Citation Nr: 24005141 Decision Date: 02/01/24 Archive Date: 02/01/24 DOCKET NO. 20-26 103 DATE: February 1, 2024 REMANDED The issue of service connection for sarcoidosis is remanded. The issue of service connection for obstructive sleep apnea (OSA) is remanded. REASONS FOR REMAND The Veteran had active service from December 1979 to June 1985. 1. The issue of service connection for sarcoidosis is remanded. 2. The issue of service connection for obstructive sleep apnea (OSA) is remanded. The matters are REMANDED for the following action: 1. BACKGROUND INFORMATION FOR THE DECISION REVIEW OPERATIONS CENTER (DROC) ADJUDICATOR: The Veteran claims that during his assignment to the USS Prairie (AD-15) from February 1981 to November 1981 and from February 1982 to June 1985, he was exposed to asbestos. He claims that this exposure caused his sarcoidosis. The present record does not show the degree of asbestos exposure sustained by the Veteran. Although the Veteran had a VA medical examination in March 2020, it is inadequate. The VA examiner did not comment on medical evidence submitted by the Veteran suggesting that he was likely exposed to asbestos during his service and that exposure may be a significant risk factor in the development and diagnosis of sarcoidosis. The Veteran's bipolar and depressive disorder are service connected. He claims that his mental disorder caused or worsened his OSA, either directly or through the development of obesity which he alleged caused or worsened his OSA. If on remand, his sarcoidosis is found service connected, the DROC should also determine if the sarcoidosis caused or worsened the Veteran's OSA. In sum, medical opinions are needed to determine: a. if the Veteran developed sarcoidosis because of in-service exposure to asbestos; b. if the Veteran developed obesity because of his service-connected bipolar and depressive disorder; and if so whether the obesity was an intermediate step towards the development or aggravation of the Veteran's OSA; c. (if the Veteran's sarcoidosis is found service connected) whether his OSA was caused or worsened by the sarcoidosis. THE REMAND DIRECTIVES FOLLOW: 2. Determine from the U.S. National Archives, OR any other appropriate records depository, whether any studies exist documenting the extent of asbestos exposure the Veteran may have had, SPECIFICALLY on the U.S.S. Prairie (AD-15) from February 1981 to November 1981 and from February 1982 to June 1985. If appropriate the researcher may ask whether Emergency Asbestos Response (EART) records are available. See www.archives.gov/research/military/navy/guided-topics/asbestos . The researcher may also ask whether the U.S. Navy's Bureau of Ships Navy Filing Manual may contain relevant information. 3. After receiving any information from the U.S. National Archives or other source as above, return the claims file to the March 2020 VA examiner and request he review the newly-obtained evidence, and respond to the questions below. If the examiner is not available, have the file examined by medical care providers qualified to give opinions about the development of sarcoidosis, and the development of OSA. QUESTION ONE: If in-service asbestos exposure is substantiated, was asbestos exposure a recognized and significant risk factor in the DEVELOPMENT or WORSENING of the Veteran's sarcoidosis? Why or why not? The examiner must review the entire record in conjunction with rendering the requested opinion. IN ADDITION TO ANY RECORDS THAT ARE GENERATED BECAUSE OF THIS REMAND, the VA examiner's attention is drawn to the following: * June 2017 private medical opinion that the Veteran's current sarcoidosis condition is at least as likely as not related to asbestos and chemical exposure in military service. See "Medical Treatment Record - Non-Government Facility," received June 29, 2017, 29 pages. * "Sarcoidosis Diagnoses Among US Military Personnel: Trends and Ship Assignment Associations," Id. at pages 14-21 of 29. * "Government and Navy Knowledge Regarding Health Hazards of Asbestos: A State of the Science Evaluation (1900 to 1970)." See "Correspondence," received May 18, 2018, page 113 of 265. * "ATSDR Case Studies in Environmental Medicine - Asbestos Toxicity" that advises if initial work history suggests asbestos exposure, the physician should consider further diagnostic workup for sarcoidosis. See Id. at page 39-40 of 265. * The New England Journal of Medicine review article "Medical Progress - Sarcoidosis," which indicates occupational studies have shown positive associations of US Navy service and sarcoidosis. See "Correspondence," received May 22, 2018, pages 25-36 of 59. * March 2020 deferred rating that notes the Veteran's MOS of electrician's mate is "probable" for asbestos exposure. See "Deferred Rating," received March 2, 2020. * March 2020 VA opinion rationale that stated, "There is no evidence in medical literature that suggests asbestos exposure causes sarcoidosis." The examiner did not distinguish any of the medical studies submitted by the private examiner nor the Veteran in their rationale. See "C&P Exam," received March 20, 2020, 3 pages. A thorough explanation must be provided for the opinions rendered. If the examiner cannot provide the requested opinion without resorting to speculation, they must expressly indicate this and provide supporting rationale as to why the opinion cannot be made without resorting to speculation. THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED, AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THE EXAMINATION/OPINION SUFFICIENT. QUESTION TWO: Did any of the Veteran's service-connected disabilities, either singly or in whole, CAUSE the Veteran to become obese? The Veteran's current service-connected disorders are bipolar and depressive disorder; degenerative arthritis to the right elbow; degenerative arthritis of the thoracic spine; degenerative arthritis of the cervical spine. (The examiner should also note that by the time of his review, the Veteran's sarcoidosis may be service connected.). * Did any of the Veteran's service-connected disabilities WORSEN the Veteran's obesity? * If the examiner finds that any of the Veteran's service-connected disabilities either caused or worsened the Veteran's obesity, was the obesity a substantial factor in CAUSING OR WORSENING OSA? The examiner must review the entire record in conjunction with rendering the requested opinion. IN ADDITION TO ANY RECORDS THAT ARE GENERATED BECAUSE OF THIS REMAND, the VA examiner's attention is drawn to the following: * December 1995 and June 1996 VA treatment records that indicate the Veteran gained significant weight after obtaining prescription treatment for substance abuse and was eventually diagnosed with bipolar and depressive disorder. See "CAPRI," 3 pages. * November 2010 private treatment records that indicate the Veteran feels fatigue, low energy and has gained weight since his sarcoidosis diagnosis. See "Medical Treatment Record - Non-Government Facility," page 136 of 497. * January 2011 VA examination report that notes the Veteran reported periods of low energy and needing to sleep. See "C&P Exam," received January 13, 2011. * June 2017 private medical opinion that states the Veteran's OSA was aggravated by his sarcoidosis condition which should also be service connected. The medical literature associated with this opinion notes an interrelationship between sleep-disordered breathing and sarcoidosis due to corticosteroid-induced obesity. See "Medical Treatment Record - Non-Government Facility," received June 29, 2017, 21 pages. * Medical studies that suggests patients with sarcoidosis are at increased risk for sleep apnea. See "Medical Treatment Record - Non-Government Facility," received May 22, 2018, 59 pages. * March 2020 VA opinion that states obesity is a common factor that causes sleep apnea. See "C&P Exam," received March 20, 2020. * March 2020 VA opinion that states the Veteran's sleep apnea was less likely than not proximately due to or the result of sarcoidosis. The examiner did not provide an opinion on whether the Veteran's sarcoidosis aggravated, or "made worse", his OSA. See Id. * August 2020 Appellate Brief that advanced the contention that the Veteran's OSA is secondary to his service-connected psychiatric disorder. See "Appellate Brief," received September 13, 2020. A thorough explanation must be provided for the opinion rendered. If the examiner cannot provide the requested opinion without resorting to speculation, s/he must expressly indicate this and provide supporting rationale as to why the opinion cannot be made without resorting to speculation. The examiner must schedule a new examination only if necessary to provide an adequate opinion. THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED, AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THE EXAMINATION/OPINION SUFFICIENT. 4. Following the review and any necessary additional development, readjudicate the claims. If the DROC does not grant the claims, issue a supplemental statement of the case (SSOC) and return the claims to the Board. The Veteran may submit additional evidence and argument. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2014). Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Anwar, Attorney-Advisor The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.