Citation Nr: 23049385 Decision Date: 09/07/23 Archive Date: 09/07/23 DOCKET NO. 20-04 997 DATE: September 7, 2023 ORDER Entitlement to an effective date earlier than September 20, 2017, for the grant of service connection for tinnitus is denied. Entitlement to a disability rating in excess of 10 percent for tinnitus is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is granted on and after September 20, 2017. Service connection for headaches is granted. Service connection for high blood pressure is denied. Service connection for a heart disability is denied. Service connection for erectile dysfunction is denied. Service connection for a disability manifested by walking impairment, other than lumbar radiculopathy of the sciatic and femoral nerves of the right and left lower extremities is denied. REMANDED Service connection for a disability manifested by sleep impairment is remanded. FINDINGS OF FACT 1. There is no indication of a claim of service connection for tinnitus prior to September 20, 2017. 2. The Veteran's service-connected tinnitus is already assigned the maximum schedular rating authorized under Diagnostic Code 6260. 3. The Veteran's service-connected disabilities have met the percentage requirements for the award of a schedular TDIU since September 20, 2017, and the evidence indicates that the nature and severity of his service-connected disabilities have prevented him from performing gainful employment for which his education and occupational experience would otherwise qualify him since September 20, 2017. 4. The most persuasive evidence does not weigh against finding that the Veteran's headaches are etiologically related to his service-connected generalized anxiety with panic symptoms and bipolar disorder. 5. The most persuasive evidence weighs against finding that the Veteran has high blood pressure that is related to active military service or events therein. 6. The most persuasive evidence weighs against finding that the Veteran has a heart disability that is related to active military service or events therein. 7. The most persuasive evidence weighs against finding that the Veteran has erectile dysfunction that is related to active military service or events therein. 8. The most probative evidence is against finding that the Veteran has a disability manifested by walking impairment, other than lumbar radiculopathy of the sciatic and femoral nerves of the right and left lower extremities, that has symptoms distinct from those of his service-connected lumbar radiculopathy of the sciatic and femoral nerves of the right and left lower extremities. CONCLUSIONS OF LAW 1. The criteria for entitlement to an effective date prior to September 20, 2017, for the grant of service connection for tinnitus are not met. 38 U.S.C. §§ 5101, 5107, 5108, 5110, 7105; 38 C.F.R. §§ 3.104, 3.400. 2. There is no legal basis for the assignment of a schedular rating in excess of 10 percent for tinnitus. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.87, Diagnostic Code 6260. 3. With resolution of reasonable doubt in the Veteran's favor, the criteria for the award of a TDIU have been met on and after September 20, 2017. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. 4. With resolution of reasonable doubt in the Veteran's favor, the criteria for a grant of service connection for headaches have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 5. The criteria for establishing service connection for high blood pressure have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 6. The criteria for establishing service connection for a heart disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 7. The criteria for establishing service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 8. The criteria for service connection for a disability manifested by walking impairment, other than lumbar radiculopathy of the sciatic and femoral nerves of the right and left lower extremities have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Air Force from November 1974 to November 1976. These matters are on appeal from a February 2018 rating decision. The Veteran's claim for service connection for sleep issues has been recharacterized as a disability manifested by sleep impairment, other than generalized anxiety with panic symptoms and bipolar disorder. The Veteran's claim for service connection for walking issues has been recharacterized as a disability manifested by walking impairment, other than lumbar radiculopathy of the sciatic and femoral nerves of the right and left lower extremities. See?Clemons v. Shinseki, 23?Vet. App.?1, 5 (2009). In his December 2019 substantive appeal (VA Form 9), the Veteran raised entitlement to a TDIU in connection with his appeal for an increased rating for tinnitus. The issue of entitlement to a TDIU has therefore been raised in connection with the claim on appeal for an increased rating for tinnitus. See Rice v. Shinseki, 22 Vet. App. 447 (2009); 38 C.F.R. § 4.16(a). The Veteran was not afforded a VA examination for high blood pressure, a heart disability, or erectile dysfunction. However, the Board finds that examinations are not warranted. As discussed in further detail below, the probative evidence does not show that there is any indication that these disabilities may be associated with his service. Additionally, to the extent that the Veteran has attempted to provide a contention by merely filing a claim for service connection, this is too general and conclusory to indicate that there may be a nexus to service. Therefore, the duty to obtain a VA medical opinion has not been triggered in connection with these issues. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Board accordingly concludes that no examination is required to support the Board's adjudication of the claims of entitlement to service connection for high blood pressure, a heart disability, or erectile dysfunction. Neither the Veteran nor his attorney have raised any issue with the duty to notify or duty to assist with regard to the claims being decided below.??See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.");?Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying?Scott?to a duty to assist argument).? 1. Tinnitus - Effective Date The Veteran contends that he should be granted an effective date earlier than September 20, 2017, for service connection for tinnitus. He has made no specific contention with regard to this claim and has not requested any specific date. Unless specifically provided otherwise by statute, the effective date of an award for compensation benefits based on (1) an original claim, (2) a claim reopened after final adjudication, or (3) a claim for increase, is the date VA received the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400; Lalonde v. West, 12 Vet. App. 377, 382 (1999). VA received notice of the Veteran's claim for service connection for tinnitus on September 20, 2017. The Board has reviewed the claims file for any document, submitted before the Veteran's September 20, 2017, claim, that could be considered a claim for service connection for tinnitus. The Board has found no communication from the Veteran to VA that could be construed as a formal or informal claim of entitlement to service connection for tinnitus prior to the claim submitted on September 20, 2017. Moreover, neither the Veteran nor his attorney assert that the Veteran filed an informal or formal claim for tinnitus during that time. For those reasons, the Board concludes that the Veteran is not entitled to an effective date earlier than September 20, 2017, for service connection for tinnitus, which is the day VA received the claim that led to the grant of service connection. 2. Tinnitus - Increased Rating The Veteran contends that his tinnitus warrants a higher rating than that currently assigned. It is currently rated under 38 C.F.R. § 4.87, Diagnostic Code 6260, with a 10 percent rating on and after September 20, 2017. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. "Staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Given the nature of the present claim for a higher initial evaluation, the Board has considered all evidence of severity from the effective date for the award of service connection. Fenderson v. West, 12?Vet. App.?119 (1999). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Diagnostic Code 6260 pertains to recurrent tinnitus and provides for only one rating: 10 percent. 38 C.F.R. § 4.87, Diagnostic Code 6260. The Veteran's tinnitus has been assigned that rating throughout the period on appeal. Because the Veteran's tinnitus has been assigned the maximum schedular rating throughout the period on appeal, the Board finds there is no legal basis upon which to award a higher schedular evaluation for tinnitus. As such, entitlement to a rating for tinnitus in excess of 10 percent is not warranted on a schedular basis. See Sabonis v. Brown, 6 Vet. App. 426 (1994). 3. TDIU The Veteran contends that his service-connected disabilities render him unemployable. He reports that he last worked full-time in March 2009. In a June 2020 statement, the Veteran's spouse added that the Veteran had not worked since 2009. VA will grant a total disability rating when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from securing and following substantially gainful employment consistent with her education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. The term "substantially gainful occupation" is not defined in the rating schedule. Rather, the Court in Ray v. Wilkie, found the phrase has two components: an economic one and a noneconomic one. 31 Vet. App. 58 (2019). In assessing the Veteran's ability to secure and follow a substantially gainful occupation, the Board is to consider the Veteran's history, education, skill, and training as well as physical abilities and mental abilities required by the occupation at issue. Id. Marginal employment is not considered substantially gainful employment and generally is deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist in certain cases, such as employment in a protected environment like a family business or sheltered workshop, when earned annual income exceeds the poverty threshold on a facts-found basis. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the purposes meeting the requirement of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16(a). The Veteran's combined disability rating on and after September 20, 2017 is 90 percent: his generalized anxiety with panic symptoms and bipolar disorder is rated 70 percent disabling, his Scheuermann's disease with spina bifida occulta and degenerative disc disease, thoracolumbar spine is rated 20 percent disabling, his lumbar radiculopathy of the sciatic nerve, right lower extremity is rated 20 percent disabling, his lumbar radiculopathy of the sciatic nerve, left lower extremity is rated 20 percent disabling, his lumbar radiculopathy of the femoral nerve, right lower extremity is rated 20 percent disabling, his lumbar radiculopathy of the femoral nerve, left lower extremity is rated 20 percent disabling, and his tinnitus is rated 10 percent disabling. The criteria for consideration of a schedular TDIU are therefore met on and after September 20, 2017. In a July 2009 decision, the Social Security Administration (SSA) found the Veteran disabled as of March 20, 2009, due primarily to his degenerative disc disease of the lumbar spine. SSA determinations, while relevant, are not binding upon the Board. Collier v. Derwinski, 1 Vet. App. 413, 417 (1991). The Veteran was afforded a VA examination for mental disorders in January 2018 by a psychologist who diagnosed generalized anxiety disorder with panic symptoms and bipolar 1 disorder and opined that the Veteran was totally occupationally impaired due to his psychiatric symptoms. The Veteran was afforded an additional VA examination for mental disorders by the same psychologist in November 2019 and the psychologist again opined that the Veteran was totally occupationally impaired due to his psychiatric symptoms. The Veteran was afforded a VA examination for back conditions in February 2018. The clinician opined that, as a result of his low back disability and radiculopathy, the Veteran was "unable to work at any job." The Veteran has submitted a July 2020 medical opinion by a private physician, who also opined that the combined limitations imposed by the Veteran's service-connected disabilities, both psychiatric and physical, had precluded all employment since at least 2009. The physician provided a thorough rationale for this opinion. The Veteran and his spouse report that he has not worked since 2009 and the record contains no evidence to the contrary. The record contains multiple opinions, including from the SSA, a private physician, a VA clinician, and two from a VA psychologist, indicating that the Veteran's service-connected disabilities render him unemployable. The SSA decision is prior to the period on appeal, the VA opinions are near the beginning of the period on appeal, and the private opinion, while more recent, specifically applies throughout the period on appeal. The Board therefore finds that the most probative evidence weighs in favor of finding that the Veteran's service-connected disabilities have rendered him unemployable under the applicable regulations since September 20, 2017. As reasonable doubt must be resolved in favor of the Veteran, entitlement to a TDIU is warranted on and after September 20, 2017, which is the entire period on appeal. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in approximate balance with the negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. It is only when the weight of the evidence is persuasively against the claim that the claim must be denied. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). 1. Headaches The Veteran contends that his headaches are etiologically related to his active-duty service. Specifically, he contends that they are secondary to his other service-connected disabilities. A December 1974 service treatment record notes the Veteran's report of a headache. An August 1975 service treatment record notes that the Veteran "had a spinal tap in December 1974 for headache." The Veteran was afforded a VA examination for headaches in November 2017. The clinician diagnosed cluster headaches and opined that they were not incurred in or caused by active duty service because "[n]o information was noted on a search of the claimant's health history that he had headaches during his time in the military." As stated above, this is inaccurate; the Veteran's service treatment records show a report of and treatment for a headache. A medical opinion based on an inaccurate factual premise has limited, if any, probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Even if it were accurate, this is not an adequate rationale. Even if it were an adequate rationale with regard to direct service connection, the Veteran's claim is for service connection on a secondary basis. For all of these reasons, this opinion is of no probative value and will play no role in the Board's analysis. The Veteran was afforded an additional VA examination for headaches in April 2018. The clinician diagnosed migraine headaches but provided no opinion as to their etiology. The Veteran has submitted June 2020 statements from his spouse and daughter, who both report that his headaches worsen along with his psychiatric symptoms. The Veteran has submitted a July 2020 examination by a private physician, who diagnosed cluster migraine headaches and opined that his service-connected disabilities "all cause and continue to permanently aggravate" them. Although this opinion included all service-connected disabilities, the physician only included a rationale with regard to his psychiatric disability: that "[m]edical research states that patients with mental health conditions are more likely to develop headaches because pain and mood are actually regulated by the same part of the brain" and it is "well established that mental disorders both cause and aggravate headaches." The record contains only one medical opinion with regard to secondary service connection. It is favorable to the Veteran's claim and contains an adequate rationale. In light of the totality of the circumstances, and after resolving all reasonable doubt in his favor, the evidence of record does not weigh persuasively against finding that the Veteran's headaches were caused or aggravated by his service-connected psychiatric disability. Accordingly, the Board finds that granting service connection for headaches is the decision that is the most consistent with VA's policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. § 3.303(a). 2. High Blood Pressure 3. Heart Disability 4. Erectile Dysfunction The Veteran contends that he has high blood pressure, a heart disability, and erectile dysfunction. His VA treatment records note diagnoses of hypertension and coronary artery disease. However, he has not provided any theory of service connection for any of these disabilities other than the implied contentions inherent in filing a claim. The record does not reflect, and the Veteran does not contend, that high blood pressure, a heart disability, or erectile dysfunction had their onset in service. The Veteran's service treatment records do not reflect any symptoms or complaint of, or diagnosis of high blood pressure, a heart disability, or erectile dysfunction and he has not provided any theory of service connection. Because the most probative evidence weighs against finding that the Veteran's high blood pressure, heart disability, or erectile dysfunction are etiologically related to his active-duty service, entitlement to service connection for high blood pressure, a heart disability, and erectile dysfunction is denied. 5. Disability Manifested by Walking Impairment The Veteran contends that he has a current disability manifested by walking impairment that was caused or aggravated by active-duty service. The Veteran has made no contentions with regard to this claim other than the implied contentions inherent in filing a claim. The Veteran is already service connected for lumbar radiculopathy of the sciatic and femoral nerves of the right and left lower extremities. The question before the Board is therefore whether the Veteran has had a disability manifested by walking impairment during the period on appeal with symptoms distinct from those of his service-connected lumbar radiculopathy. The Veteran was afforded VA examinations for knee and lower leg conditions, as well as back conditions, in November 2017. The Veteran reported weakness, numbness, tingling, and radiating pain down his legs. The clinician found radiculopathy of the left and right lower extremities, that its symptoms included bilateral pain, paresthesias and/or dysesthesias, and numbness, and that the functional impact of the Veteran's low back disability and radiculopathy included abnormal gait, limited ability to stand, walk or sit for long periods of time, and pain radiating to both legs with decreased sensation. The Veteran was afforded additional VA examinations for back conditions in February 2018 and March 2020 which also noted that the symptoms of his lumbar radiculopathy included pain, paresthesias and/or dysesthesias, and numbness. The Veteran has submitted a June 2020 statement from his daughter, who reported that he had "trouble getting around and he [had] to use a cane at times because of" "pain in his back and legs." The Veteran and his daughter are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in this case they are not competent to establish a diagnosis or provide an etiology opinion for his reported walking impairment. The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person to provide an opinion as to etiology. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Veteran and his daughter in this case are not shown to possess any pertinent medical training or expertise that would make them competent to render an opinion on the etiology of any current walking impairment or to express an opinion about when his symptoms first warranted any medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Further, they do not have the training necessary to opine that his walking impairment is a separate disability from his lumbar radiculopathy, as opposed to a symptom of this service-connected disability. Thus, to the extent that the Veteran and his daughter have contended that his walking impairment represents a disability distinct from his service-connected lumbar radiculopathy, those opinions are not competent evidence and they cannot be assigned any probative weight. Rather, the medical findings and opinions of trained medical professionals warrant greater probative weight than the Veteran's and his daughter's lay contentions in this case. Neither the Veteran nor any treatment provider or examiner has identified any walking symptom distinct from those attributed to his lumbar radiculopathy on which a separate rating could be based. The Veteran's walking impairment is already one of the bases for his ratings for lumbar radiculopathy. The Veteran does not have any walking symptoms that have been differentiated from his lumbar radiculopathy and excluded from the rating that has been assigned. All of his walking symptoms are already being compensated as service connected. Mittleider, 11 Vet. App. at 182. There are no symptoms that have been excluded from his rating. Because the most persuasive evidence is thus against finding that the Veteran has a walking disability, other than lumbar radiculopathy, that has symptoms distinct from those of his service-connected lumbar radiculopathy, entitlement to service connection for a disability manifested by walking impairment is denied. REASONS FOR REMAND 1. Service connection for a disability manifested by sleep impairment is remanded. Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran has clarified that this claim includes sleep apnea. The Veteran was afforded a VA examination for sleep apnea in November 2017. The clinician's opinion with regard to service connection was based entirely on a finding that the Veteran had not been diagnosed with sleep apnea. Because this opinion does not address multiple VA treatment records noting a diagnosis of obstructive sleep apnea, including an April 2011 sleep study, it is inadequate. In addition, the Veteran has submitted a July 2020 examination and medical opinion by a private physician, who opined that the Veteran's "pain from his service-connected back, the medications used to treat his pain, his mental health symptoms, and his obesity, have all caused and continue to permanently aggravate his obstructive sleep apnea." In 2017, VA's General Counsel issued a precedent opinion which held that obesity is not subject to service connection on a direct basis, cannot qualify as an in-service disease or injury for the purposes of service connection, and generally cannot be service connected on a secondary basis as a disability directly resulting from a service-connected disability. VAOPGCPREC 1-2017 (Jan. 22, 2017). It was further held, however, that obesity can be an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis. Id. In order for obesity to be such an "intermediate step," (1) a service-connected disability must have caused the Veteran to become obese or aggravated her obesity, (2) obesity must have been a substantial factor in causing the disability in question and (3) the disability in question must have been one that would not have occurred but for obesity caused or aggravated by the service-connected disability. Walsh v. Wilkie, 32 Vet. App. 300, 307 (2020). Considerations that can give rise to a reasonably raised theory of secondary service connection with obesity as an intermediate step "may include, but are not limited to, mobility limitations or reduced physical activity as a result of a service-connected physical disability (in particular, orthopedic conditions or chronically painful conditions); reduced physical activity or inability to follow a course of exercise or diet as a result of service-connected mental disability; side effects of medication (e.g., weight gain), where the medication is prescribed for a service-connected disability; treatise evidence suggesting a connection between all or some combination of obesity, service-connected disability, and the claimed condition; lay statements by a veteran attributing weight gain or obesity to the service-connected disability; and statements by treating physicians or medical examiners attributing weight gain or obesity to the service-connected disability." Garner v. Tran, 33 Vet. App. 241, 248 (2021). The private physician did not opine that the Veteran's service-connected disabilities, without the additional factor of obesity, would be sufficient to cause or aggravate his sleep apnea and did not make the necessary findings referenced above for obesity as an intermediate step. A remand is therefore necessary to afford the Veteran an additional VA medical opinion. The matters are REMANDED for the following action: 1. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran's sleep apnea. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide opinions as to the following: a. Whether any current sleep apnea is related to service? b. Whether any current sleep apnea was caused by his service-connected psychiatric or low back disabilities, including as a result of medication take for those disabilities. b. Whether any current sleep apnea was aggravated by his service-connected psychiatric or low back disabilities, including as a result of medication taken for those disabilities. c. Whether the Veteran's psychiatric or low back disabilities caused him to become obese or aggravated his obesity. d. If the answer to (c) is yes, whether the Veteran's obesity was a substantial factor in causing his sleep apnea. e. If the answer to (d) is yes, whether the Veteran's sleep apnea would not have occurred but for obesity that was caused or aggravated by his service-connected psychiatric or low back disabilities. Although an independent review of the claims file is required, the Board calls the clinician's attention to the July 2020 private medical opinion finding that the Veteran's "pain from his service-connected back, the medications used to treat his pain, his mental health symptoms, and his obesity, have all caused and continue to permanently aggravate his obstructive sleep apnea." The rationale for any opinion expressed should be provided. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 2. Ensure that the directives specified in this remand have been implemented.? If they have not, appropriate corrective action must be undertaken before?readjudication. ?Stegall v. West, 11?Vet. App.?268 (1998).??? 3. Then, readjudicate the claim.? If the decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response.? Then, return the case to the Board. DUSTIN L. WARE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Frank, 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.