Citation Nr: 22019065 Decision Date: 03/31/22 Archive Date: 03/31/22 DOCKET NO. 17-23 883 DATE: March 31, 2022 ORDER Entitlement to service connection for a lumbar spine disability characterized as degenerative disc disease of the lumbar spine is granted. Entitlement to service connection for lumbosacral radiculopathy of the bilateral lower extremities is granted. Entitlement to service connection for organic periodic limb movement disorder (PLMD) is granted. Entitlement to service connection for chronic insomnia is granted. FINDINGS OF FACT 1. The Veteran's current lumbar spine disability had its onset in service. 2. The Veteran's current lumbosacral radiculopathy of the bilateral lower extremities had its onset during service. 3. The Veteran's current organic PLMD had its onset in service. 4. The Veteran's current chronic insomnia had its onset in service. CONCLUSIONS OF LAW 1. The criteria for service connection for a lumbar spine disability characterized as degenerative disc disease of the lumbar spine are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303(a), (c); 3.307, 3.309(a). 2. The criteria for service connection for lumbosacral radiculopathy of the bilateral lower extremities are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303(a), (c), 3.307, 3.309(a). 3. The criteria for service connection for organic PLMD are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303(a), (c). 4. The criteria for service connection for chronic insomnia are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303(a), (c). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from January 1980 to January 1984 and February 2012 to April 2014. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2014 Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) rating decision, which in pertinent part, denied entitlement to service connection for restless leg syndrome (RLS), and sleep disturbances. These issues were previously before the Board in April 2020, at which time, the Board remanded the issues to the AOJ for further evidentiary development, including scheduling the Veteran for a VA examination to determine the nature and etiology of any sleep disorder, to include insomnia and PLMD. Additionally, the Board remanded the Veteran's claim to obtain updated VA treatment records. These records have been retrieved and the AOJ substantially complied with the Board's remand instructions. See July 2020, March 2021 CAPRIs. The issues were returned to the Board in March 2021, at which time, the Board again remanded the issues to the AOJ for further evidentiary development, including, obtaining an addendum opinion to determine the etiology of the Veteran's claimed leg disorder and sleep disorder. The subsequent VA examinations are in substantial compliance with the Board's remand instructions and applicable law and regulations. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As noted, the November 2014 rating decision denied entitlement to service connection for RLS and sleep disturbance. In addition, the November 2014 rating decision denied entitlement to service connection for a back condition essentially based upon a finding that the Veteran did not have a diagnosed chronic back disability related to active military service. In May 2015, the Veteran filed VA Form 21-0958 Notice of Disagreement, regarding the November 2014 rating decision's denial of entitlement to service connection for RLS and sleep disturbances, and liberally construed, regarding the denial of service connection for a low back condition. Palmer v. Nicholson, 21 Vet. App. 434, 437 (2007) ("VA has always been, and will continue to be, liberal in determining what constitutes a Notice of Disagreement") (quoting 57 Fed. Reg. 4088, 4093 (Feb. 3, 1992)). In May 2015, the Veteran noted that the November 2014 rating decision stated that he had not been diagnosed with RLS or a sleep disturbance, and in response the Veteran submitted an August 2013 service treatment record which indicated a diagnosis of organic PLMD and insomnia. Similarly, the August 2013 service treatment record also indicated that the Veteran had a current diagnosis of lumbar neuritis, which is a chronic back condition. See 38 C.F.R. §§ 3.303(b); 3.309(a). As such, the issue of entitlement to service connection for a lumbar spine disability with radiculopathy claimed as a low back condition is added to the issues on appeal. SERVICE CONNECTION Service connection will be granted if the evidence demonstrates that current disability resulted from an injury or disease incurred in active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). "Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service." Service connection may also be granted based on chronicity or continuity of symptomatology for a disability which is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a), including arthritis and peripheral neuropathy. See 38 C.F.R. § 3.303(b). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. 1. Entitlement to service connection for a lumbar spine disability with radiculopathy For reasons set forth below, it is at least as likely as not that, the Veteran's lumbar spine disability with radiculopathy of the bilateral lower extremities had its onset during service. An August 2013 follow-up visit to discuss the results of a recent sleep study reflects diagnoses of organic periodic limb movement sleep disorder and lumbar neuritis. The neurologist noted that the Veteran reported difficulty sleeping, as well as occasional symptoms of RLS, and mild to moderate bilateral S1 radicular symptoms. The neurologist opined that the etiology of the Veteran's PLMD was likely secondary to lumbar spine radiculopathy and/or anemia. In April 2017, a VA examiner noted that a neurologist, who saw the Veteran for a follow-up of a sleep study in August 2013, indicated that the etiology of the Veteran's organic PLMD was likely secondary to his lumbosacral radiculopathy or anemia. The examiner noted that the Veteran was not service connected for either lumbosacral radiculopathy or anemia. In May 2017, the Veteran denied that he had a low back disability. The Veteran stated that his PLMD was documented as beginning during his service period. A September 2018 VA treatment record reflects a normal examination of the right lower extremity without electrodiagnostic evidence of peripheral neuropathy, plexopathy or radiculopathy. A September 2019 MRI of the lumbar spine revealed multilevel lumbar spondylosis with disc bulges contributing to neural foraminal stenosis. In November 2019, a VA neurological surgeon noted that the findings from chart review and review of imaging revealed degenerative disc and arthritis changes with multiple mild disc bulges. The treatment provider noted that there was no nerve compression or significant canal stenosis, and no explanation on the MRI for the Veteran's left leg symptoms. The treatment provider noted that a September 2018 electromyography (EMG) of the Veteran's right leg was normal. The treatment provider noted an impression of left buttock pain to the knee and recommended EMG and/or physical medicine and rehabilitation consultation for further evaluation. A March 2020 lumbar spine rehabilitation consultation record reflects a diagnosis of lumbosacral radiculitis/radiculopathy, low back pain, and disc bulges. See also June 2020 VA treatment record. The treatment provider noted that the Veteran had been referred for consultation regarding right foot numbness and back pain since 2015. The Veteran reported the gradual onset of low back pain from about 1984 to 1987, which became more frequent in 2014 without any identifiable inciting event. The Veteran reported that his low back pain would radiate into the left buttock, but not in the right buttock or lower extremities. The Veteran also reported the onset of numbness, tingling and pain of the tip of the right great toe in approximately 2015 without any identifiable inciting event. The treatment provider referenced the September 2019 MRI of the lumbar spine which revealed multilevel lumbar spondylosis with disc bulges contributing to neural foraminal stenosis. The Veteran was afforded a VA examination in September 2020, the VA examiner noted that the Veteran did not have a peripheral nerve condition or peripheral neuropathy. The examiner noted that an August 2013 treatment provider opined that PLMD was most likely secondary to lumbosacral radiculopathy and/or anemia which, the September 2020 VA examiner noted were not service-connected conditions. In April 2021, the September 2020 VA examiner once again noted that although an August 2013 sleep study diagnosed the Veteran with PLMD, the treatment provider opined that the etiology of the Veteran's PLMD was secondary to his non-service-connected lumbar spine radiculopathy and/or anemia. In September 2021, the Veteran stated that he did not have radiculopathy of the lower extremities during the 2013 sleep study, which opined that the Veteran's PLMD was secondary to lumbar spine radiculopathy and/or anemia. Based on the evidence as outlined above, the Board finds that the Veteran has a current diagnosis of degenerative disc disease of the lumbar spine with radiculopathy of the bilateral lower extremities, which had its onset during a period of active-duty service. Although no VA examiner has provided an opinion regarding whether the Veteran's current lumbar spine disability had its onset during service, based on the evidence as outlined above, the April 2017, September 2020, and April 2021 VA opinions coupled with the other medical evidence of record including service medical records, post service medical records, and lay evidence, support a conclusion that service connection for a lumbar spine disability is warranted. Although the April 2017 and September 2020 VA examiners did not explicitly state that the Veteran's lumbar spine disability had its onset in service, the examiners' statement that an August 2013 neurologist opined that the etiology of the Veteran's PLMD was likely secondary to lumbar spine radiculopathy and/or anemia; and the April 2017 VA examiner's statement that the Veteran was not currently service connected for lumbosacral radiculopathy, can be interpreted as supporting a finding that the Veteran's current lumbar spine disability had its onset during service by indicating that the Veteran currently has a lumbar spine disability which existed in service. Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). Similarly, no VA examiner has provided an opinion regarding whether the Veteran's current lumbosacral radiculopathy had its onset in service; however, the April 2017 and April 2021 VA opinions coupled with the other medical evidence of record including service medical records, post service medical records, and lay evidence, supports a conclusion that service connection for lumbosacral radiculopathy of the bilateral lower extremities is warranted. Although the April 2017 and September 2020 VA examiners did not explicitly state that the Veteran's radiculopathy of the bilateral lower extremities had its onset in service, the examiner's statement that an August 2013 neurologist opined that the etiology of the Veteran's PLMD was likely secondary to lumbar spine radiculopathy and /or anemia; and the April 2017 VA examiner's statement that the Veteran was not currently service connected for lumbosacral radiculopathy, can be interpreted as supporting a finding that the Veteran's current lumbosacral radiculopathy had its onset during service by indicating that the Veteran currently has lumbosacral radiculopathy which existed in service. Further, although the September 2020 VA examiner opined that the Veteran did not have a peripheral nerves condition or peripheral neuropathy, the examiner did not discuss the March 2020 and June 2020 VA treatment records which reflect a diagnosis of lumbosacral radiculitis/radiculopathy, which renders the opinion inadequate. See also June 2020 VA treatment record. Additionally, as noted, the Veteran asserts that he did not have a lumbar spine disability or radiculopathy in August 2013. Although the Veteran is competent to report presence of symptoms, the record does not indicate that the Veteran has the skill or expertise to determine whether he had a lumbar spine disability or radiculopathy. Thus, his statements in this regard are not probative evidence of whether the Veteran did not have a diagnosis of a lumbar spine disability or radiculopathy in August 2013. Based on the evidence as outlined above, the clinical evidence of record, including the August 2013 service treatment record, as well as the April 2017 and April 2021 VA opinions, support a finding that the Veteran's low back disability and radiculopathy of the bilateral lower extremities had their onset during service. Resolving reasonable doubt in favor of the Veteran and based on the medical and lay evidence of record, the Board finds that the evidence of record supports a finding that service connection for a lumbar spine disability characterized as degenerative disc disease of the lumbar spine with radiculopathy of the bilateral lower extremities is warranted. See 38 U.S.C. § 5107. 2. Entitlement to service connection for PLMD For reasons set forth below, it is at least as likely as not that, the Veteran's organic PLMD had its onset during service. An August 2013 follow-up visit to discuss the results of a recent sleep study reflect diagnoses of organic periodic limb movement sleep disorder and lumbar neuritis. The neurologist noted that the Veteran reported difficulty sleeping, as well as occasional symptoms of RLS, and mild to moderate bilateral S1 radicular symptoms. The neurologist opined that the etiology of the Veteran's PLMD was likely secondary to lumbar spine radiculopathy and/or anemia. The Veteran was afforded a VA examination for sleep apnea in April 2017. The examiner noted that the Veteran had organic PLMD. The examiner noted that the Veteran had been referred to a sleep clinic in June 2013 for loud snoring, witnessed apneic spells, leg movements, early morning headaches, sore throat and daytime drowsiness. The examiner noted that the results of the June or July 2013 sleep study were unknown; and noted that no actual sleep study was available for review. VA obtained an opinion in April 2017. The examiner opined that the Veteran's organic PLMD was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that although there was a record of a diagnosis for organic PLMD when the Veteran was in service in August 2013, there was no permanent residual or chronic disability subject to service connection which had been shown by the service-treatment records, or any other medical documentation related to the condition. The examiner noted that the neurologist, who saw the Veteran in August 2013 for a follow-up of the sleep study indicated the etiology for the Veteran's organic PLMD was likely secondary to his lumbosacral radiculopathy or anemia. The examiner noted that the Veteran was not service connected for either lumbosacral radiculopathy or anemia. Also, the examiner noted that the Veteran's organic PLMD had not worsened during service and was not caused by service. The examiner also noted that the Veteran did not have RLS. The examiner noted that organic PLMD only occurred during sleep, unlike RLS, which occurred while a person was awake or sleep. The examiner noted that periodic leg movement often only last the first half of the night during non-REM sleep stages and usually the person was unaware that they were occurring, and the movements did not occur during REM because of muscle atonia. In May 2017, the Veteran denied that he had anemia or a low back disability. The Veteran stated that his PLMD was documented as beginning during his service period, and the sleep disturbances caused by limb movement have continued since service, resulting in fatigue which often interfered with his daily activities and decision-making. A February 2020 VA treatment record reflects a diagnosis of chronic insomnia and sleep related movement disorder. A March 2020 VA treatment record reflects a diagnosis of severe sleep apnea and periodic limb movement in sleep. The Veteran was afforded a VA examination in September 2020 for sleep apnea, which reflects a diagnosis of obstructive sleep apnea and periodic limb movement in sleep (PLMS). During the September 2020 VA examination, the Veteran reported that he had been diagnosed with PLMD in August 2013 while he was in service. The Veteran's spouse reported that he moved around a lot and reported that she first noticed his leg movements in 2013. During the September 2020 VA examination, the Veteran reported that his spouse noticed leg movements more than gasping. The examiner opined that the Veteran's PLMD was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness; and noted that the August 2013 treatment provider opined that PLMD was most likely secondary to lumbosacral radiculopathy and/or anemia. Pursuant to the March 2021 Board remand, the AOJ obtained an addendum opinion from the September 2020 VA examiner in April 2021. The VA examiner opined that the Veteran's diagnosed PLMD, was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that although an August 2013 sleep study diagnosed the Veteran with PLMD, the treatment provider opined that the etiology of the Veteran's PLMD was secondary to his nonservice connected lumbar spine radiculopathy and/or anemia and was not a primary diagnosis. In September 2021, the Veteran stated that he did not have radiculopathy of the lower extremities during the 2013 sleep study, which opined that the Veteran's PLMD was secondary to lumbar spine radiculopathy and/or anemia. Additionally, the Veteran reported that he had never been anemic, and reported that his blood tests for hemoglobin, non and ferritin had always been normal. Based on the evidence as outlined above, the Board finds that the Veteran has a current diagnosis of organic PLMD, which had its onset during a period of active-duty service. See also September 2020 and April 2021 VA examinations. Although the September 2020 VA examiner opined in September 2020 and April 2021 that the Veteran's diagnosed PLMD, was less likely than not incurred in or caused by the claimed in-service injury, event or illness, the September 2020 and April 2021 VA opinions coupled with the other medical evidence of record including service medical records, post service medical records, and lay evidence, supports a conclusion that service connection for organic PLMD is warranted. Although the September 2020 VA examiner did not explicitly state that the Veteran's organic PLMD had its onset in service, the examiner's statement that an August 2013 sleep study diagnosed the Veteran with PLMD, and the treatment provider opined that the etiology of the Veteran's PLMD was secondary to his non service-connected lumbar spine radiculopathy and/or anemia and was not a primary diagnosis, can be interpreted as supporting a finding that the Veteran's current organic PLMD had its onset during service by indicating that the Veteran currently has organic PLMD which existed in service. The April 2017 VA examiner who opined that although there was a record of a diagnosis for organic PLMD when the Veteran was in service in August 2013 and there was no permanent residual or chronic disability subject to service connection which shown by the service-treatment records or any other medical documentation related to the condition, did not provide a convincing rationale as to why the Veteran no longer had a current diagnosis of organic PLMD. Although no VA examiner has adequately addressed whether the Veteran's organic PLMD had its onset during service; based on the evidence as outlined above, a remand for a new examination is not appropriate in this case, because the evidence of record, including service medical records, post-service medical records, and lay evidence are sufficient to support a finding that entitlement to service connection for organic PLMD is warranted. A request for another opinion could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304(c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"); Andrews v. McDonough, 34 Vet. App. 216, 225 (2021) ("Remand is inappropriate where the predominant purpose is not to allow the Board to make a fully informed decision unencumbered by error but to allow VA to obtain more evidence so that it can properly deny the claim"); Gardner-Dickson v. Wilkie, 33 Vet. App. 50, 62 (2020) (Order), aff'd per curiam sub nom. Gardner-Dickson v. McDonough, No. 2021-1462, 2021 U.S. App. LEXIS 33000 (Fed. Cir. Nov. 5, 2021) (Order) (denying petition for a writ of mandamus challenging a remand, but agreeing "with the petitioner that it 'would not be permissible for VA to undertake... additional development if a purpose was to obtain evidence against an appellant's case.'") (citing Mariano v. Principi, 17 Vet. App. 305, 312 (2003) and Hart v. Mansfield, 21 Vet. App. 505, 508 (2007)). For these reasons, the Board finds that the VA examinations are in substantial compliance with applicable law and regulations, and there is no prejudice to the Veteran in proceeding to a decision without a remand under the circumstances. Resolving reasonable doubt in favor of the Veteran and based on the medical and lay evidence of record, the Board finds that the evidence of record supports a finding that service connection for organic PLMD is warranted. See 38 U.S.C. § 5107. 3. Entitlement to service connection for sleep disturbances The Veteran seeks service connection for insomnia, which he asserts is related to service. For reasons set forth below, it is at least as likely as not that, the Veteran's current diagnosis of chronic insomnia had its onset during service. "Determining for disability compensation purposes whether a disease or injury is related to service often raises the question whether the disease or injury arose during service or preexisted the veteran's military service. Section 1111 provides a framework for making this determination and provides that a veteran who claims entitlement to disability compensation under section 1110 is entitled to a presumption that he or she was in sound condition upon entry into service "except as to defects, infirmities, or disorders noted" during an entrance examination." McKinney v. McDonald, 28 Vet. App. 15 (2016). Every Veteran is presumed to have been in sound condition at entry into service except as to defects, infirmities, or disorders noted at the time of such entry, or where clear and unmistakable evidence demonstrates that the injury or disease existed before entry and was not aggravated by such service. 38 U.S.C. § 1111. The term "noted," in 38 U.S.C. § 1111, refers to "[o]nly such conditions as are recorded in examination reports." 38 C.F.R. § 3.304(b). A "[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions." 38 C.F.R. § 3.304(b)(1); see also Crowe v. Brown, 7 Vet. App. 238, 245 (1994). When no preexisting medical condition is noted upon entry into service, a Veteran is presumed to have been in sound condition. 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The presumption of soundness can only be rebutted by clear and unmistakable evidence that the Veteran's disorder was both preexisting and not aggravated by service. Id. Clear and unmistakable evidence means evidence that "cannot be misinterpreted and misunderstood, i.e., it is undebatable." Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (quoting Vanerson v. West, 12 Vet. App. 254, 258-59 (1999)). Service treatment records are silent as to any complaints, treatment or clinical diagnosis for insomnia prior to November 1985. See December 1984 and August 1994 report of medical history and examinations. Following the Veteran's separation from active-duty service in the United States Navy, the Veteran was transferred to the United States Naval Reserve. See April 2014 DD 214. During the Veteran's service in the United States Naval Reserve, the Veteran was afforded an annual medical examination in November 1985. The November 1985 medical examination and history reports reflect that the Veteran reported that he had been prescribed valium for insomnia due to marital discord. He reported that he and his spouse were currently separating awaiting the final divorce, and he had no current difficulties with insomnia. Following the November 1985 report of past treatment of insomnia, service treatment records from April 1987 are silent as to any complaints, treatment or clinical diagnosis for insomnia. See May 1988, December 1988, November 1989, November 1991, May 1994, August 1999, December 2004 report of medical history and examinations. In January 2012, the Veteran underwent a medical examination prior to mobilization to active-duty service in February 2012. The January 2012 medical examination and history reports for mobilization were also silent as to any complaints, treatment or clinical diagnosis for insomnia. Based on the evidence as outlined above, the presumption of soundness has not been rebutted, and the Veteran is presumed to have been in sound condition and did not have insomnia prior to service. Service treatment records reflect complaints, treatment and a clinical diagnosis of insomnia from November 2012. In November 2012, the Veteran was afforded a post-deployment health assessment, which reflects that the Veteran began complaining about trouble sleeping and insomnia following his deployment. The Veteran reported that he fell during deployment and developed problems sleeping; and problems sleeping had begun or had gotten worse after a fall. The Veteran reported that right hip, knee and ankle pain kept him from sleeping at night. In addition, the Veteran reported that his sleeping problems continued to bother him, and he had been having problems sleeping within the past week. The Veteran was diagnosed with insomnia in March 2013. During the medical visit, the Veteran complained that he had difficulty sleeping and staying asleep, and reported that he was often tired during the day. He also reported that his spouse had told him that he would occasionally snore, without episodes of apnea. The Veteran reported that this had been a problem for years, and it would wax and wane. The Veteran was afforded a post-deployment health re-assessment in March 2013. During the medical assessment, the Veteran reported that during the past month he had been bothered a little by feeling tired or having low energy; and he had been bothered a lot by trouble sleeping; trouble concentrating on things; memory problems; and had nightmares about it or thought about it. The Veteran reported that it was extremely difficult to fall asleep. An August 2013 service treatment record reflects that the neurologist noted that the Veteran reported frequent difficulty sleeping. The neurologist noted that the polysomnograms revealed abundant lower extremity associated arousals, many of which were associated with microarousals. The neurologist noted that an arousal index of 17 was calculated, which was significantly abnormal for a patient of the Veteran's age. The neurologist noted that the Veteran was instructed to avoid excessive caffeinated beverages and alcohol consumptions, no caffeine seven hours before bedtime, and proper sleep habits were reviewed with the Veteran, including setting up a regular sleep time and awakening. The August 2013 service treatment record also noted that the Veteran's chronic problems included insomnia. In April 2014, following separation from active-duty service, the Veteran filed a claim for entitlement to service connection for insomnia. The Veteran was afforded a VA examination for sleep apnea in October 2014. The VA examiner noted that the Veteran never had sleep apnea. During the examination, the Veteran reported that he had been having sleep disturbances since 2012, for which he underwent a sleep study, which was negative for sleep apnea. The Veteran reported that he was not on any medications or other types of treatments, and he denied daytime somnolence and sleepiness or daytime naps. The examiner did not discuss whether the Veteran had a current diagnosis of insomnia, which was related to service. The Veteran was afforded a VA examination for sleep apnea in April 2017. The examiner noted that the Veteran had never had sleep apnea. The examiner noted that the Veteran had organic PLMD. The examiner noted that the Veteran had been referred to a sleep clinic in June 2013 for loud snoring, witnessed apneic spells, leg movements, early morning headaches, sore throat and daytime drowsiness. The examiner noted that the results of the June or July 2013 sleep study was unknown because no actual sleep study was available for review. The examiner did not discuss whether the Veteran had a current diagnosis of insomnia which was related to service. The Veteran underwent a sleep consultation in February 2020, which reflects a diagnosis of chronic insomnia which the treatment provider noted was secondary to an underlying medical disorder, psychiatric disorder, psychophysiological insomnia, poor sleep hygiene, undiagnosed/untreated sleep disordered breathing and/or movement disorder. The sleep consultant recommended assessment for possible better control of psychiatric/medical disorder; discussed stimuli control and improved sleep hygiene, recommended consideration of an evaluation by the behavioral health team for cognitive behavioral therapy for insomnia, and medication side effects were assessed and discussed. The consultant noted that the Veteran had an insomnia severity index of 16. The Veteran reported snoring, gasping, unrefreshing and restless sleep and insufficient sleep hours at night combined with daytime fatigue and sleepiness. He reported that he had a sleep study at an outside facility in 2013 which he stated did not reveal sleep apnea. The Veteran's spouse denied dream enactment or bed falls; however, she admitted that he was very jittery during sleep; and he also had occasional involuntary jerking in his legs at night approximately 2 to 3 times a week and did not prevent him from falling asleep. The consultant noted that the duration of the Veteran's symptoms was from 2012. The consultant noted that the Veteran had a total Epworth sleepiness score of 15/24. The Veteran's bedtime was midnight, and he had a sleep latency of 15 minutes. He had 2 nocturnal awakenings and the time it took to return to sleep after arousal varied. His final awakening was at 4 to 5 am, and his estimated total sleep time was 4 to 5 hours. The Veteran reported taking spontaneous naps. The Veteran reported nonrestorative sleep, daytime fatigue, and frequent nocturnal arousals. The Veteran's other symptoms related to sleep included leg movements during sleep. The consultant noted that the Veteran's sleep hygiene included insomnia with mind racing and worry. The Veteran reported having anxiety. VA obtain an opinion in September 2020. The VA examiner opined that the Veteran's sleep apnea was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that although the Veteran reported that his problems with sleeping began in approximately 2011, based upon the June 2013 note, he had a sleep study in 2013, which was negative for sleep apnea. The examiner also noted that the Veteran's service treatment records were silent for complaints of apnea as was the 2013 sleep study. The examiner noted that the Veteran was not diagnosed with obstructive sleep apnea until March 2020 which, the examiner noted, was nearly 6 years after separation from service. The examiner did not discuss whether the Veteran had a current diagnosis of insomnia which was related to service. VA obtained an addendum opinion in April 2021 from the September 2020 VA examiner, pursuant to the Board's March 2021 remand. The April 2021 VA examiner noted that they were unable to provide an opinion regarding a diagnosis of insomnia, as it was beyond the scope of their practice, and it was not asked or addressed on the September 2020 disability benefits questionnaire. The examiner noted that a diagnosis of insomnia required an examination by a mental health provider. The Veteran was afforded a mental disorders examination in August 2021. The Veteran reported that he had an average of 4 hours of broken sleep due to his shoulder pain and reported that he did not use his C-PAP machine. In addition, the Veteran reported that he had restless leg syndrome, and he was not getting enough air. The Veteran reported that he did not have problems initiating sleep, no suicidal thoughts, or panic attacks. The Veteran reported that his mood was ok, but he felt tired due to not getting restful sleep, and would get easily irritated occasionally. The examiner opined that the Veteran did not meet the DSM-V criteria for a mental disorder; therefore, no mental health diagnosis was rendered and an opinion was considered moot. The VA examiner did not discuss whether the Veteran had a current diagnosis of insomnia which was related to service. Based on the evidence as outlined above, it is at least as likely as not that the Veteran's chronic insomnia had its onset in service. The February 2020 VA treatment record combined with the other evidence of record, including the service treatment records, post service medical records, and lay evidence support a finding that the Veteran's insomnia had its onset during service, and has been continuous since service. As noted, the February 2020 consultant noted that the Veteran reported symptoms of snoring, gasping, unrefreshing and restless sleep and insufficient sleep hours at night combined with daytime fatigue and sleepiness; the Veteran's sleep hygiene included insomnia with mind racing and worry; and the duration of the Veteran's symptoms were from 2012. Although the February 2020 VA treatment provider did not explicitly state that the Veteran's chronic insomnia had its onset in service, the consultant's diagnosis of chronic insomnia in this context, can be interpreted as supporting the necessary causal relationship by indicating that the treatment provider considered the Veteran's statements regarding the onset and the nature of his symptoms to be credible and consistent with a diagnosis of chronic insomnia. See Monzingo, supra; Acevedo, supra. The October 2014 and April 2017 VA examiners who opined that the Veteran never had sleep apnea, did not discuss whether the Veteran had a current diagnosis of insomnia, which was related to service. The September 2020 VA examiner who opined that the Veteran's sleep apnea was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness, did not discuss whether the Veteran had a current diagnosis of insomnia which was related to service. The August 2021 VA examiner who opined that the Veteran did not meet the DSM-V criteria for a mental disorder, did not discuss whether the Veteran had a current diagnosis of insomnia which was related to service. Although the October 2014, April 2017, September 2020, August 2021 VA examiners have not sufficiently addressed whether the Veteran has a current diagnosis of insomnia which is related to service, a remand for a new examination is not appropriate in this case, because the February 2020 VA treatment record combined with the other evidence of record is sufficient to support a finding that entitlement to service connection for chronic insomnia is warranted. 38 C.F.R. § 3.304(c); Andrews, supra; Gardner-Dickson; supra. Resolving reasonable doubt in favor of the Veteran and based on the medical and lay evidence of record, the Board finds that the evidence of record supports a finding that service connection for chronic insomnia is warranted. See 38 U.S.C. § 5107. RAY BARTO SLABBEKORN, JR. Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Fleury Johnson, Gerline R. 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.