SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

KELLI A. KORDICH · 2025 · Case ID: 25012234

MIXED

Summary

The Veteran served from June 1969 to March 1971. This case involves an appeal for service connection for sleep apnea, claimed as secondary to PTSD, and entitlement to a Total Disability based on Individual Unemployability (TDIU), which was dismissed due to withdrawal. The Veteran also appeals the denial of service connection for peripheral neuropathy of the bilateral upper and lower extremities. The Board previously denied the sleep apnea claim, but a subsequent Court remand led to further development. Multiple VA examinations were conducted for sleep apnea, with conflicting opinions regarding its relationship to PTSD, obesity, and herbicide exposure. The Board found the private medical opinions inadequate due to speculation and lack of specific rationale linking the Veteran's PTSD to his obesity and subsequent sleep apnea. The Board ultimately denied service connection for sleep apnea, finding the evidence persuasively against a service connection, citing the lack of in-service findings, the diagnosis occurring 45 years post-service, and inadequate nexus opinions from private examiners. The peripheral neuropathy claims were remanded due to inadequate examination and failure to address potential secondary service connection due to alcohol use secondary to PTSD.

Rationale

Service treatment records lack findings or treatment for sleep apnea.; VA examiner opinions found no causal link between PTSD and sleep apnea.; Private opinions were found inadequate due to speculation and lack of specific rationale.; Obesity, the primary risk factor for sleep apnea, was not shown to be caused or aggravated by service-connected disabilities.

Special Benefit

TDIU

Docket No.

17-56 340

Full Decision Text

Citation Nr: 25012234
Decision Date: 09/29/25 Archive Date: 09/29/25

DOCKET NO. 17-56 340
DATE: September 29, 2025

ORDER

Entitlement to service connection for sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD), is denied.

Entitlement to a total disability rating based on individual unemployability (TDIU) is dismissed.

REMANDED

Entitlement to service connection for peripheral neuropathy of the bilateral upper extremity is remanded.

Entitlement to service connection for peripheral neuropathy of the bilateral lower extremity is remanded.

FINDINGS OF FACT

1. The Veteran's sleep apnea was not incurred during service and is not otherwise etiologically related to his active service or any service-connected disability, to include with obesity as an intermediate step.

2. On August 27, 2025, prior to the promulgation of a decision in the appeal, the Board received notification from the appellant, through his authorized representative, that a withdrawal of the appeal as to entitlement to a TDIU is requested.

CONCLUSIONS OF LAW

1. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for withdrawal of the appeal as to entitlement to a TDIU by the appellant have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from June 1969 to March 1971.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO).

In a March 2023 Board decision, the Board denied the Veteran's claims for entitlement to service connection for peripheral neuropathy of the bilateral upper extremity, peripheral neuropathy of the bilateral lower extremity, and sleep apnea as secondary to PTSD, as well as a claim of entitlement to a TDIU. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court), which granted a December 2023 Joint Motion for Remand (JMR). The Court's December 2023 Order vacated the Board's March 2023 decision and remanded the matter to the Board for readjudication consistent with the terms of the JMR.

In October 2024, the Board remanded the claims for further development. For the claim for service connection for sleep apnea, the Board finds that there has been substantial compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Specifically, the Board remanded the claim to afford the Veteran a VA sleep apnea examination and obtain a new medical opinion, and the record reflects that in March 2025 the Veteran was provided with the VA examination and the requested medical opinion was obtained.

In April 2025, the agency of original jurisdiction (AOJ) issued a supplemental statement of the case and returned the appeal to the Board. In May 2025, the Veteran's representative requested 90 days to submit additional evidence and argument, and the Board granted the motion for extension of time. As the 90-day period has passed, the Board will now proceed with adjudication.

1. Entitlement to service connection for sleep apnea.

The Veteran contends that his sleep apnea is secondary to his PTSD, to include with obesity as an intermediate step.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 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 be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence showing that (1) a current disability exists and (2) the current disability
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 be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence showing that (1) a current disability exists and (2) the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448-49 (1995).

Obesity may serve 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). Walsh v. Wilkie, 32 Vet. App. 300 (2020); see also VAOGCPREC 1-2017.

On August 10, 2022, the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act) was enacted and directs that in certain circumstances, when a veteran is found to have been involved in a toxic exposure risk activity (TERA) during service, VA must obtain an opinion addressing whether such toxic exposure caused a diagnosed disability. 38 U.S.C. § 1168.

Turning to the case, the Veteran's service treatment records (STRs) do not contain findings or treatment for sleep apnea.

In March 2016, the Veteran was provided with a VA sleep apnea examination, and the examiner reported that a review of the medical record showed no evidence of the diagnosis or treatment for sleep apnea or diagnostic polysomnography. The examiner stated that a review of the current medical literature and research shows no physiologic or biomechanical causal relationship between a mental health disorder (PTSD) and the physiologic condition of sleep apnea. The examiner stated that sleep apnea is due to obesity, and obesity is caused by excessive caloric intake and reduced caloric expenditure which is a choice. The examiner indicated that PTSD does not cause obesity.

In September 2016, the Veteran underwent a sleep study, and the impression was severe obstructive sleep apnea.

In a June 2017 letter, the Veteran's primary VA physician stated that it was his opinion that "this Veteran's obstructive sleep apnea is directly related to his service in the Vietnam War." No rationale was provided. Accordingly, the opinion was found to be inadequate, and the Board remanded the claim to afford the Veteran a VA examination in December 2019.

In May 2021, the Veteran was provided with another VA sleep apnea examination, and the examiner reported a diagnosis of obstructive sleep apnea with a date of diagnosis of September 2016. The examiner opined that the obstructive sleep apnea was less likely than not related to an in-service injury, event, or disease, to include as due to exposure to herbicides while serving in Vietnam. The examiner stated that sleep apnea is not caused by exposure to herbicides, and the claims file did not show any diagnosis or treatment of sleep apnea while in service. The examiner noted that the Veteran was diagnosed with sleep apnea in 2016. The examiner stated that the Veteran is morbidly obese, which was most likely the cause of his obstructive sleep apnea.

The examiner also opined that the sleep apnea was less likely than not proximately due to or the result of his service-connected PTSD. The examiner stated that sleep apnea syndromes and PTSD are not medically related. The examiner explained that sleep apnea syndromes are a separate entity entirely from the PTSD and unrelated to it and that a thorough review of the medical literature failed to demonstrate a causal relationship. The examiner reported that the medical literature did not support a mental health disorder (PTSD) as causative or the potential for aggravation of the physiologic condition of obstructive sleep apnea, which is due to upper airway soft tissue abnormalities. The examiner explained that while some studies have suggested an association between obstructive sleep apnea and PTSD, they are cohort studies and do not show causality. The examiner reported that obesity is the best documented risk factor for obstructive sleep apnea, and the Veteran is morbidly obese.

In April 2022, the Board remanded the matter to obtain
from the PTSD and unrelated to it and that a thorough review of the medical literature failed to demonstrate a causal relationship. The examiner reported that the medical literature did not support a mental health disorder (PTSD) as causative or the potential for aggravation of the physiologic condition of obstructive sleep apnea, which is due to upper airway soft tissue abnormalities. The examiner explained that while some studies have suggested an association between obstructive sleep apnea and PTSD, they are cohort studies and do not show causality. The examiner reported that obesity is the best documented risk factor for obstructive sleep apnea, and the Veteran is morbidly obese.

In April 2022, the Board remanded the matter to obtain an opinion addressing obesity as an intermediate step.

In July 2022, the Veteran was provided with another VA sleep apnea examination and medical opinions were obtained. The examiner opined that the Veteran's obstructive sleep apnea was proximately due to or the result of his PTSD. As rationale, the examiner stated that there is evidence that many veterans have both obstructive sleep apnea and PTSD and that sleep problems, such as obstructive sleep apnea, can worsen PTSD. The examiner stated that he was unable to find evidence that obstructive sleep apnea actually is caused by PTSD, only that obstructive sleep apnea can worsen PTSD. The examiner also opined that the Veteran's sleep apnea was aggravated from having PTSD. As rationale, the examiner stated that "people who have both OSA and PTSD are more likely to have severe PTSD symptoms."

In another opinion, the examiner opined that the Veteran's obstructive sleep apnea was at least as likely as not proximately due to or the result of his service-connected disabilities. As rationale, the examiner stated that "conditions such as peripheral neuropathy, knee arthritis can cause a person not to be physically active therefore gain weight, cause being overweight/obese." The examiner further stated that "being obese/overweight can cause OSA" and "having OSA has been found to worsen PTSD." The examiner also opined that the Veteran's OSA was aggravated from having PTSD. The examiner stated that "OSA has been known to aggravate PTSD. PTSD has been known to aggravate depression, and depression tends to cause lack of exercise and some cases overeating, unhealth eating." The examiner further stated that "arthritis has been known to cause obesity due to lack of physical activity. Obesity has been known to cause and aggravate OSA." Therefore, the examiner concluded that it was at least as likely as not that the Veteran's sleep apnea was aggravated from having PTSD.

In an August 2022 opinion, the examiner reported that weight gain and obesity can be part of the cause and worsen obstructive sleep apnea. The examiner stated that many times as people gain weight, the obstructive sleep apnea worsens, and if they lose weight, the obstructive sleep apnea can improve. The examiner stated that the combination of Agent Orange exposure and being overweight/obese can be more likely than not the cause of and cause aggravation of obstructive sleep apnea.

In September 2022, the AOJ requested a new opinion due to conflicting information provided by the examiner and failure to provide the requested medical opinions.

In October 2022, an addendum opinion was obtained, and the examiner explained that although sleep apnea and PTSD may "coexist," sleep apnea is an obstructive process of the oral-pharyngeal airway, a separate and unrelated entity to the PTSD that does not cause the physical airway obstruction. The examiner stated that there was no established causal relationship between PTSD and sleep apnea, and a nexus had not been established. The examiner further stated that it was more likely than not that the Veteran's peripheral neuropathy and pain caused obesity. The examiner opined that chronic pain can be related to obesity and weight gain but may not be the cause of obstructive sleep apnea; therefore, it was less likely that knee pain caused the obstructive sleep apnea.

The AOJ subsequently asked for a clarifying opinion, and in November 2022, a VA examiner advised to "please disregard the previous response as it was provided in error." The examiner opined that it was less likely than not that the Veteran's OSA was due to, the result of, or aggravated by PTSD. The examiner explained that sleep apnea is a physical oral tissue collapse during sleep and not related to PTSD. The examiner reported that sleep apnea and PTSD may coexist, however, sleep apnea is an obstructive process of the oral-pharyngeal airway, a separate and unrelated entity to the PTSD that does not cause the physical airway obstruction. The examiner stated that
sleep apnea.

In addressing whether obesity served as an intermediate step, the examiner opined that it is less likely that any service-connected disability, including PTSD, "either alone or in combination with another service-connected disability or disabilities, caused the Veteran to gain weight or to become obese." In the rationale, the examiner indicated that the Veteran established service connection for PTSD in 2011. The examiner documented the Veteran's weight history from July 2008, showing he gained 89 pounds after stopping smoking with history of heavy alcohol use. He gained weight and occasionally lost weight from March 2009 to March 2012 from 281 pounds to 267 pounds. His weight continued to fluctuate between 2018 and 2020 from 294 pounds to 280 pounds. Based on review of the Veteran's history, the examiner explained that the Veteran "has been able to lose weight indicating weight loss can be achieved despite SC condition. Obesity is caused by excessive caloric intake and reduced caloric expenditure which is a choice. A nexus is not established." The examiner also opined that it was less likely than not that any service-connected disability, including PTSD, aggravated the Veteran's obesity/weight gain.

In March 2023, the Board found the November 2022 opinions the most probative and denied the claim for service connection for sleep apnea as secondary to PTSD. The Veteran appealed the decision to the Court, and in the December 2023 JMR, the parties agreed that the Board erred by failing to ensure that an adequate examination was provided as to whether any service-connected disability at least as likely as not caused or aggravated the Veteran's obesity/weight gain. The parties found that the November 2022 opinion contained inadequate rationale. First, the lowest weight cited by the examiner was 259 pounds, which a March 2012 VA treatment record indicated was still considered obese. The parties found that the rationale failed to explain why being able to lose and gain weight within the obese range would indicate that the Veteran's service-connected disabilities did not cause or aggravate his obesity. Second, the parties found that it was not clear from the examiner's rationale whether the examiner found that excessive caloric intake and reduced caloric expenditure were entirely a choice unrelated to any disability or just found that the Veteran would be able to overcome any limitations caused by his disabilities, which would not explain whether the Veteran's disabilities contributed in a causative manner to his obesity. Accordingly, the parties agreed that on remand, the Board shall ensure that VA obtains a new examination with an adequate rationale as to whether any service-connected disability at least as likely as not caused or aggravated the Veteran's obesity/weight gain.

In September 2024, the Veteran submitted a copy of a private opinion, and the private examiner opined that "his service-related PTSD, more likely than not, directly led to his post-service obesity and obstructive sleep apnea syndrome." As part of his rationale, the private examiner stated that "[r]esearch indicates a higher prevalence of sleep apnea in individuals suffering from PTSD than in the general population. The relationship appears to be bidirectional, where the physiological and psychological effects of PTSD, such as heightened arousal and disrupted sleep architecture, may increase vulnerability to sleep apnea." Further, the private examiner stated that "[d]isruptions in REM sleep like [the Veteran's] sleepwalking and limb 'jerking' can lead to increased sympathetic nervous system activity, which contribute to airway collapse during sleep, a hallmark sign of OSA and demonstrative of a direct link between PTSD and the pathophysiology of OSA."

In October 2024, the Board remanded the claim in accordance with the terms of the JMR to provide the Veteran with a new VA examination and medical opinion addressing whether any service-connected disability at least as likely as not caused or aggravated the Veteran's obesity/weight gain.

In March 2025, the Veteran was provided with a new VA sleep apnea examination based on a review of the available records in conjunction
stated that "[d]isruptions in REM sleep like [the Veteran's] sleepwalking and limb 'jerking' can lead to increased sympathetic nervous system activity, which contribute to airway collapse during sleep, a hallmark sign of OSA and demonstrative of a direct link between PTSD and the pathophysiology of OSA."

In March 2025, the Veteran was provided with a new VA sleep apnea examination based on a review of the available records in conjunction with an interview with the Veteran. As requested by the Board, the examiner addressed obesity as an intermediate step between the Veteran's service-connected disabilities and his sleep apnea. After reviewing all the medical evidence, the examiner opined that it was less likely than not that the Veteran's service-connected disabilities caused or aggravated the Veteran's obesity. The examiner explained that obesity usually results from a combination of causes and contributing factors including family inheritance and influences, lifestyle choices, certain diseases and medications, social and economic issues, age, quitting smoking, lack of sleep, stress, and microbiome. The examiner explained that if someone has one or more of the risk factors, it did not mean that the person was destined to develop obesity and that a person can counteract most risk factors through diet, physical activity, exercise, and behavior change. The examiner stated that it was not possible to attribute the obesity to any one or group of different risk factors. The examiner reported that "[a]t no point in the Veteran's entire e-file was the obesity caused or aggravated due to his service-connected disabilities." The examiner concluded that a nexus had not been established.

A VA TERA Memorandum documented that the Veteran participated in a TERA during his military service based on his exposure to herbicide agents. A TERA medical opinion was therefore also obtained, and the examiner opined that the Veteran's sleep apnea was less likely than not cause by the herbicide exposure after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner explained that there are risk factors outside of military service (hereditary, male gender, weight, multifactorial) that far outweigh the factors identified in the TERA, and that there was no medical or scientific evidence available that provides any indication of a relationship between the development of sleep apnea and the TERA.

In August 2025, the Veteran submitted an addendum opinion by the private examiner, Dr. P.C. He reiterated his prior opinion that the Veteran's "PTSD, more likely than not, directly led to his post-service obesity and obstructive sleep apnea syndrome" and disagreed with the March 2025 VA examiner's opinion, asserting that the VA examiner "did not delve into the literature cited here which shows the relationship between PTSD, obesity, and OSA." As rationale, Dr. P.C. stated that "[t]wo meta-analyses encompassing > 500,000 participants show that individuals with PTSD are 40-55% more likely to become obese than trauma-exposed controls after adjustment for antidepressants and socioeconomic status" and that "[l]arge veteran cohort studies replicate these findings and have identified accelerated post-deployment weight-gain trajectories attributable to HPA-axis dysregulation, stress-induced hypercortisolemia, and emotional over-eating."

Dr. P.C. stated that the Veteran's "BMI rose from 24.6 on separation to 35.8 by the time his PTSD was well-documented, squarely within this trajectory." Dr. P.C. further stated that the "American Academy of Sleep Medicine recognizes obesity as the dominant modifiable risk factor for OSA." He reported that "[t]win registry polysomnography shows that, even after matching shared genetics and BMI, PTSD independently raises AHI by 10 events/hour. This effet size equals that of a 5-unit BMI increase." He stated that "parallel military cohort work demonstrates a bidirectional escalation where untreated OSA potentiates PTSD hyperarousal, while PTSD-related REM-fragmentation predisposes to airway instability."

Dr. P.C. concluded that "[t]hese studies show how [the Veteran's] PTSD both (i) materially contributed to his weight-gain that produced a collapsible airway and (ii) further destabilized that airway via sympathetic surges and fragmented REM resulting in OSA that would not have occurred but for his PTSD-driven physiologic milieu."

After reviewing the evidence of record, the Board finds that service connection is not warranted.

First,
. This effet size equals that of a 5-unit BMI increase." He stated that "parallel military cohort work demonstrates a bidirectional escalation where untreated OSA potentiates PTSD hyperarousal, while PTSD-related REM-fragmentation predisposes to airway instability."

After reviewing the evidence of record, the Board finds that service connection is not warranted.

First, the evidence is persuasively against finding that his sleep apnea was incurred during service or is otherwise etiologically related to his active service, to include his in-service exposure to herbicide agents. In so finding, the Board affords significant probative weight to the May 2021 VA examiner's opinion as it was based on a thorough review of the evidence of record and includes adequate rationale. The examiner explained that sleep apnea is not caused by exposure to herbicides, and the claims file did not show any diagnosis or treatment of sleep apnea while in service. The examiner noted that the Veteran was diagnosed with sleep apnea in 2016, which the Board points out is approximately 45 years after his separation from service.

Additionally, the March 2025 VA examiner opined that the Veteran's sleep apnea was less likely than not cause by the herbicide exposure after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner explained that there was no medical or scientific evidence available that provided any indication of a relationship between the development of sleep apnea and the TERA. Accordingly, the evidence is against finding that his sleep apnea was incurred during service or is otherwise related to his service, to include his in-service exposure to herbicide agents.

Second, the evidence is persuasively against finding that the Veteran's sleep apnea was caused or aggravated by his PTSD. In so finding, the Board affords significant probative weight to the May 2021 VA opinion. The examiner explained that the examiner reported that the medical literature did not support a mental health disorder (PTSD) as causative or the potential for aggravation of the physiologic condition of obstructive sleep apnea, which is due to upper airway soft tissue abnormalities.

The Board acknowledges the September 2024 private opinion and the August 2025 addendum which reiterated the prior September 2024 opinion but finds the opinion inadequate as it is speculative and does not sufficiently relate the cited medical literature to the Veteran's specific circumstances. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, the May 2021 VA examiner explained that while some studies have suggested an association between obstructive sleep apnea and PTSD, they are cohort studies and do not show causality.

In addition, the evidence is persuasively against finding that his sleep apnea was caused or aggravated by his service-connected disabilities with obesity as an intermediate step. The Board finds the March 2025 VA opinion the most probative. This opinion was based on an interview with the Veteran, review of the record, and consideration of relevant medical literature, and it contains adequate rationale. After reviewing all the medical evidence, the March 2025 VA examiner opined that it was less likely than not that the Veteran's service-connected disabilities caused or aggravated the Veteran's obesity. The examiner explained that obesity usually results from a combination of causes and contributing factors and it was not possible to attribute the obesity to any one or group of different risk factors. The examiner further explained that "[a]t no point in the Veteran's entire e-file was the obesity caused or aggravated due to his service-connected disabilities."

The Board acknowledges the September 2024 private examiner's finding that the Veteran's PTSD led to his obesity. However, the opinion does not sufficiently establish the required elements, specifically that the Veteran's PTSD caused or aggravated his obesity, that such obesity was a substantial factor in causing his sleep apnea, and that the sleep apnea would not have occurred but for such obesity.

The Board also acknowledges the August 2025 addendum. The private examiner cited to medical literature and concluded that the studies showed how the Veteran's PTSD both "materially contributed to his weight-gain that produced a collapsible airway" and "further destabilized that airway via sympathetic surges and fragmented REM resulting in OSA that would not have occurred but for his PTSD-driven physiologic milieu." The private examiner overall based the opinion on finding that the Veteran's BMI rose from 24.6 at separation from service to 35.8 by the time his PTSD was documented but did not explain how this Veteran's PTSD caused his weight gain or address his other risk factors for obesity.

The Board acknowledges the Veteran's belief that his sleep apnea was caused by his PTSD. However, as a layperson lacking in medical training and expertise, he cannot provide a competent opinion on matters as complex as the etiology of his sleep apnea. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As such, the Board finds that his lay assertions are not competent medical evidence.

For the reasons and bases stated above, the Board finds that service connection for sleep apnea is not warranted. In reaching this conclusion, the Board has considered the benefit-of-the-doubt doctrine; however, as the evidence of record persuasively weighs against the claim and the positive and negative evidence is not nearly in balance, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Accordingly, the claim is denied.

2. Entitlement to a TDIU.

The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his authorized representative. Id.

In the present case, in an August 2025 written correspondence, the Veteran's representative advised that the Veteran "hereby withdraws his TDIU claim." As the Veteran has withdrawn this appeal, there remains no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal as to entitlement to a TDIU and it is dismissed.

REASONS FOR REMAND

1. Entitlement to service connection for peripheral neuropathy of the bilateral upper extremity.

2. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremity.

Regarding the Veteran's claim for entitlement to service connection for bilateral lower extremity peripheral neuropathy, the parties to the JMR agreed that VA failed to satisfy the duty to assist when it failed to attempt to associate certain community care consult result notes with the Veteran's VA file. The JMR noted that VA records indicated the Veteran was treated through community care for chronic bilateral ankle pain and left ankle pain by Dr. W.R. Specifically, VA records contain February 2019 and October 2019 community care consult requests. April 2019 and July 2019 community care consult notes indicate that scanned documents, specifically progress notes from Dr. W.R. were attached to the note. Additionally, a March 2020 community care consult result note indicates that December 2019 progress notes were scanned into VistA imaging.

In October 2024, the Board remanded the claim for the AOJ to attempt to obtain the Veteran's community care records and those scanned into VistA imaging and associate the records with the claims file.

In March 2025, the April 2019 and July 2019 progress notes from Dr. W.R. were associated with the Veteran's claims file. However, the December 2019 progress notes were not obtained. On remand, the AOJ must again attempt to obtain the December 2019 progress notes with a date of service of December 19, 2019, from Clarke County Public Hospital/Dr. R.W.
2019 progress notes were scanned into VistA imaging.

In March 2025, the April 2019 and July 2019 progress notes from Dr. W.R. were associated with the Veteran's claims file. However, the December 2019 progress notes were not obtained. On remand, the AOJ must again attempt to obtain the December 2019 progress notes with a date of service of December 19, 2019, from Clarke County Public Hospital/Dr. R.W. Per the March 9, 2020, community care consult note, these progress notes were scanned into VistA imaging.

The parties to the JMR also agreed that for the claims for entitlement to service connection of peripheral neuropathy of the bilateral upper and lower extremity, the Board failed to provide adequate reasons or bases for its determinations when it failed to address whether the Veteran experienced peripheral neuropathy of the upper or lower extremities secondary to alcohol use caused by PTSD, either with alcohol abuse being a symptom of PTSD or an alcohol use disorder being a disorder entitled to be separately service-connected secondary to PTSD.

In October 2024, the Board remanded the claims to obtain a VA medical opinion addressing whether the Veteran's alcohol use was a symptom of his PTSD, whether his alcohol use was caused or aggravated by his PTSD, and whether his bilateral upper and lower extremity peripheral neuropathy was caused or aggravated by his alcohol use.

In December 2024, the Veteran was provided with a VA review PTSD examination, and the examiner reported diagnoses of PTSD and major depressive disorder. The examiner found that the Veteran did not meet the DSM-5 criteria for alcohol use disorder. Although the examiner found that the Veteran did not meet the DSM-5 criteria for an alcohol use disorder, the examiner did not address whether the Veteran had alcohol abuse as a symptom of PTSD.

As substantial compliance with the prior remand directives was not achieved for the claims of service connection for peripheral neuropathy of the upper and lower extremities, remand of these claims to obtain an addendum opinion is required.

By this remand, the Board makes no determination, express or implied, concerning the credibility of any lay statements on file.

The matters are REMANDED for the following action:

1. Attempt to obtain the December 19, 2019, progress notes from Clarke County Public Hospital/ Dr. R.W that were scanned into VistA imaging and associate the records with the Veteran's claims file. If the AOJ concludes that such records do not exist or further efforts to obtain them would be futile, document this in the file and notify the Veteran accordingly.

2. Return the claims file to the December 2024 VA examiner, if available, or to an appropriate clinician if the December 2024 VA examiner is not available, and obtain an addendum opinion regarding the nature and etiology of the Veteran's alcohol use and peripheral neuropathy. The examiner is asked to address the following:

(a.) Does the Veteran have alcohol abuse as a symptom of PTSD?

(b.) If the answer to (a.) is yes, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's peripheral neuropathy of the upper extremities was caused or aggravated by his alcohol abuse?

(c.) If the answer to (a.) is yes, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's peripheral neuropathy of the lower extremities was caused or aggravated by his alcohol abuse?

A complete rationale for all opinions must be provided.

KELLI A. KORDICH

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board C. Bruce, Associate Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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