Citation Nr: 21041416 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 16-61 502 DATE: July 9, 2021 REMANDED Entitlement to service connection for a sleep disorder, to include as secondary to service-connected tinnitus is remanded. Entitlement to service connection for degenerative arthritis of the left hand with tenosynovitis of the left thumb and left fourth finger (left hand disorder) is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1977 to March 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). A February 2014 rating decision denied entitlement to service connection for a left-hand disorder. A June 2015 rating decision, in pertinent part, denied entitlement to service connection for obstructive sleep apnea. When these matters were last before the Board in May 2019, they were remanded for further development. At that time, the issues of an earlier effective date for the grant of service connection for bilateral hearing loss, and entitlement to a compensable rating for bilateral hearing loss were also remanded, as a statement of the case (SOC) had not been issued to address the claims. An SOC was issued in August 2020 and in his substantive appeal of October 2020, the Veteran appealed these issues and requested a video hearing. Accordingly, those matters will be addressed by a separate decision once that hearing has been held. 1. Entitlement to service connection for a sleep disorder, to include as secondary to service-connected tinnitus is remanded. When this matter was last before the Board in May 2019, it was remanded, in pertinent part, to afford the Veteran a new VA examination. Specifically, the examiner was asked to opine as to whether the Veteran's obstructive sleep apnea was caused or aggravated by his service-connected tinnitus. The examiner was also instructed to address a medical study submitted by the Veteran which found an association between tinnitus and insomnia. The Veteran was afforded an examination in November 2019. The examiner explained the anatomical causes of sleep apnea and what occurs while a person is sleeping, and then made a general conclusory statement that sleep apnea and tinnitus are unrelated. This opinion is deficient, as the examiner failed to provide rationale for the conclusion reached. Simply explaining the anatomical causes of sleep apnea without applying such to the Veteran's specific contentions, leaves no basis upon which the Board can reach a decision. Moreover, the examiner failed to provide an opinion that addressed both causation and aggravation of the Veteran's sleep apnea by his service-connected tinnitus. For a secondary service connection claim, a VA medical opinion should address both causation and aggravation prongs; separate findings and rationales should be provided for each one. Atencio v. O'Rourke, 30 Vet. App. 74, 90 (2018). A remand is therefore necessary to obtain an addendum medical opinion for the Veteran's secondary service connection claim. Finally, the examiner failed to address the medical study submitted by the Veteran which found an association between tinnitus and insomnia. Based on the foregoing, a remand is necessary to obtain an addendum medical opinion. Entitlement to service connection for degenerative arthritis of the left hand with tenosynovitis of the left thumb and left fourth finger (left hand disorder) is remanded. When this matter was last before the Board in May 2019, it was remanded, in pertinent part, to afford the Veteran a new VA examination to determine the nature and etiology of his left-hand disorder. Notably, the examiner was instructed to address the Veteran's competent and credible statements regarding the onset of his left-hand symptomatology and his statements regarding the continuity of symptomatology, in addition to the lay statements which corroborate the Veteran's reports. The Veteran was afforded a VA examination in November 2019. The examiner noted the Veteran's history of a subungual hematoma of the left ring finger after an oxygen tank fell on the finger during service. The examiner also noted that the Veteran was seen by a hand specialist in June 2016, at which time he was noted to have left thumb and ring flexor tenosynovitis and degenerative joint disease of the left hand. The Veteran's prior x-rays in 2014 were noted to be normal. Based on the foregoing, the examiner stated that it was less likely than not that the Veteran's left-hand disorder was related to service. A remand by the Board confers on the claimant, as a matter of law, a right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Here, the Board finds that the November 2019 examination is inadequate for adjudicative purposes. The opinion rendered failed to address (1) the statements regarding the onset of his left-hand symptomatology, (2) his statements regarding the continuity of symptomatology, and (3) the lay statements which corroborate the Veteran's reports. Accordingly, the matter must be remanded to obtain an adequate medical opinion which properly addresses the remand directives. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to determine the etiology of his left-hand disorder. The entire claims file must be reviewed by the examiner in conjunction with the opinion. The examiner should confirm in the examination report that he or she has reviewed the folder in conjunction with the examination. The examiner is asked to provide the following opinions: a.) Identify, by diagnosis, each left-hand disorder found to be present to include degenerative arthritis and tenosynovitis of the left ring finger and left thumb. b.) For each left hand disorder found to be present, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's left hand disorder, to include degenerative arthritis and tenosynovitis of the left ring finger and left thumb, had its clinical onset during active service or is related to any incident of service. In rendering these opinions, the examiner must address the following: (i.) An April 1978 left thumb injury after playing basketball, resulting in pain and tenderness. (ii.) A February 1980 injury where an oxygen tank fell on the Veteran's hand, resulting in a subungual hematoma of the left ring finger. (iii.) The Veteran's reports of left-hand pain after service, that he would self-treat with Motrin. (iv.) A May 2016 statement indicating that the Veteran had a left-hand injury at the time of separation from service. (v.) A March 2017 statement indicating that the Veteran continued to complain of left-hand pain following service. 2. Schedule the Veteran for an examination to determine the nature and etiology of his sleep disorder(s). The entire claims file must be reviewed by the examiner in conjunction with the opinion. The examiner should confirm in the examination report that he or she has reviewed the folder in conjunction with the examination. The examiner is asked to provide the following opinions: a.) Identify, by diagnosis, each sleep disorder found to be present, to include obstructive sleep apnea and insomnia. b.) For each sleep disorder found to be present, opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sleep disorder was caused by his service-connected tinnitus. c.) For each sleep disorder found to be present, opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sleep disorder was aggravated (worsened beyond normal progression) by his service-connected tinnitus. In rendering this opinion, the examiner must address the following: i.) A May 2015 sleep study showing an assessment of obstructive sleep apnea with insomnia. ii.) The medical study submitted by the Veteran which found an association between tinnitus and insomnia. The examiner is reminded that causation and aggravation are separate inquiries, and therefore, separate findings and rationales should be provided for each one. In rendering the opinions above, the examiner is reminded that the Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Marsh II, 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.