was found during numerous clinical visits after 2009. The Veteran now reports the ear problems began in service, but there is no record in VBMS that tinnitus began in service. If taking 2009 as the onset timing of the tinnitus based on the clinical notes from Sentara Careplex ED, and noting that there is no evidence of hearing loss from military noise, it is her opinion that there is no evidence that the tinnitus that began in 2009 was caused by or a result of military service. The Board remanded the issue in January 2020 for a supplemental opinion to address the etiology of the Veteran's hearing loss in light of his reports of difficulty hearing at his separation from service. Additionally, the Board remanded for an opinion regarding whether the Veteran's ear pain is productive of functional impairment and, if so, whether it is related to the ear pain noted in service. The record includes an opinion provided in April 2020 by a VA audiologist that there was no evidence that the Veteran's reported ear pain produces a functional impairment, there is no evidence on VA examinations of any disease that may be causing the pain, and further questions on ear pain and functional impairment may need to be considered by a physician. See April 2020 VA medical opinion. The Board remanded the issue again in July 2020 for an addendum opinion to address the etiology of the Veteran's bilateral hearing loss, with consideration of the Veteran's lay reports of difficulty hearing at the time of his separation from service, and also for an addendum opinion regarding whether the reported complaints of ear pain constitute functional impairment and, if so, whether the ear pain is related to the ear pain noted in service. The record includes a November 2020 VA opinion that the Veteran's bilateral hearing loss disability was less likely than not (less than 50 percent probability) incurred in or caused by a disease or injury in service. The VA examiner noted that the evidence reviewed included the Veteran's VA e-folder. The VA examiner noted that it is readily conceded that the Veteran believes the presence and severity of any current diagnosis of hearing loss was caused uniquely and exclusively by hazardous noise exposure during and related to military service. The examiner further noted that it is readily conceded that the Veteran could have and/or was certainly exposed to hazardous noise during military service, such that could have caused hearing loss, because such only stands to establish circumstances under which hearing loss could have been caused, and is therefore neither fatal nor not fatal to a positive or negative etiology opinion. The examiner explained that hearing loss is known to have many causes outside of noise exposure, and the question posed herein regards not mere possibility, but probability, that presence and severity of any current diagnosis of hearing loss was caused uniquely and exclusively by or a result of noise exposure, specifically that incurred during and related to his military service. They further explained that, regarding the right ear, audiometric results from most recent available audiology examination performed in 2019 do not meet any of the criteria required to be defined as hearing loss for VA purposes, and do not support a diagnosis of right-sided hearing loss for VA purposes. Therefore, it is less likely than not that the Veteran's right-sided hearing loss was caused by or a result of military noise exposure. Regarding the left ear, audiometric results from the most recent available audiology examination performed in 2019 only meet criteria for hearing loss for VA purposes for the left ear by Maryland CNC Test score. They explained that noise-induced hearing loss is known to manifest as an elevation in pure tone thresholds and reduction in word recognition score (WRS), or elevation in pure tone thresholds alone. However, reduction in WRS in isolation of pure tone threshold elevation is not a configuration consistent with noise-induced hearing loss. Rather, this is most consistent with central auditory processing disorder but, even then, this diagnosis is unrelated to acoustic trauma. Therefore, it is less likely than not that the claimant's left-sided hearing loss was caused by or a result of military noise exposure. See November 2020 VA examination report. The Board finds the November 2020 VA opinion to be the most probative evidence as to the Veteran's bilateral hearing loss. The VA examiner based the opinion on a review of the Veteran's record, including his service treatment records and the Veteran's lay statement, as well as his October 2014 and July 2019 audiological examinations. The VA examiner acknowledged the Veteran's belief that his hearing loss is due to noise exposure in service; however, the examiner offered a thorough rationale explaining the distinction between pure tone and speech discrimination testing with respect to their relation to acoustic trauma and noted that hearing loss based exclusively on speech discrimination to the exclusion of elevation of pure tone thresholds is most consistent with a central auditory processing disorder, which is unrelated to acoustic trauma. The Board finds the October 2014 and July 2019 VA opinions to be the most probative evidence as to the Veteran's tinnitus. The VA examiners based their opinions on a review of the Veteran's record, including his service treatment records, as well as the October 2014 and July 2019 examinations. The VA examiners also noted the Veteran's reports during examination that his tinnitus had onset 20 years earlier, and also noted that the condition was first reported to a private physician in 2006, as noted in the record. Lastly, the October 2014 VA examiner noted that diabetes mellitus and high blood pressure, both of which the Veteran reported during the October 2014, can both lead to tinnitus onset. The Board recognizes the lay statements by the Veteran indicating the existence of current symptoms of hearing loss and tinnitus. These statements help to establish the presence of a current disability, but are less credible as to continuity of symptomatology. The Veteran has not reported symptoms consistent with the disabilities throughout the appeal period. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care." Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003); see also Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment). In summation, although the Veteran has current bilateral hearing loss and tinnitus disabilities, the preponderance of the evidence demonstrates that the Veteran's current bilateral hearing loss and tinnitus disabilities were not incurred in, or otherwise related to, in-service noise exposure. Service connection also cannot be established based on a finding of continuity of symptoms since service, nor can it be presumed under the provisions of 38 C.F.R. § 3.309(a). Accordingly, the claims for service connection for bilateral hearing loss and tinnitus must be denied. 3. Entitlement to service connection for obstructive sleep apnea is denied. The Veteran filed his claim for service connection for a sleep disorder in April 2006. See April 2006 VA Form 21-526. A review of the record indicates that the Veteran complained of trouble sleeping and that he was not sleeping well due to arthritis. See August 2005 and May 2006 private treatment records. During an emergency room visit in April 2006, he reported that he had a difficult time sleeping and that he "can't rest since the war." See April 2006 VA treatment records. During this visit, the Veteran was diagnosed with insomnia and was prescribed sleep medications. See April 2006 VA treatment records. The Veteran contends that he snored and had trouble sleeping while in service and that he suffered from daytime fatigue and sleepiness. See February 2011 VA Form 646. The record indicates that the Veteran has been assessed with insomnia regularly. See September 2011, December 2011, February 2012, May 2012, February 2013, May 2013, and August 2013 private treatment records. The Veteran was afforded a VA examination in October 2014. The VA examiner reviewed the Veteran's C-file, VBMS, and electronic records and conducted an in-person examination of the Veteran. As a result of the examination, the VA examiner found that the Veteran did not have sleep apnea. They explained that there was no diagnosis of sleep apnea noted, and the Veteran reports no history of sleep apnea, but a history of snoring was noted. No apnea or CPAP were reported, and obstructive sleep apnea was denied per the Veteran. The examiner noted a history of insomnia and that the records reflected therapy including sleep medications. The examiner noted that a sleep study was not indicated. The examiner offered negative nexus opinions both to service and to any service-connected disability, but further noted that she could not render a determination that the lower back condition would be related to the Veteran's insomnia, as this is commonly related to mental health concerns and it would be mere speculation as mental health evaluations are not her field of expertise. See October 2014 VA examination report. VA treatment records indicate that the Veteran underwent a portable sleep study in October 2014 which did confirm a diagnosis of sleep apnea and, based on this information, a further review of the Veteran's records was conducted in October 2014. The examiner cited the medical opinion nonetheless remained unchanged, military nexus had not been evidenced, and condition was not related secondarily to a lower back condition. The rationale offered was that obesity is the best documented risk factor for obstructive sleep apnea. They explained that anatomical upper airway configuration may explain the reason OSA occurs in young healthy people who are not obese, hence obesity should not be considered the only risk factor for OSA. They further explained that obese patients and non-obese patients who have a narrow anatomical airway, a significant snoring history, and a history of possible apneic episodes are screened, and lower back condition would not be considered to be related based upon review of the medical literature. See October 2014 VA treatment records. In its March 2016 decision, the Board found the October 2014 examination report to be inadequate to decide the issue and remanded the issue for an examination conducted by someone with the requisite expertise. The record includes a May 2016 VA opinion that noted a sleep study was done in September 2014 that confirmed OSA with AHI of 23.7 and CPAP was instituted. The VA examiner noted that OSA has multiple risk factors such as age over 40, obesity, and the male gender. It has never, to the examiner's knowledge, been associated with IVDS (back pain), and therefore, the examiner concurred with the opinion offered in October 2014. See May 2016 VA examination report. The Veteran was afforded another VA examination in August 2016. As a result of in-person examination and review of CPRS and VBMS, the VA examiner opined that the Veteran's OSA was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. They noted that the Veteran's service treatment records were silent for an insomnia condition with chart review including serial multiple "Report of Medical History" from 1972 to 1984. They noted that community progress notes reviewed beginning with a note dated 10/12/2004. The examiner noted that community progress notes evidence for a diagnosis of insomnia on August 2, 2005 with a Class 4 controlled medication prescribed (Restoril). They also noted that the second sleeping complaint came a couple years later, dated 5/1/2006 with the Veteran reporting trouble sleeping second to his arthritis, and that Naprosyn was prescribed. The examiner noted that service treatment records and progress notes are silent for reports of snoring or apnea, and the first two sleeping complaints in 2004 and 2006, which was 20 years after military service, were silent for snoring and apnea while sleeping. The August 2016 VA examiner explained that the Veteran has a neck circumference of 17.50" with a large upper body muscle development and an extremely narrow oropharynx opening on physical examination, and his current BMI is 35. They explained that obesity is the best documented risk factor for OSA, and anatomical upper airway configuration may explain the reason OSA occurs in young healthy people who are not obese, hence, obesity should not be considered the only risk factor for OSA. They further explained that large upper body proportions are also a risk factor and that medical literature review show that obese and non-obese patients who have a narrow anatomical airway or well-developed upper body structure and significant snoring history with apneic episodes can have OSA. They concluded, therefore, it is less likely than not that insomnia is a direct cause to the patient's OSA or his service-connected disability, and military nexus is not evident. The examiner explained that a review of medical literature showed that approximately 10 percent of individuals develop chronic insomnia with related daytime consequence, the prevalence of insomnia increases with age, and late-life insomnia is often persistent and may prompt self-medication with OTC sleep aids or alcohol. They opined that it is "less likely than not that the insomnia condition was caused by a service-connected disability 5-1-2006 due to the condition previously diagnosis and treated with a class 4 controlled medication (Restoril) on 8/2/2005." The examiner noted that a review of the medical chart is silent for an increase in severity of insomnia per Veteran's complaint; therefore, it is less likely than not that insomnia caused an increase in the severity of symptoms due to the Veteran's military service and/or service connected disability. They also noted that a review of medical chart is silent for aggravation (chronic worsening of the insomnia condition) of insomnia per Veteran's complaint beyond its natural progress, and therefore it is less likely than not that insomnia was aggravated beyond its natural progression due to the Veteran's military service and "again, no military nexus evident." See August 2016 VA examination report. In its March 2017 decision, the Board found that there was no indication whether the August 2016 VA examiner, a physician's assistant, had expertise in mental health evaluations, and again remanded the issue for an examination conducted by an examiner with requisite expertise in mental health evaluations. The Veteran was afforded a VA mental disorders examination in February 2019. As a result of the examination, the VA examiner opined that the Veteran did not have nor had he ever been diagnosed with a mental disorder. The examiner noted that the Veteran reported that since service he had been having difficulties sleeping, and that he now sleeps from 10 PM to 2 AM and then wakes up to go to the bathroom to relieve his bladder, then goes back to sleep from 2 AM to 6 AM. The examiner noted that the Veteran reported he may have 2 to 4 awakenings during the night for this reason, but that the Veteran does not complain of any mental health condition. The examiner noted that CPRS does not contain any mental diagnosis, and that his CPRS diagnosis of mild cognitive impairment is not a mental diagnosis per se. The examiner noted that the Veteran does not taken any sleep medications as per CPRS and as per his report, but that he has a diagnosis of diabetes mellitus. The examiner noted the history of sleeping complaints in 2004 and 2006 as well as the Veteran's diagnosis of obstructive sleep apnea. The VA examiner opined that the Veteran does not meet criteria to be diagnosed with any mental disorder. They explained that at this time the Veteran reports sleeping issues sleep interruptions due to the need to relieve his bladder, which may be caused by his condition of diabetes, which may need to be evaluated by an MD. On the other hand, in 2016 he was diagnosed with sleep apnea, and that may also be an explanation to some of his sleeping issues, the examiner supposed. The examiner did not see any problems with the Veteran's sleep which cannot be explained by medical conditions, and he could not opine on the questions asked in the VA 21-5207 as she did not see any mental disturbance with the Veteran now. She noted that the Veteran may have had one in 2005 2006 when he said he had "stress" and the Veteran himself cited his stress as a cause of his sleeping problems at that time. The examiner explained that as there is no mental disturbance with the Veteran now and his sleep disorder can be explained by medical conditions, she did not think it is feasible to comment on the three questions in the VA 21-5207; there is no diagnosis of insomnia due to medical condition in the DSM-5, so the examiner could not formally state the condition on the form. See February 2019 VA examination report. The record also includes a September 2019 VA medical opinion in which the VA examiner noted that the Veteran's obstructive sleep apnea was less likely than not (less than 20 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. They explained that they did review the VA treatment records dated in April 2006 and May 2009 that show the Veteran's reported continuous symptoms since separation from service, which was given consideration. They also noted that they had reviewed and considered May 2006 private treatment records showing that the Veteran reported not sleeping well due to right-sided arthritis, lumbar arthritis, and/or right thumb arthritis. They further opined that the Veteran's obstructive sleep apnea is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. Additionally, they opined that the Veteran's claimed condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. They explained that OSA is an anatomical structural condition strongly associated with obesity, age, male gender, a narrow or shallow oropharynx, large upper body habitus, and an increased neck circumference. They noted that OSA is not an organic illness, but a structural (functional) condition, and review of medical literature is silent for a large clinical studies or medical literature that supports right-sided arthritis, lumbar arthritis, and/or right thumb arthritis with OSA. They noted that the Veteran has obesity, large neck circumference, shallow oropharyngeal opening, increased age over 60 years old, and a male gender, which are all strongly linked to structural disease. They concluded, therefore, it is less likely than not that the Veteran's OSA condition resulted from an incident during military service, is a secondary condition to his service-connected right-sided arthritis, lumbar arthritis, and/or right thumb arthritis, or was aggravated beyond its natural progression by his right-sided arthritis, lumbar arthritis, and/or right thumb arthritis. See September 2019 VA examination report. The Board remanded the issue in January 2020 for an addendum opinion addressing whether the Veteran's sleep disorder has been aggravated by the Veteran's service-connected disabilities. The record includes a January 2020 addendum opinion that the Veteran's sleep disorder, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. The VA examiner noted that the Veteran's chart review with review of medical literature and large clinical trial studies are silent/absent for OSA being aggravated beyond its natural progression by muscular/skeleton conditions or deviation (degeneration of the spine or thumb to include limitation of thumb motion), impairment of sphincter control, foot condition, bilateral sciatica condition, or deviation of the nasal septum. They further explained that chart review is silent/absent for evidence that the Veteran's OSA condition was aggravated beyond its natural progression, which could include carbon dioxide retention, chronic respiratory failure, tracheostomy, or col pulmonale from his OSA condition. Therefore, it is less likely than not that an OSA condition was aggravated beyond its natural progression by his service-connected muscular/skeleton conditions (degeneration of spine or thumb to include limitation of thumb motion, impairment of sphincter control, foot condition, bilateral sciatica condition, or deviation of the nasal septum. See January 2020 VA examination report. The Board again remanded the issue in July 2020 for an addendum opinion regarding whether the Veteran's sleep disorder is proximately due to his service-connected disabilities, or whether the Veteran's sleep disorder is aggravated by his service-connected disabilities. The examiner was also asked to explain how the functional limitations posed by the service-connected disabilities could contribute to the Veteran's OSA. The examiner was also asked to opine whether the Veteran's service-connected disabilities could have caused him to become obese and, if so, whether the Veteran's obesity was a substantial factor in causing the Veteran's sleep disability. Additionally, the examiner was asked to opine on whether the Veteran's sleep disorder would not have occurred but for the obesity caused by his service-connected disabilities. The record includes November 2020 VA opinions that it is less likely than not (less than 50 percent probability) that the Veteran's sleep disorder is proximately due to or the result of the Veteran's service-connected conditions; that the Veteran's sleep disorder is aggravated beyond its natural progression by the Veteran's service-connected conditions; and that the Veteran's service-connected disabilities have caused him to become obese. The VA examiner opined that they cannot determine a baseline level of severity of sleep disorder based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by service-connected disabilities. The VA examiner explained that, based on review of the provided medical records, there is no evidence documenting that any of the Veteran's service-connected conditions directly or indirectly caused or aggravated his obesity or his obstructive sleep apnea. They further explained that there is no plausible pathophysiologic mechanism discussed in the medical literature and known medical principles that would explain such a causal relationship between these conditions. See November 2020 VA examination reports. The Board finds the November 2020 VA medical opinions to be most probative, as they include consideration of the Veteran's specific medical history, his service treatment records, his prior VA and private treatment, and his sleep studies. The VA examiner offered a thorough rationale including discussion of the Veteran's service-connected disabilities as well as his obesity and the relationship these conditions have with his OSA. The Board acknowledges that the Veteran believes his OSA is related to his service-connected disabilities; however, he does not have the medical expertise to competently establish such a relationship. In sum, the evidence is against a finding that the Veteran's sleep apnea was caused or aggravated by his service-connected disabilities. Therefore, service connection for the Veteran's sleep apnea, including as on a secondary basis, is not established. Accordingly, the benefit sought on appeal must be denied. REASONS FOR REMAND 1. Entitlement to service connection for a bilateral ear disability, other than hearing loss and tinnitus, is remanded. A review of the Veteran's service treatment records reveals complaints of earaches and ear pain in cold weather. The record indicates the Veteran experienced vertigo during service. See December 1978 service treatment records. Service treatment records indicate that the Veteran was treated for ear problems on numerous occasions, including ear pain following exposure to cold weather, a retracted right tympanic membrane, discolored ears, and an ear infection. The Veteran contends that all his ear trouble started while in Germany and on field training exercise, he still suffers from severe earaches most of the time, and that his ear pain is worse over the last "20 some" years. He further contends that he never got proper treatment while stationed in Germany. See December 2007 and January 2008 correspondence; see also February 2009 and April 2009 statement. The record includes a November 2020 opinion that the Veteran's reports of ear pain are less likely than not productive of a functional impairment. The VA examiner explained that the Veteran gets ear pain when he runs in cold weather. He appears to have a sensitive ear canal. As this is a unique situation and not part of an occupational requirement or a required activity of daily life it is less likely than not that his ear pain when running in cold weather is productive of a functional impairment. The VA examiner also opined that the Veteran's ear pain is less likely than not (less than 50 percent probability) related to ear pain noted in service. The examiner explained that he could not find any references to ear pain while in the service. As such, he cannot comment on this without resorting to speculation. The Board finds the November 2020 opinion inadequate, as it relies on inaccurate facts; as discussed above, the Veteran's service treatment records include numerous references to ear pain. When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). On remand, a new opinion must be obtained. To date, although the Veteran has been afforded several VA examinations for hearing loss and tinnitus, he has not been afforded a VA ear conditions examination. As part of its duties to assist a Veteran in a claim for service connection, VA may be required to provide an examination. Such an exam is required when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the claimant's service or with another service-connected disability, and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, the Board finds that there is competent evidence to suggest that there may be a link between the Veteran's claimed condition and his active duty service. As such, the Board finds that the evidence of record surpasses the "low" threshold set forth in McLendon. On remand, a VA examination should be scheduled, and an opinion obtained addressing the etiology of the Veteran's ear disability other than hearing loss and tinnitus. 2. Entitlement to service connection for a sleep disorder other than OSA, to include insomnia, and as secondary to his service-connected disabilities is remanded. As discussed above, the record indicates that the Veteran has been diagnosed with insomnia. See August 2005, September 2011, and May 2012 private treatment notes; see also April 2006 VA treatment notes. The record indicates that the Veteran reported having a difficult time sleeping and getting any rest at night and that he "cannot rest since the war." See April 2006 ER treatment report. In May 2006, the Veteran reported not sleeping well due to right-sided arthritis. See May 2006 private treatment records. The record also includes the Veteran's report of "sleep disturbance lethargy for 20 years." See May 2009 VA treatment notes. The Board remanded the issue in May 2019 for an addendum opinion to include consideration of the Veteran's report of continuous symptoms since separation from service as well as for an opinion addressing the etiology of insomnia on a secondary basis (causation and aggravation) and addressing the etiology of sleep apnea on secondary basis (aggravation) by his service-connected disabilities for arthritis in the lumbar spine and/or right thumb. Although the Board sincerely regrets additional delay, a remand is necessary to afford the Veteran due process of law and to ensure that there is a complete record upon which to decide the Veteran's appeal, so as that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Board has previously remanded this claim numerous times, most recently in July 2020 for, in pertinent part, opinions with respect to sleep disorders, to include insomnia. However, as discussed above, the November 2020 opinions that were provided discussed sleep apnea, but not insomnia. Therefore, the Board finds the medical opinions to be inadequate with respect to service connection for a sleep disorder other than OSA, to include insomnia. Thus, a VA addendum medical opinion is required. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (explaining that a remand by the Court or Board "confers on the veteran... as a matter of law, the right to compliance with the remand orders"). The issues are REMANDED for the following action: 1. Schedule the Veteran for a VA ear conditions examination to address the nature and etiology of his current ear disability. The claims file should be sent to, and reviewed by, the VA examiner. The examiner should take a history from the Veteran as to the progression of his ear disability. Following review of the file, interview, and examination of the Veteran, the examiner is asked to address the following: (a) Identify all current bilateral ear disabilities. (b) For each disability, is it at least as likely as not (50 percent or greater probability) that such had onset in, or is otherwise related to active duty service? (c) Whether the Veteran's reports of ear pain during the appeal period are productive of functional impairment? (The examiner must be advised that it is not necessary for pain to be attributed to a specific diagnosis to be considered a service-connected disability as long as the pain is productive of functional impairment.) If the ear pain is productive of functional impairment, the examiner should determine: (d) Whether the ear pain is at least as likely as not (50 percent probability or greater) related to the ear pain noted in service? The examiner must provide a rationale in support of all opinions provided. If any opinion cannot be provided without resorting to speculation, the examiner must explain why this is so. 2. Request an addendum to the November 2020 opinion from the November 2020 examiner, if available, for the claim for service connection for insomnia. The clinician providing the opinion must be provided access to the electronic claims file and indicate review of the file in the examination report. If examination of the Veteran is necessary, such should be arranged. The examiner must determine: (a) whether it is at least as likely as not (50 percent probability or greater) that the Veteran's insomnia is proximately due to his service-connected disabilities, or (b) whether the Veteran's insomnia is aggravated by his service-connected disabilities. The examiner should also explain how the functional limitations posed by the service-connected disabilities could contribute to insomnia. (c) If the answers to (a) and (b) above are negative, then opine whether it is at least as likely as not (probability of at least 50 percent) that the Veteran's service-connected disabilities have caused him to become obese. (d) If so, was the Veteran's obesity as a result of a service-connected disability/disabilities a substantial factor in causing the Veteran's insomnia? (e) Would the Veteran's insomnia not have occurred but for obesity caused by his service-connected disability/disabilities? In other words, did the obesity caused by his service-connected disability/disabilities proximately cause his insomnia (it was a substantial factor in developing insomnia such that insomnia would not have occurred but for the obesity attributable to his service-connected conditions)? The examiner must provide a rationale in support of all opinions provided. If the examiner cannot provide the opinion without conducting an examination of the Veteran, then an examination must be scheduled. If any opinion cannot be provided without resorting to speculation, the examiner must explain why this is so. In forming the opinions, the examiner is asked to consider the Veteran's lay statements of continuity of symptomatology, and to address whether they make sense from a medical perspective. 2. After completing the above, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a SSOC. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. B. G. LeMoine Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Fulmer, 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.