Citation Nr: 21028711 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 08-13 302 DATE: May 11, 2021 REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service-connected major depressive disorder, is remanded. Entitlement to service connection for sexual dysfunction, to include as secondary to service-connected major depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1971 to February 1973. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board most recently remanded this matter in January 2021. There has not been substantial compliance with the remand directives. Another remand is needed before the Board can adjudicate the claims on appeal. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for sleep apnea is remanded. The Board previously remanded this issue to obtain an addendum opinion that specifically considers a January 2018 private sleep study which formally diagnosed the Veteran with obstructive sleep apnea. However, the VA examiner who provided a response to the Board's remand directive in February 2021 was unable to review the sleep study and therefore concluded that she could not comment on whether sleep apnea is related to the Veteran's service or is secondary to major depressive disorder. It is apparent from the examiner's response that her review of the medical evidence was limited to VA medical records. Remand is needed for an addendum opinion from an examiner who both has access to and has actually taken the time to review the relevant medical record prior to addressing the Board's questions. 2. Entitlement to service connection for sexual dysfunction is remanded. The Board previously remanded this issue to obtain a more thorough addendum opinion. The February 2021 VA examiner's opinion is inadequate to adjudicate the claim because its conclusions are based on an inaccurate factual premise. In addressing the Board's questions, the February 2021 examiner did not address all of the instances in the record where the Veteran requested prescriptions for erectile dysfunction. The examiner ends the opinion stating that sexual dysfunction was "only briefly mentioned once in 2004 and once in 2012." However, the record shows that the Veteran sought or was given prescriptions to treat erectile dysfunction in August 2004, October 2005, January 2006 and March 2012. The examiner was also asked to opine whether the Veteran's service-connected major depressive disorder caused or aggravated his claimed erectile dysfunction. The examiner declined to write an opinion as "there is no documentation as to the severity of his depression which would allow for an opinion". In fact, the Veteran underwent psychiatric examinations in May 2008, April 2011 and February 2018. Remand is needed for an addendum opinion from an examiner who both has access to and has actually taken the time to review the relevant medical record prior to addressing the Board's questions. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from a medical professional with appropriate expertise for the Veteran's sleep apnea claim. The examiner must be provided access to the Veteran's complete claims file, including the January 2018 sleep study which formally diagnosed the Veteran with obstructive sleep apnea. The examiner is asked to answer the following questions: a) Is it at least as likely as not (50 percent probability or greater) that the Veteran's diagnosed obstructive sleep apnea had its onset in or is otherwise related to active duty service? b) Is it at least as likely as not (50 percent probability or greater) that the Veteran's diagnosed obstructive sleep apnea was caused by his service-connected major depressive disorder? c) Is it at least as likely as not (50 percent probability or greater) that the Veteran's diagnosed obstructive sleep apnea was aggravated by his service-connected major depressive disorder? The RO MUST provide for the examiner's review the January 17, 2018 sleep study conducted by "American Sleep Medicine" in San Diego, California. This study confirms the Veteran's diagnosis of obstructive sleep apnea and includes data relevant to the examiner's opinion. The study is located in the claims file labeled "C&P Exam", dated March 5, 2018. The examiner should specifically address the Veteran's contentions that he had sleeping difficulties immediately upon return from service, as well as his assertion that fellow servicemembers commented on his loud snoring during service. 2. Obtain an addendum medical opinion from a medical professional with appropriate expertise for the Veteran's sleep apnea claim. The examiner must be provided access to the Veteran's complete claims file, including all prior psychiatric examinations. The examiner is asked to answer the following questions: a) Is it at least as likely as not (50 percent probability or greater) that any diagnosed sexual dysfunction had its onset in or is otherwise related to active duty service? b) Is it at least as likely as not (50 percent probability or greater) that any diagnosed sexual dysfunction was caused by his service-connected major depressive disorder? c) Is it at least as likely as not (50 percent probability or greater) that any diagnosed sexual dysfunction was aggravated by his service-connected major depressive disorder? In answering these questions, the examiner must specifically address the: i) August 2004 VA treatment note documenting his request for a Viagra prescription; ii) October 2005 and January 2006 VA treatment notes showing an active prescription for Sildenafil to treat his erectile dysfunction; iii) The assertions the Veteran made in his December 2007 claim; and iv) His March 2012 prescription for Sildenafil, as seen in a February 28, 2013 entry in the claims file labeled as "CAPRI" records. It is most essential the examiner provide explanatory rationales for all opinions, with specific reference to the evidence of record where appropriate. If the examiner is unable to provide any further comment, that is, without resorting to mere speculation, then he or she must explain why a more definitive response is not possible or feasible. If an opinion cannot be provided because it would require speculation, the examiner should so state and explain why this is so. In addition, the examiner should state whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge, there are multiple possible etiologies, with none more prevalent than another, or whatever may be the case. J. Komperda Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. McDonald