Citation Nr: 21032821 Decision Date: 05/28/21 Archive Date: 05/28/21 DOCKET NO. 18-13 951 DATE: May 28, 2021 ORDER Entitlement to service connection for a respiratory disability, to include asthma and chronic obstructive pulmonary disease (COPD), to include as due to exposure to hazardous chemicals is denied. Entitlement to service connection for a sinus or allergy disability, to include allergic rhinitis, to include as due to exposure to hazardous chemicals is denied. REMANDED Entitlement to service connection for obstructive sleep apnea, to include as due to service-connected disease or injury is remanded. FINDINGS OF FACT 1. The weight of competent and credible evidence is against finding that asthma or COPD began during active service or is otherwise caused by service, to include as due to exposure to hazardous chemicals. 2. The weight of competent and credible evidence is against finding that the Veteran's allergic rhinitis is attributable to service, to include as due to exposure to hazardous chemicals. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for asthma and COPD, to include as due to exposure to hazardous chemicals, have not been met. 38 U.S.C. §§ 1110, 1111, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2020). 2. The criteria for service connection for allergic rhinitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Marine Corps from July 1979 to July 1982. The Board most recently remanded these issues in October 2020 to the RO for additional development. There has been substantial compliance with the remand instructions. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service or for aggravation of a preexisting injury suffered or disease contracted in line of duty. 38 U.S.C. § 1110, 1131. In general, to establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present 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 - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). "[W]hen no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry." See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). This is generally referenced as the "presumption of soundness." If the presumption of soundness applies, the burden then shifts to "the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both preexisting and not aggravated by service." See id. 1. Entitlement to service connection for a respiratory disability, to include as due to exposure to hazardous chemicals The Veteran contends that he is entitled to service connection for a respiratory disability due to exposure to hazardous chemicals including asbestos, dust, and the San Diego climate. Service treatment records (STRs) are associated with the claims file. In a May 1979 enlistment medical history questionnaire, the Veteran denied any history of asthma, sinusitis, chronic cough, or shortness of breath. In November 1979, the Veteran was treated for sinus congestion, fever, and productive cough. Clinicians diagnosed pneumonia and prescribed rest and antibiotic medication. After three days, he was returned to full duty with instructions to continue medication. There was no follow up and clinicians considered the illness resolved. In June 1980 while performing duties in correctional custody, the Veteran sought medical attention for asthma. He told a treating physician that, "he was instructed to lie during induction and deny history of asthma." He reported that he was unable to keep up with other children as a youth and now he was unable to keep up with his fellow Marines. A clinician first diagnosed possible bronchitis, but after investigation, a physician diagnosed "hyperventilation syndrome," advised use of a paper bag when dizzy, and returned the Veteran to duty. A November 1980 record shows that the Veteran was exposed to asbestos during the installation or removal of floor tile. A respiratory examination performed after the exposure reflects that there were no abnormalities. A June 1981 STR reveals that the Veteran reported smoking one pack of cigarettes daily. A corresponding examination revealed that the Veteran's lungs were clear, and a review of his systems were "completely unremarkable." The Veteran attended a VA examination in October 1982. He reported intermittent periods of wheezing associated with shortness of breath in the prior two years. He stated that it seemed to be a little worse during damp days, but not much of a problem during warm dry days. He denied any chronic cough or sputum production. Examination of his chest was within normal limits and chest x-rays were normal. There was no wheezing. He also underwent a pulmonary function test which was normal. The examiner diagnosed with the Veteran with bronchial asthma, quiescent. November 1986 private treatment records reveal that the Veteran drank socially and smoked cigarettes. He denied any asthma or bronchitis, as well as any cough or sputum production. Examination revealed that his lungs were clear. On a September 1988 self-completed private medical history form, the Veteran reported smoking one pack of cigarettes daily, and, when asked if he had ever had asthma, the Veteran did not report it. He also denied shortness of breath or breathing difficulties while exercising or with exertion. An October 1990 private treatment record reflects that the Veteran reported some bronchitis and asthma, related to cigarette smoking. He stated that he quit smoking around July 1990. Examination revealed clear lungs and he denied any cough or sputum production. The Veteran denied shortness of breath during June 2004 and a corresponding respiratory examination was normal. The Veteran denied shortness of breath during August 2004 VA treatment. He had a normal respiratory examination in October 2005, and again denied shortness of breath during September 2006 VA treatment. An April 2007 VA treatment record reflects that the Veteran denied any asthma. He denied shortness of breath during December 2007, September 2008, November 2009, November 2011, and December 2012 VA treatment. The Veteran submitted a claim for entitlement to service connection for a respiratory disability in March 2015. He reported in-service respiratory symptoms that gradually worsened over time. The Veteran submitted an undated, incomplete private treatment record in June 2015 which revealed that he had been diagnosed with chronic obstructive pulmonary disease (COPD). A July 2015 private treatment record reveals that the Veteran reported chronic cough and shortness of breath for the past 7-8 years. The corresponding medical note reflects that the Veteran was a past smoker and had COPD. Examination revealed bilateral perihilar bronchovascular prominence with associated bronchial wall thickening. There was no pleural effusion and no pneumothorax. The findings were consistent with acute and/or chronic bronchitis. Another July 2015 private treatment record reflects that the Veteran's private physician noted that clinically it looked like the Veteran had chronic obstructive asthma or COPD with concomitant restriction from his weight and deconditioning. An October 2015 VA examiner determined that the Veteran's COPD was less likely than not related to in-service acute bronchitis. The examiner determined that the combination of a history of childhood asthma and smoking as an adult caused the Veteran's current chronic bronchitis or COPD. He explained that the Veteran's in-service bronchitis was acute and resolved prior to discharge. In October 2015 correspondence, the Veteran stated that prior to his service he did not have any respiratory issues. In service, the Veteran reported exposure to naval seaport air pollution, dust and dense aviation pollution, CS gas, and tile floor particles. The Veteran submitted a private opinion with his correspondence from a neuro-radiologist, who stated that dust was known cause to both bronchitis and asthma. The private opinion did not comment on the Veteran's long-term tobacco use. In November 2015 correspondence, the Veteran's spouse stated that during their courtship in 2009, the Veteran enjoyed hiking, swimming and jogging several times a week. She stated that he had stopped exercising within the last five years because of shortness of breath. Another VA opinion was obtained in January 2016. Following an in-person examination and review of the claims file, the examiner explained that the Veteran's current respiratory conditions were not aggravated beyond their natural progression by an in-service event, injury or illness. The examiner explained that STRs did not reflect that the Veteran was prescribed the use of inhalers or bronchodilators until two decades following separation. After detailing the Veteran's in-service treatment, the examiner concluded that there was no indication that the pre-existing asthma was worsened in service. In April 2016 correspondence, the Veteran refuted any smoking history, aside from a brief period during basic training. In an April 2016 new patient evaluation, a private doctor stated that the Veteran's respiratory symptoms began in the service during heavy exercising and after exposure to dust, fumes, and deodorants but improved following his separation. The private doctor stated that the Veteran was respiratory symptom free until 2009, when he began to notice shortness of breath, coughing, wheezing, and chest tightness. Limited tobacco use and asbestos exposure were noted, and the private doctor reported that the Veteran was diagnosed with exercise induced asthma while in the service. She diagnosed the Veteran with partially controlled asthma. The private doctor stated that she did not believe the Veteran had COPD because of the lack of smoking history and because his DLCO was within normal limits. In May 2016 correspondence, the Veteran stated that he only smoked for a brief period in service and that his limited tobacco exposure could not have impacted his pulmonary systems. He reiterated that he did not have any respiratory symptoms prior to his service. He reported breathing issues continuously from active duty but stated that because of a lack of health insurance he did not receive any treatment from 1982 to 1984. Private June 2016 treatment records reflect that the Veteran was told to lose weight and increase exercise because of his dyspnea on exertion. In July 2019 and October 2019 buddy statements, fellow service members reported that during their service between July 1980 and July 1982 they were exposed to excessive dust and asbestos in the barracks. The Veteran submitted another private opinion in October 2019, which reported that the Veteran's asthma symptoms started in the military following exposure to asbestos and dust. The opinion also stated that the Veteran was never a smoker, as he smoked five cigarettes a day for less than two months. Instead, the opinion related the Veteran's asthma to significant exposure in service. In December 2019, the Veteran submitted several articles regarding the relationship between tear gas and asthma, increased emissions from international airports, and air toxins in San Diego, During his March 2020 Board hearing, the Veteran testified that he did not have asthma prior to service. He stated that while in bootcamp in San Diego he was exposed to air pollution. He also testified to asbestos exposure. A VA opinion was obtained in July 2020. The examiner stated that although the claims file contained some reports of asthma prior to service, there were no medical records to confirm. The examiner determined that the Veteran had eczema. This was relevant because it meant that it was more likely than not that the Veteran's asthma was more likely than not an atopic disease, which began in childhood. He stated that the atopic disease and the Veteran's history of smoking resulted in the Veteran's current COPD. The Veteran attended a VA examination in January 2021. The Veteran's chest x-ray was normal. The examiner determined that the Veteran had asthma. The examiner reviewed the Veteran's claims file. He explicitly listed the relevant evidence, to include the inservice respiratory treatment, the March 2020 Board hearing transcript, and the Veteran's contention regarding exposure to hazardous materials in service. The examiner determined that it was less likely than not that the Veteran's respiratory issues were incurred in or caused by service. He explained that the Veteran's chest x-ray revealed no asbestos nodules or abnormalities. The examiner explained that the Veteran was not diagnosed with asthma in service, and his respiratory symptoms and pneumonia in-service resolved prior to discharge. The Veteran was diagnosed with quiescent asthma about nine months following his separation and therefore it was less likely that asthma was due to exposure to asbestos, dust, general air pollution, training with CS gas or other hazardous contaminants during service. The examiner also explained that although during his service the Veteran reported trouble keeping up with other Marines during exercises, there was no indication that he was prescribed or treated for asthma prior to or during service. In February 2021, the Veteran submitted several buddy statements stating that no asthma symptoms were observed during his childhood. Analysis As an initial matter, in regard to his cigarette use, although the Veteran reports using cigarettes for only a brief period in 1979, treatment records reflect that the Veteran smoked one pack of cigarettes a day for nearly ten years. A June 1981 STR reveals that the Veteran reported smoking one pack of cigarettes daily. November 1986 private treatment records reveal that the Veteran drank socially and smoked cigarettes. The Board finds the September 1988 self-completed private medical history form, in which the Veteran self-reported reported smoking one pack of cigarettes daily to be highly probative. An October 1990 private treatment record reflects that the Veteran reported some bronchitis and asthma, related to cigarette smoking. He stated that he quit smoking around July 1990. Therefore, the medical evidence of record overwhelmingly confirms the Veteran's tobacco use for many years. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). The Board also finds that the presumption of soundness applies, as there is not clear and unmistakable evidence that the Veteran's asthma preexisted service. However, after a complete review of the Veteran's records the Board finds that service connection for a respiratory disability, to include asthma or COPD, is not warranted. The Veteran's contentions are that he developed asthma while in service, and he has continued to experience respiratory symptoms since that time. He also contends the exposure to hazardous materials in service caused his current asthma. There are many medical opinions of record, but the Board finds that the most probative evidence weighs against the Veteran's contentions. STRs reflect that the Veteran was treated for pneumonia and hyperventilation syndrome. There is no probative evidence that the Veteran was diagnosed with asthma in service and throughout that period of strenuous physical activity, it does not appear he was ever prescribed an inhaler. When examined in 1982, the Veteran was asymptomatic, and his chest x-ray and pulmonary function tests were normal. The Veteran denied respiratory symptoms, including asthma and shortness of breath, several times following his discharge. An October 1990 private treatment record reflects that a private doctor attributed "some bronchitis and asthma" to the Veteran's cigarette smoking. The April 2016 private new patient evaluation reveals that the Veteran did not have any respiratory symptoms between 1982 and 2009. Furthermore, the Veteran's spouse reports that the Veteran was very active, hiking, swimming and jogging several times a week, but had to stop around 2010 because of respiratory symptoms. The Board finds the culmination of the VA examination opinions to be highly probative as they are based on a review of the entire record. The October 2015 VA examination partially attributed the Veteran's current respiratory disability to his cigarette use and explained that his in-service respiratory conditions were acute and resolved prior to discharge. The July 2020 VA examiner also determined that the Veteran's current respiratory issues were unrelated to service. He explained that the combination of a genetic predisposition to lower airway problems such as asthma and long-term cigarette smoking were the most likely cause of the Veteran's current respiratory condition. The examiner also discredited the private October 2015 opinion because it did not address the Veteran's tobacco use. The examiner also noted the Veteran's exposure to hazardous material in service but noted the long period between exposure and symptom onset. Lastly, the January 2021 VA examination report extensively lists the relevant evidence and contentions made by the Veteran but still determined that the Veteran's current respiratory disability was less likely than not related to service because the Veteran's in-service respiratory issues were acute resolved prior to discharge, and his examinations were all normal. The Board does not afford significant probative weight to the private opinions of record because they are founded on the Veteran's lay statements and history, instead of a review of the claims file. The Board finds that the Veteran's lay statements regarding his respiratory symptoms and smoking history have limited credibility and limited probative value because he has been an inconsistent historian. While the Veteran has insisted on a limited history of tobacco use in support of his claim, medical records from several private providers and the VA reflect otherwise. The Board also finds it highly probative that the Veteran reported smoking a pack a day on a September 1988 self-completed private medical history form. In regard to symptom onset, one private provider reflects the Veteran reported symptom onset around 2009, another private provider lists 2007, and a different private provider reflects symptom onset around 1990 due to smoking. See October 1990, July 2015, April 2016 private treatment. To the extent that the Veteran contends that his asthma is due to service to include exposure to hazardous materials, the Board observes that lay people are competent to testify to visible or otherwise observable symptoms of disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). The Veteran is competent to report that he was diagnosed with asthma by a medical professional and the symptoms associated with the disability. However, he has not established his competence to establish etiology and there are no Jandreau exceptions. The lay statements of the Veteran concerning a relationship between his asthma and his service are therefore not probative in this regard. In conclusion, considering the lay and medical evidence in this case, the preponderance of the evidence is against the claims for service connection for a respiratory disability, to include as due to exposure to hazardous material. Thus, as the preponderance of the evidence is against the claims, the benefit-of-the-doubt standard of proof does not apply, and the benefits sought on appeal must be denied. 38 U.S.C. § 5107(b). 2. Entitlement to service connection for a sinus or allergy disability, to include as due to exposure to hazardous chemicals The Veteran contends that he is entitled to service connection for a sinus disability, to include as due to exposure to irritants. STRs reflect that the Veteran received treatment for an upper respiratory infection in October 1979. He was treated for a cough and sore throat in November 1979. He denied any sinus trouble in April 1981 and January 1982. During an October 1982 VA examination, the Veteran reported difficulty breathing and nasal congestion over the last year and a half. The examiner stated that the Veteran had intermittent sinusitis and rhinitis associated with stuffiness and headaches and usually treated with decongestants. He had not required antibiotics and symptoms were currently dormant. A November 1986 private examination did not reveal any sinus issues, and none were reported by the Veteran. His nostrils were normal. On a September 1988 self-completed private medical history form, the Veteran did not check the box for allergies or hay fever. An October 1990 private examination did not reveal any sinus issues, and none were reported by the Veteran. He denied headaches and coughing. His pharynx and throat were normal. During VA August 2004 VA treatment, the Veteran reported difficulty breathing through his nose for most of his life. The Veteran received VA treatment for a sinus infection in October 2004. July 2012 and December 2012 VA treatment records reflect that the Veteran had chronic rhinitis and nasal congestion. April 2013 VA treatment records reflect that the Veteran had a septoplasty in 2005 but continued to have persistent sinus symptoms. In March 2015 correspondence, the Veteran reported ongoing chronic nasal congestion since his time in the service. The Veteran attended a VA examination in October 2015. The examiner acknowledged the October 1979 upper respiratory infection and November 1979 sinus congestion, however he determined that the Veteran did not have chronic rhinitis or a consistent pattern of repeat medical visits for nasal complaints while in service. Accordingly, it was less likely than not that the Veteran current rhinitis was related to his service. The Veteran submitted a privately completed disability benefits questionnaire in October 2015 which reported that the Veteran was diagnosed with allergic rhinitis in December 2013. He submitted a correspondence letter, stating that his current sinus issues were due to the exposure to hazardous materials in service. In November 2015 correspondence, the Veteran's spouse reported observing current sinus symptoms exhibited by the Veteran. During his March 2020 Board hearing, the Veteran testified that he began having congestion symptoms during bootcamp which persisted to the present. In a July 2020 VA opinion, an examiner stated that the Veteran's sinus problems were less likely than not due to service because it was an atopic disease. He explained that atopic diseases are chronic lifelong conditions that wax and wane over time, but because they are genetic conditions, they do not spontaneously resolve. The Veteran attended a VA examination in December 2020. The examiner reiterated that the Veteran was diagnosed with allergic rhinitis. He explicitly listed the relevant evidence, to include the inservice treatment, the March 2020 Board hearing transcript, the private and VA treatment records, and the Veteran's contentions regarding exposure to hazardous materials in service. The examiner determined that it was less likely than not that the Veteran's allergic rhinitis was incurred in or caused by service. He explained that the Veteran was not diagnosed with a chronic sinus condition or rhinitis in service, and his sinus symptoms in-service resolved prior to discharge. He also explained that there was no indication that the Veteran had been impacted by any hazardous materials as his examination and chest x-ray was normal. The examiner stated that the Veteran's two episodic visits in service in his three-year period of active duty did not reflect a condition caused by exposure to contaminants like dust and asbestos and did not reflect a chronic sinus disability. After consideration of all the evidence of record the Board finds that the weight of the evidence is against finding that service connection for allergic rhinitis is warranted. The Board concludes that service connection is not warranted as the Veteran's current allergic rhinitis is not caused by service, to include exposure to hazardous materials in service. While the Veteran reports that his current symptoms and in-service events and exposure are related the record does not reflect that he has the requisite training or expertise to offer a medical opinion linking a current disability to service decades earlier and environmental exposures and as such he is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board finds that the VA medical evidence is more probative and credible than the lay opinions of record. The Board gives more probative weight to the competent medical evidence specifically the December 2020 VA examination opinion. The VA examiner found that it is less likely than not that the Veteran's allergic rhinitis was incurred in or caused by a claimed in-service injury, event or illness. The examiner noted the Veteran's contentions regarding environmental allergens, dust, and asbestos but provided sufficient rationale in his determination that a chronic condition did not develop in service. Further, the examiner noted that the Veteran's in-service treatment for sinus issues were acute and resolved and did not represent a chronic condition. The Board finds that service connection is not warranted as the Veteran's current allergic rhinitis is not caused by service, to include exposure to hazardous materials. Further, the Board notes that the Veteran explicitly denied sinus issues while in service in April 1981 and January 1982. Although he reported sinus issues during the prior 18 months at the October 1982 examination, the STRs reflect otherwise and his October 1982 examination determined that the Veteran did not have any current symptoms. The Board also finds it highly probative that the Veteran did not report any sinus symptoms during his private treatment following discharge. In fact, the earliest report of sinus symptoms does not appear until 2004, more than 20 years following his discharge. The Board has considered the Veteran's lay statements however, the Board gives more probative weight to the competent medical evidence especially the December 2020 VA examination and opinion. As such the Board finds that the Veteran's current allergic rhinitis is less likely than not related to active service, to include exposure to hazardous materials. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for allergic rhinitis. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 5557 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. REASONS FOR REMAND 3. Entitlement to service connection for obstructive sleep apnea, to include as due to service-connected disease or injury Unfortunately, additional development is necessary prior to adjudicating the issue of entitlement to service connection for obstructive sleep apnea. The Veteran asserts that he is entitled to service connection for obstructive sleep apnea (OSA). STRs are associated with the claims file and there is no indication that the Veteran received any treatment for or had any reports of OSA. On a September 1988 self-completed private medical history form, the Veteran did not check the box for extreme, lasting fatigue. An October 1990 private treatment record reflects that "there was at one time a question of sleep apnea, although that was never documented." The Veteran underwent a VA home sleep study clinic in November 2004. He was diagnosed with mild sleep apnea in January 2005. The corresponding medical note states that the Veteran had a mild study without much snoring or significant desaturation and was not a candidate for a CPAP. In March 2015 correspondence, the Veteran reported that he was diagnosed with COPD in September 2005. He stated that his OSA symptoms first appeared at the same time as his COPD, "and continue to worsen, secondarily to and at a pace similar to that of my COPD." In August 2015, the Veteran submitted an article regarding the relationship between OSA and COPD. The Veteran submitted a privately completed disability benefits questionnaire from a consultant in October 2015. The private consultant stated that the Veteran was diagnosed with OSA in January 2005. In a corresponding letter, the Veteran stated that he had breathing issues in service and began snoring at night. He stated that he began a relationship with his first wife in 1985 and she regularly complained of his loud snoring. In October 2015 correspondence, the Veteran's son reported hearing the Veteran snore through his childhood. In November 2015 correspondence, the Veteran's spouse reported observing snoring exhibited by the Veteran as early as 2009. In an April 2016 new patient evaluation, a private doctor stated that the Veteran had occasional nocturnal symptoms on active duty, but his symptoms improved significantly when he was discharged. The private doctor stated that following the Veteran's discharge his snoring worsened and he underwent the uvuloplasty in 1994 to treat the snoring. He saw improvement and did not need additional treatment until 2005 when he was treated with oxygen at night. She noted that the Veteran gained significant weight in the last 20 years, from 145 pounds to 220 pounds. In May 2016 correspondence, the Veteran stated that he sought medical attention for his snoring in 1991 and had his uvula removed. He also submitted several articles regarding the relationship between asthma and OSA. A VA opinion was obtained in December 2020. Although the examiner reviewed the claims file, he did not comment on the October 1990 private treatment record regarding potential sleep apnea or the 1994 uvuloplasty. The examiner's conclusion was heavily based on the inaccurate factual premise that the Veteran did not report snoring or fatigue until 2005. Accordingly, an addendum opinion is necessary. The matters are REMANDED for the following action: 1. Contact the Veteran, and with his assistance identify any outstanding records of pertinent medical treatment from private providers and associate them with the claims file. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's obstructive sleep apnea and whether is it at least as likely as not (a 50 percent probability or greater) that the Veteran's obstructive sleep apnea began in service or was caused by his service. Review of the entire claims file is required and the examiner is asked to comment on the October 1990 private treatment record regarding questionable sleep apnea and the 1994 uvuloplasty. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Fitzgerald, 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.