Citation Nr: 26001663 Decision Date: 02/05/26 Archive Date: 02/05/26 DOCKET NO. 14-24 602A DATE: February 5, 2026 ORDER Entitlement to service connection for obstructive sleep apnea is granted. REMANDED Entitlement to service connection for a lumbar spine disability is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, it is at least as likely as not that the Veteran's current obstructive sleep apnea is due to, caused by, or the result of, or aggravated by the service-connected panic disorder with agoraphobia and generalized anxiety disorder, including through the intermediate step of obesity. CONCLUSION OF LAW The criteria for entitlement to service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from November 1994 to February 1997. These matters come before the Board of Veterans' Appeals (Board) on appeal from the August 2011 and April 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In August 2017, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In a December 2017 decision, the Board denied entitlement to service connection for sleep apnea, and remanded the issue of entitlement to service connection for a back disability. The Veteran appealed the denial of entitlement to service connection for sleep apnea to the United States Court of Appeals for Veterans Claims (CAVC). In an October 2018 order, the CAVC granted an October 2018 Joint Motion for Partial Remand (JMPR) filed by the parties (the Veteran and the Secretary of VA), vacated the part of the December 2017 Board decision that denied entitlement to service connection for sleep apnea, and remanded the matter back to the Board for additional development. In April 2019, the Board remanded the issue of entitlement to service connection for sleep apnea for additional development. Thereafter, in a December 2019 decision, the Board denied entitlement to service connection for sleep apnea and a lumbar spine disability. The Veteran appealed the December 2019 Board decision to the CAVC. In a November 2020 order, the CAVC granted an October 2020 Joint Motion for Remand (JMR), vacated the December 2019 Board decision that denied entitlement to service connection for a lumbar spine disability and sleep apnea, and remanded these matters back to the Board for additional development consistent with terms of the October 2020 JMR. Subsequently, the Board remanded these matters in June 2021 and June 2022 to complete additional development. Thereafter, in a December 2022 decision, the Board denied entitlement to service connection for sleep apnea and a lumbar spine disability. The Veteran appealed the December 2022 Board decision to the CAVC. In a May 2024 memorandum decision, the CAVC reversed the Board's finding in the December 2022 decision that the March 2022 and July 2022 VA medical opinions were adequate for adjudication purposes, set aside the remainder of the December 2022 Board decision, and remanded these matters back to the Board for further development and readjudication consistent with the memorandum decision. Pursuant to the May 2024 memorandum decision, the Board remanded these matters for additional development in January 2025 and then in May 2025. After completing the additional development, the RO issued a December 2025 Supplemental Statement of the Case (SSOC) denying entitlement to service connection for obstructive sleep apnea and a lumbar spine disability, and returned these matters to the Board for appellate review. Entitlement to service connection for obstructive sleep apnea is granted. The Veteran claims entitlement to service connection for obstructive sleep apnea as directly related to active service or secondary to the service-connected disabilities, including obesity as an intermediate step between the service-connected disabilities and sleep apnea. During the June 2011 VA examination, the Veteran reported that shortly after his military service, his wife informed him that he would skip breaths while sleeping and wake up gasping for air. Initially, the Board notes that the Veteran has established service connection for panic disorder with agoraphobia and generalized anxiety disorder, tinnitus, and bilateral knee disability. Also, a July 2011 VA treatment record noted the Veteran's body mass index (BMI) was 35.7, an August 2019 VA treatment record noted the Veteran's BMI was 41.4, and a May 2021 VA treatment record noted the Veteran's BMI was 40.5. In a November 2025 VA medical opinion, the examiner noted that the Veteran's obesity existed before obstructive sleep apnea as his BMI was 35.7 in 2011. Thus, the Board notes that these records reflect that the Veteran has obesity. Generally, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be granted for a disability that is due to, caused by, or resulted from, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Secondary service connection requires: (1) a service-connected disability; (2) a nonservice-connected disability; and (3) evidence that the nonservice-connected disability is either (a) due to, caused by, or the result of the service-connected disability or (b) aggravated (increased in severity) by the service-connected disability. Id. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt should be given to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt should be resolved in favor of the claimant. 38 C.F.R. § 3.102. Regarding assessing the issue of obesity, VA's Office of General Counsel (OGC) issued a precedential opinion in 2017. One of the primary holdings of the opinion is that obesity is not a disability for purposes of VA benefits; hence, it cannot be the subject of service connection. VAOPGCPREC No. 1-2017 (Jan. 6, 2017); see also Marcelino v. Shulkin, 29 Vet. App. 155, 157-158 (2018). However, the CAVC has recently held that obesity could be considered a disability if it results in a functional impairment of earning capacity, a finding that requires an "individualized assessment" of the "degree of impairment" caused by a claimant's obesity. See Adams v. Collins, 38 Vet. App. 273, 284 (July 8, 2025). Thus, the CAVC invalidated VAOPGCPREC No. 1-2017 to the extent it determined obesity per se is not a disability. Nonetheless, obesity may still act as an "intermediate step" between a service-connected disability and another disability for the purposes of secondary service connection. OGC recognized that obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a). VAOPGCPREC No. 1-2017 (Jan. 6, 2017). OGC further explained that adjudicators would have to resolve the following issues: (1) whether the service-connected disability caused the veteran to become obese; (2) if so, whether the obesity as a result of the service-connected disability was a substantial factor in causing the claimed disability; and (3) whether the claimed disability would not have occurred but for obesity caused by the service-connected disability. Id. If these questions are answered in the affirmative, the service connection for the claimed disability may be granted on a secondary basis. Id. In Walsh v. Wilkie, the CAVC held that the Board needs to consider the obesity-intermediate step theory based on aggravation where appropriate. See Walsh v. Wilkie, 32 Vet. App. 300, 306-07 (2020). Thus, the CAVC held that proper interpretation of G.C. Prec. Op. 1-2017 requires consideration of both proximate causation and aggravation in its analytical framework: (1) whether the service-connected disability caused the veteran to become obese or aggravated the veteran's obesity; (2) if so, whether the obesity or aggravation of obesity as a result of the service-connected disability was a substantial factor in causing the current disability; and (3) whether the current disability would not have occurred but for obesity caused or aggravated by the service-connected disability. Id. Thus, the first question for the Board is whether the Veteran has a current diagnosis of obstructive sleep apnea that began during his active service or is at least as likely as not related to an in-service injury, event, or disease. The second question for the Board is whether the Veteran currently has a diagnosis of obstructive sleep apnea, which is due to, caused by, or the result of, or aggravated (increased in severity) by a service-connected disability. The third question for the Board is whether (i) the Veteran's service-connected disabilities caused the Veteran to become obese or aggravated his obesity, (ii) if so, whether the obesity or aggravation of obesity resulted from the service-connected disabilities was a substantial factor in causing obstructive sleep apnea, and (iii) whether the current obstructive sleep apnea would not have occurred but for the obesity caused or aggravated by the service-connected disabilities. The existence of a current disability of obstructive sleep apnea is not in question because in the June 2025 VA disability benefits questionnaires (DBQ) for sleep apnea, the examiner noted the diagnosis of obstructive sleep apnea. Also, a June 2011 sleep study report noted the diagnosis of severe obstructive sleep apnea. Thus, the requirement of a current disability for service connection is met. In the May 2024 memorandum decision, the CAVC found that since the Board did not find the Veteran's reports of his wife noting apnea "skipping breathing during sleep and waking up gasping for air" immediately after separation from active service not credible, the Board implicitly found them credible. Also, the March 2022 VA examiner explained that witnessed apnea during sleep is a symptom of sleep apnea, but stated that these statements of the Veteran were not supported by evidence. Thus, the CAVC found that without explanation from the examiner indicating specific review of the June 2011 examination report reflecting the lay statements by the Veteran as to sleep apnea since service, and the Veteran's spouse witnessing apnea during the Veteran's sleep immediately after separation, and without specific citation to records that contradict this, the examiner's rationale for the negative linkage opinion is inadequate. Thus, the CAVC found that the proper remedy is to obtain a new medical opinion. Regarding obesity as an intermediate step between a service-connected disability and the Veteran's sleep apnea, the CAVC found that despite the June 2022 Board remand for consideration of aggravation of obesity by the service-connected disabilities, the July 2022 examiner merely stated that the Veteran's service-connected disabilities did not aggravate his obesity, but did not adequately address aggravation of obesity in the supporting rationale. Pursuant to the CAVC order, in January 2025, the Board remanded this matter to obtain a new medical opinion on the Veteran's sleep apnea. Pursuant to the January 2025 Board remand, the RO obtained a medical opinion in January 2025 on the direct and secondary service connection for the Veteran's sleep apnea. However, the RO found that the January 2025 VA medical opinion on direct and secondary service connection, including obesity as an intermediate step between the service-connected disabilities and the claimed sleep apnea, was inadequate. Therefore, the RO requested an addendum medical opinion in March 2025 from the same examiner who rendered the January 2025 VA opinion. The examiner provided an addendum medical opinion in March 2025. Specifically, regarding the question as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that a service connected disability, to include panic disorder with agoraphobia and generalized anxiety disorder, tinnitus, and bilateral knee disability and the claimed antalgic gait due to bilateral knee disability, caused the Veteran to become obese or aggravated the Veteran's obesity, in the March 2025 VA addendum medical opinion, the examiner stated that it was less likely than not that the Veteran's service-connected disabilities caused or aggravated his obesity. As a supporting rationale, the examiner stated that while psychiatric conditions such as panic disorder with tinnitus, and agoraphobia and generalized anxiety disorder can contribute to stress, and bilateral knee disabilities can affect activity levels, however, there is no sufficient evidence to suggest that these conditions directly led to significant weight gain. Obesity is not considered a secondary service-connected disability unless it results from a service-connected condition and subsequently causes or aggravates another disability. In this case, the evidence of record does not establish a clear causal relationship between the Veteran's obesity and his service-connected disabilities. Medical providers have consistently recommended diet and lifestyle changes, with evidence suggesting that the Veteran was able to adhere to these recommendations, which were not impeded by his service-connected conditions. While psychiatric disorders can influence eating habits or physical activity, there is no conclusive evidence that they resulted in significant weight gain. The bilateral knee condition may have slightly limited physical activity, but it did not prevent the Veteran from following weight management strategies. As for the onset of sleep apnea, it is notable that the Veteran's BMI was already in the obese range by 2010, and his provider recommended lifestyle changes for weight management, suggesting that weight gain was influenced by modifiable factors, not by his service-connected conditions. The Veteran has demonstrated that his weight gain is not due to his service-connected conditions because with provider recommendations, Veteran was able to bring to his BMI of 41.4, in June 2021, down to 38.2 in December 2024. The Board finds that the above described part of the March 2025 VA medical opinion on obesity as an intermediate step between the service-connected disabilities and the claimed sleep apnea is inadequate because in the supporting rationale, the examiner focused only on the claimed causation of obesity by the service-connected disabilities, but did not explain as to whether the Veteran's obesity was aggravated by the service-connected disabilities, including the antalgic gait due to bilateral knee disability. Furthermore, regarding the direct service connection and the Veteran's wife observing the Veteran gasping for air after leaving service, the examiner stated that during the June 2011 VA examination, the Veteran reported that his wife observed him waking up gasping for air after leaving service. While it is acknowledged that a layperson, such as the Veteran's wife, can observe and report observable symptoms like gasping for air, this description is nonspecific and she is unlikely qualified to medically evaluate, diagnosis and form a treatment plan for a sleep apnea syndrome. Gasping for air can be caused by various factors, including nightmares, and does not necessarily point to a diagnosis of sleep apnea. The absence of records indicating consistent sleep disturbances or a treatment plan for sleep apnea between 1996 and 2010 raises questions about the onset of this condition which likely developed well after separation from service. Additionally, a January 2025 primary care visit did not note complaints of sleep issues, further suggesting a later onset of a chronic sleep disorder. The Board also finds the above described part of the March 2025 VA medical opinion inadequate because the examiner solely relied on the absence of contemporaneous medical evidence documenting sleep apnea after the Veteran's active service, but did not address the March 2022 VA examiner's explanation that witnessed apnea during sleep is a symptom of sleep apnea, which the Veteran's wife noted shortly after the Veteran's separation from active service. Moreover, in the March 2025 VA medical opinion, the examiner stated that posttraumatic stress disorder (PTSD) is a recognized risk factor for obstructive sleep apnea, it is important to understand that the mere presence of a risk factor does not establish causality. While PTSD may contribute to disturbed sleep patterns, it does not directly cause the muscle relaxation responsible for the airway blockage in obstructive sleep apnea. Psychiatric disorders may cause awakening for various reasons but they do not cause the muscle relaxation that causes airway blockage in obstructive sleep apnea. The Board finds that the above described part of the March 2025 VA medical opinion on secondary service connection for sleep apnea is also inadequate because the examiner addressed the direct causation of obstructive sleep apnea by the Veteran's service-connected psychiatric disorder, but did not address as to whether the Veteran's service-connected disabilities aggravated the existing obstructive sleep apnea, which might have been caused by factors other than the service-connected disabilities. Accordingly, in May 2025, the Board remanded the matter again to obtain new medical opinion on the nature and etiology of the Veteran's diagnosed obstructive sleep apnea. Pursuant to the Board remand, the RO obtained a medical opinion in June 2025 (signed by the examiner in August 2025), in which the examiner opined that the Veteran's claimed obstructive sleep apnea was at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) incurred in or caused by the claimed in-service injury, event, or illness. The examiner provided a supporting rationale that was contrary to the opinion because the examiner stated that per the Veteran's wife lay statement, the Veteran started having sleep disturbances when he was in service. A 2010 sleep study reveals sleep apnea. The Veteran served from 1994 to 1997, nonetheless, there is no evidence of sleep apnea during military service. However, in the October 2025 addendum opinion, the same examiner, who rendered the June 2025 VA medical opinion, corrected the previous opinion and stated that based on the review of the claims file and medical literature, the claimed obstructive sleep apnea was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Nonetheless, in the June 2025 opinion, the same examiner also stated that per the Veteran's claims file, generalized anxiety and panic disorder with agoraphobia can cause obesity which is one of the risk factors of obstructive sleep apnea. The examiner explained that anxiety can trigger the release of cortisol, the stress hormone, which can increase appetite and lead to overeating, especially of high-calorie comfort foods. Per the Veteran's claims file, he was diagnosed with obesity in 2016. Most significantly, the same examiner rendered an addendum VA medical opinion in November 2025, in which the examiner stated that the private sleep study report that initially diagnosed the Veteran with obstructive sleep apnea specifically listed obesity as a risk factor. Review of VA medical records from July 11, 2011 indicates that the Veteran had a BMI of 35.7, which meets criteria for obesity. Therefore, the examiner stated that contrary to prior opinions, the evidence shows that the Veteran's obesity existed well before the initial obstructive sleep apnea diagnosis. Thus, the examiner opined that it is at least as likely as not that the Veteran's obstructive sleep apnea is secondary to, or aggravated by, obesity present at the time of obstructive sleep apnea diagnosis. Regarding the relationship between mental health conditions and obstructive sleep apnea, the examiner stated that scientific literature supports a relationship between certain mental health conditions (e.g., depression, PTSD, anxiety) and metabolic dysregulation, including obesity, which is a recognized risk factor for obstructive sleep apnea. The examiner explained that the Veteran's mental health conditions could contribute indirectly to obstructive sleep apnea by exacerbating obesity or metabolic factors. Therefore, the examiner stated that it is at least as likely as not that the Veteran's mental health condition(s) contribute to the development or aggravation of his obstructive sleep apnea, via their association with obesity and other physiological risk factors. The examiner stated that the prior opinion failed to consider the 2011 BMI evidence and the private sleep study, which listed obesity as a risk factor. Thus, the examiner stated that obesity existed before obstructive sleep apnea diagnosis (BMI 35.7 in 2011). Mental health conditions may contribute indirectly to obstructive sleep apnea through obesity and metabolic dysregulation. Thus, the examiner concluded that the Veteran's obstructive sleep apnea is at least as likely as not aggravated by both pre-existing obesity and mental health conditions. The Board notes that the RO obtained another VA medical opinion on the Veteran's obstructive sleep apnea in December 2025, in which the examiner stated that obesity is often caused by an increase in caloric intake and decrease in physical activity. There is limitation of certain physical activities due to the service-connected condition/diagnosed conditions. However, this does not imply that all physical activity would be restricted as there are many ways to stay active to include non-weight bearing activities. Dietary choices also play a very important role in increasing BMI and there is no documentation showing that dietary restrictions have been made. The Veteran's service-connected conditions would not impact all physical activity or dietary choices. Therefore, the examiner concluded that it is less likely than not that the service-connected condition has caused or aggravated the Veteran's obesity. Given this it would also be less likely than not that the sleep apnea is solely caused from the service-connected condition. The Board finds the December 2025 VA medical opinion inadequate because the examiner did not provide an adequate rationale on potential aggravation of the Veteran's obstructive sleep apnea by his service-connected disabilities, specifically the service-connected panic disorder with agoraphobia and generalized anxiety disorder. Whereas, in the November 2025 VA medical opinion, the examiner adequately explained the relationship between the Veteran's diagnosed obstructive sleep apnea and the service-connected panic disorder with agoraphobia and generalized anxiety disorder, including through the intermediate step of obesity. Thus, upon review of the record, the Board finds that the evidence of record is in favor or at least in equipoise as to whether the Veteran's current obstructive sleep apnea is due to, caused by, or the result of, or aggravated by the service-connected panic disorder with agoraphobia and generalized anxiety disorder, including through the intermediate step of obesity. Accordingly, after resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to service connection for obstructive sleep apnea as secondary to the service-connected panic disorder with agoraphobia and generalized anxiety disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for a lumbar spine disability is remanded. In the May 2024 memorandum decision, the CAVC found that in making its credibility finding, the Board reviewed only the Veteran's lay statements that postdated the September 2011 car accident, and failed to address earlier statements concerning reports of continuing back pain since service, and relied exclusively on the lack of corroborating treatment records between separation in 1997 and the earliest, 2008, car accident. The CAVC noted that in his February 1997 claim, the Veteran reported that his back pain began during service in July 1995, and at an April 1997 vocational evaluation, he reported lower back pain, and both of these statements predate the 2008 car accident. Similarly, the CAVC found that in the March 2022 VA medical opinion, the examiner failed to consider the Veteran's statements, which undermines her opinion finding no link between service and lumbar spine degenerative joint disease. The CAVC noted that the examiner found the Veteran's lay statements as to chronic back pain since active duty to be unsupported by the evidence because he did not complain of back pain until after the post-service car accidents. The CAVC noted that a medical opinion that fails to consider a veteran's lay statements and relies solely on the absence of contemporaneous medical evidence to conclude that there is no link between a veteran's in-service injury and current disability is inadequate. Thus, the CAVC found that the March 2022 VA medical opinion on the Veteran's back condition is inadequate. Regarding secondary service connection for the Veteran's back condition, the CAVC noted that the March 2022 VA examiner did not address the May 2011 VA orthopedic examination report noting an antalgic gait, the December 2016, March 2017, and April 2017 VA physical therapy records noting decreased velocity of gait, and the January, March, and May 2018 VA physical therapy records from a different therapist noting gait abnormality. The CAVC found that the March 2022 VA medical opinion is inadequate because the examiner determined that the Veteran's condition did not result in an altered gait as severe as an obvious Trendelenburg and opined that "the postural theory is not supported by validated literature and treatment notes i.e. gait," without citing or discussing the foregoing evidence of gait abnormality in the treatment notes or explaining the significance of any potential distinction between the Veteran's abnormal gait and a Trendelenburg gait. Thus, the CAVC found that the March 2022 examiner's failure to address the evidence of an altered gait in the record or to explain why this evidence was insufficient to demonstrate a causal or aggravative relationship between the Veteran's service-connected knee disability and the claimed back disability deprives the Board of the information it needed to resolve that dispositive medical question. Regarding obesity as an intermediate step between a service-connected condition and non-service-connected back disability, the CAVC found that despite the June 2022 Board remand for consideration of aggravation of obesity by the service-connected disabilities, the July 2022 examiner merely stated that the service-connected disabilities did not aggravate the Veteran's obesity, but did not adequately address aggravation of obesity in the supporting rationale. Pursuant to the CAVC order, in January 2025, the Board remanded this matter to obtain a new medical opinion on the Veteran's lumbar spine disability, in which the examiner addresses the evidence of record prior to the 2008 automobile accident that noted the Veteran's lower back pain, and the Veteran's assertion of continuity of lower back pain since active service. Furthermore, the Board directed the examiner to address as to whether the Veteran's service-connected disabilities caused or aggravated his lower back disability, including the altered gait due to bilateral knee condition, and obesity as an intermediate step between the service-connected disabilities and lumbar spine disability. Specifically, regarding the obesity, the Board directed the examiner to provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that (i) a service-connected disability, to include panic disorder with agoraphobia and generalized anxiety disorder, tinnitus, and bilateral knee disability and the claimed antalgic gait due to bilateral knee disability, caused the Veteran to become obese or aggravated the Veteran's obesity; (ii) if so, whether the obesity or aggravation of obesity resulted from the service-connected disabilities was a substantial factor in causing a lumbar spine disability; and (iii) whether the current lumbar spine disability would not have occurred but for the obesity caused or aggravated by the service-connected disabilities. Pursuant to the January 2025 Board remand, the RO obtained a medical opinion in January 2025 on the direct and secondary service connection for a lumbar spine disability. However, the RO found that the January 2025 VA medical opinion on direct and secondary service connection for a lumbar spine disability, including obesity as an intermediate step between the service-connected disabilities and the claimed back disability, was inadequate. Therefore, the RO requested an addendum medical opinion in March 2025 from the same examiner who rendered the January 2025 VA opinion. Specifically, regarding the question as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that a service connected disability, to include panic disorder with agoraphobia and generalized anxiety disorder, tinnitus, and bilateral knee disability and the claimed antalgic gait due to bilateral knee disability, caused the Veteran to become obese or aggravated the Veteran's obesity, in the March 2025 VA addendum medical opinion, the examiner stated that impaired mobility, including gait abnormality, or antalgic gait, does not cause obesity. The antalgic gait is most likely related to [the Veteran's] knee condition, as medical records consistently note knee pain; however last two most recent PCP encounter records in 2024 were silent for complaint, specific back diagnosis. There was a diagnosis of osteoarthritis (degenerative arthritis) that likely included his knee condition. While an antalgic gait related to bilateral knee conditions is unlikely to directly cause obesity, it could potentially contribute to reduced physical activity. However, medical literature generally attributes obesity to factors such as excessive caloric intake, rather than mobility issues alone. The Board finds that the above described part of the March 2025 VA medical opinion on obesity as an intermediate step between the service-connected disabilities and the claimed back disability is inadequate because in the supporting rationale, the examiner focused only on the claimed causation of obesity by the service-connected disabilities, but did not explain as to whether the Veteran's obesity was aggravated by the service-connected disabilities, including the antalgic gait due to bilateral knee disability. Furthermore, the examiner stated that there was no documentation of any diagnosed back issues between 1996 and the 2011 car accident. The examiner explained that based on the available records, the lumbar spine condition is more likely a result of age-related degenerative changes rather than a direct consequence of either the Veteran's service or the automobile accident. Prior to the 2011 accident, the Veteran's low back pain was described as intermittent and related to activity levels, not a progressive or chronic condition. Furthermore, the X-ray findings in 2015 suggest degenerative changes consistent with aging, not trauma from the accident. The assertion that the automobile accident aggravated a pre-existing lumbar spine condition is unsupported by medical evidence because there was no evaluated and diagnosed condition to aggravate in the first place. Additionally, the Veteran's complaints post-service, including following the 2011 automobile accident, demonstrate no significant link to service or the earlier lumbar pain. The current pain is primarily due to natural degeneration, not service-related factors. The current lumbar spine pain is not related to the Veteran's active duty service. Medical records from that period indicate only intermittent, activity-related discomfort, which does not suggest a chronic or service-connected condition. The Veteran's lumbar spine issues are more consistent with age-related degenerative changes, as confirmed by X-rays in 2015, showing no evidence of injury-related trauma. Additionally, the Veteran's complaints post-service, including following the 2011 automobile accident, demonstrate no significant link to service or the earlier lumbar pain. The current pain is primarily due to natural degeneration, not service-related factors. The Board also finds the above described part of the March 2025 VA medical opinion inadequate because the supporting rationale consists of several conclusory statements, in which the examiner solely relied on the absence of contemporaneous medical evidence documenting lower back conditions prior to the 2011 automobile accident, but did not address the Veteran's lay statements, when specifically in the May 2024 memorandum decision, the CAVC noted that a medical opinion that fails to consider a veteran's lay statements and relies solely on the absence of contemporaneous medical evidence to conclude that there is no link between a veteran's in-service injury and current disability is inadequate. Furthermore, the examiner noted that there was no documentation of any diagnosed back issues between 1996 and the 2011 car accident, but did not address the February 1997 claim, in which the Veteran reported that his back pain began during service in July 1995; and the April 1997 vocational evaluation, during which the Veteran reported lower back pain. Furthermore, the examiner stated that spine issues and degenerative changes showed on 2015 X-rays are more consistent with age-related degenerative changes, but the examiner did not address the Veteran's age because in 2015, the Veteran was only 39 years old, and the May 2015 X-ray report noted "multilevel facet degenerative changes." Accordingly, in May 2025, the Board remanded the matter again to obtain a new medical opinion on the nature and etiology of the Veteran's lumbar spine disability. Pursuant to the May 2025 Board remand, the RO obtained a VA medical opinion in June 2025, in which the examiner opined that the Veteran's claimed lumbar spine disability was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness. As a supporting rationale, the examiner stated that there is no evidence of lumbar spine disability or lumbar spine diagnosis when the Veteran was in service. The lumbar spine or lower back can experience a variety of issues causing pain and discomfort. These can range from injuries like strains, sprains, and fractures to degenerative conditions like osteoarthritis and spinal stenosis. Other causes include herniated discs, spinal infections, spondylolisthesis, scoliosis, and even poor posture or obesity. Regarding secondary service connection, the examiner stated that there is no evidence in the literature review that lumbar spine disability or condition is caused by panic disorder with agoraphobia and generalized anxiety disorder, bilateral tinnitus, patellofemoral pain syndrome of the right knee, and patellofemoral pain syndrome of the left knee. However, the examiner did not provide a supporting rationale for the rendered opinion. Nonetheless, the examiner stated that per the Veteran's claims file, generalized anxiety and panic disorder with agoraphobia can cause obesity. The examiner also stated that anxiety can trigger the release of cortisol, the stress hormone, which can increase appetite and lead to overeating, especially of high-calorie comfort foods. But the examiner did not explain as to whether the Veteran's obesity, which was caused by the service-connected generalized anxiety and panic disorder with agoraphobia, caused or aggravated his lower back disability. The RO also obtained an addendum medical opinion in October 2025, in which the examiner opined that the Veteran's claimed lumbar spine disability was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness. The examiner provided exactly the same supporting rationale that was provided for the above noted June 2025 medical opinion. Thus, the Board finds that the June 2025 and October 2025 VA medical opinions are inadequate because the examiner found that there is no evidence of lumbar spine disability or lumbar spine diagnosis when the Veteran was in service, but the examiner did not address the August 1996 in-service report of medical history, in which the Veteran reported that he had lower back pain for one year and the April 1997 vocational evaluation, during which the Veteran reported lower back pain. Furthermore, the examiner did not provide an opinion as to whether the Veteran's obesity caused or aggravated by a service-connected disability caused or aggravated his lower back disability. Accordingly, the Board finds that another remand is warranted to obtain a new medical opinion on the nature and etiology of the Veteran's lumbar spine disability that addresses the above noted concerns and the Veteran's assertion of continuity of lower back pain since active service, and which is also consistent with the CAVC May 2024 memorandum decision. The matter is REMANDED for the following action: Obtain a new medical opinion on the nature and etiology of the Veteran's diagnosed lumbar spine disability. Claims file should be available to the examiner for review. After reviewing the claims file and copies of this remand and the May 2024 CAVC memorandum decision, the examiner should address the following: (a) Provide a medical opinion as to whether it is "at least as likely as not" (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's current lumbar spine disability began during his active service or is related to an in-service injury, event, or disease, including the lower back pain noted during the Veteran's active service. The examiner should review the Veteran's competent reports of lower back pain in the evidence of record prior to the 2008 car accident. (b) Provide an opinion as to whether the Veteran's lumbar spine disability is "at least as likely as not" (likelihood is at least approximately balanced or nearly equal, if not higher) due to, caused by, or resulted from, a service-connected condition, to include panic disorder with agoraphobia and generalized anxiety disorder, tinnitus, and bilateral knee disability, including the claimed antalgic gait due to bilateral knee disability. (c) Provide an opinion as to whether the Veteran's lumbar spine disability is "at least as likely as not" (likelihood is at least approximately balanced or nearly equal, if not higher) aggravated by a service-connected condition, to include panic disorder with agoraphobia and generalized anxiety disorder, tinnitus, and bilateral knee disability, including the claimed antalgic gait due to bilateral knee disability. In providing the above requested opinion on aggravation of the Veteran's lumbar spine disability, the examiner should also opine as to whether a service-connected disability, to include panic disorder with agoraphobia and generalized anxiety disorder, tinnitus, and bilateral knee disability and the claimed antalgic gait due to bilateral knee disability, caused any "incremental increase, regardless of its permanence" in the Veteran's non-service-connected lumbar spine disability. (d) As noted above, in the June 2025, October 2025, and specifically in the November 2025 VA medical opinions on the Veteran's obstructive sleep apnea, the examiner opined that the Veteran's obesity was caused by the service-connected panic disorder with agoraphobia and generalized anxiety disorder; therefore, the examiner should provide an opinion as to whether the obesity or aggravation of obesity resulted from the service-connected panic disorder with agoraphobia and generalized anxiety disorder was a substantial factor in causing a lumbar spine disability; and whether the current lumbar spine disability would not have occurred but for the obesity caused or aggravated by the service-connected panic disorder with agoraphobia and generalized anxiety disorder. In this regard, the examiner should address the June 2025 VA medical opinion, where while noting the potential causes of a lumbar spine disability, the examiner stated, "Other causes include herniated discs, spinal infections, spondylolisthesis, scoliosis, and even poor posture or obesity." In providing the above requested opinions, besides reviewing the claims file in general, the examiner should specifically review and address the evidence of record associated with the Veteran's claims file with entries dated: (i) 09/15/2014, titled "STR - Medical" page 4 of 75 that contains an August 1996 in-service report of medical history, in which the Veteran reported that he had lower back pain for one year; (ii) 02/24/1997, titled "VA 21-526 Veterans Application for Compensation or Pension" in which the Veteran reported that his back pain began in July 1995 during active service; (iii) 03/07/1997, titled "Education - General" page 2 of 8 that contains an April 1997 vocational evaluation, during which the Veteran reported lower back pain; (iv) 11/15/2019, titled "Appellate Brief (VSO IHP; Post remand Brief; Attorney Brief)," which includes arguments and reference to medical literature regarding lumbar spine disability; (v) 4/19/2021, titled "Appellate Brief (VSO IHP; Post remand Brief; Attorney Brief)," which also includes reference to medical literature regarding lumbar spine disability: (vi) 03/08/2012, titled "Medical Treatment Record -Government Facility," page 17 of 17, which contains treatment record for back pain and report of an automobile accident in September 2011; (vii) 08/20/2014, titled "Form 9," in which the Veteran contended that his lumbar spine condition persisted since service, and the automobile accident aggravated the condition; (viii) 08/22/2017, titled "Hearing Transcript," in which the Veteran testified that he had to carry 80 pounds weight, while marching during active service, which took a toll on his lower back; (ix) 05/24/2011, titled "VA Examination" that contains the May 2011 VA examination report for joints, in which the examiner noted the Veteran's antalgic gait; (x) 01/15/2019, titled "CAPRI" pages 584 and 611 of 1152, which contain the April 2017 and December 2016 VA treatment records respectively that noted decreased velocity of the Veteran's gait; pages 146, 299, and 349 of 1152, which contain the May, March, and January 2018 VA treatment records respectively that noted the Veteran's gait abnormality: (xi) 04/23/2013, titled "CAPRI" page 141 of 151 that contains a July 2011 VA treatment record noting the Veteran's BMI as 35.7; (xii) 06/09/2021, titled "CAPRI" page 7 of 248 that contains a May 2021 VA treatment record noting the Veteran's BMI as 40.5; page 146 of 248 that contains an August 2019 VA treatment record noting the Veteran's BMI as 41.4; (xiii) 08/06/2025, titled "C&P Exam" page 3 of 29 that contains the June 2025 VA medical opinion, where while noting the potential causes of a lumbar spine disability, the examiner stated, "Other causes include herniated discs, spinal infections, spondylolisthesis, scoliosis, and even poor posture or obesity." Clear supporting rationales must be provided for the opinions rendered. If the examiner determines that it is not possible to provide an opinion without resorting to speculation, then the examiner must provide an explanation of why that is so and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or a deficiency in the examiner's knowledge (the examiner does not have the required knowledge or training). MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Nadeem Tariq, 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.