Citation Nr: 1752981 Decision Date: 11/17/17 Archive Date: 11/22/17 DOCKET NO. 13-25 839 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for sleep apnea, to include as secondary to service-connected hypertension. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Vang, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1961 to January 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran testified in a travel Board hearing before the undersigned Veterans Law Judge in November 2015. A transcript of the hearing is associated with the claims file. The claim was previously before the Board and was remanded for further development in February 2016. The Board additionally notes that the appeal previously included the issue of entitlement to service connection for a skin disorder. During the pendency of the appeal, service connection for a skin disorder was granted in an April 2016 rating decision. Accordingly, the issue of entitlement to service connection for a skin disorder has been resolved and is no longer before the Board. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The Veteran asserts service connection for sleep apnea and variously contends that his sleep apnea is due to in-service low potassium levels; in-service jaw fracture; in-service broken nose; in-service swollen glands in relation to colds; and service-connected hypertension. The Veteran also noted problems in service with stomach ulcers that affected his sleep. See November 2015 Hearing Transcript; May 2016 Correspondence. In April 2016, a VA examiner noted that the Veteran's sleep apnea less likely than not had its onset or service or was otherwise related to service. She opined that his sleep apnea was more likely related to his BMI. She further stated that the Veteran's reported symptoms of fatigue in service appear to have been related to a low potassium state. The Board finds that remand is warranted in light of the Veteran's new contentions. See May 2016 Correspondence. In August 2009, the Veteran submitted a medical article indicating that sleep apnea is associated with lower-face abnormalities, including the chin, maxilla, and mandible. Of note, the record contains an October 1961 service treatment record indicating that the Veteran's mandible was fractured during a fight. Additionally, the August 2009 articles suggest that there may be an association between sleep apnea and hypertension. Here, a July 2009 letter from physician assistant W.M. indicates that the Veteran's sleep apnea may have contributed to the development of hypertension. In light of the above, remand is warranted for an addendum opinion to address whether the Veteran's sleep apnea is related to the 1961 jaw fracture or service-connected hypertension. The Board also notes that it would be helpful to obtain additional clarification on whether low potassium levels are related to sleep apnea. Accordingly, the case is REMANDED for the following actions: 1. Obtain any outstanding VA treatment records not already of record relating to the claim. 2. Forward the Veteran's claims file to April 2016 VA examiner (or a suitable substitute) for an addendum opinion to determine the etiology of his sleep apnea. If the examiner determines that the Veteran should be provided another examination, one should be scheduled. Following a review of the file, the clinician should provide the following opinions: a) Whether sleep apnea at least as likely as not (a probability of 50 percent or greater) began in or is otherwise related to the Veteran's active service, to include: in-service mandible fracture, low potassium levels, broken nose, stomach ulcers and swollen glands from colds. The examiner is also requested to address whether low potassium levels are related to the development of sleep apnea. The examiner's attention is invited to October 1961 STRs documenting treatment for a fractured mandible; the May 2016 statement by the Veteran that his sleep apnea is related to broken nose, swollen glands due to colds, and stomach ulcers in-service; and the August 2009 article suggesting an association between sleep apnea and lower-face abnormalities of the mandible. b) Whether it is at least as likely as not (a probability of 50 percent or greater) that sleep apnea is proximately caused by or aggravated by service-connected hypertension. If aggravation is found, to the extent feasible, the clinician should attempt to identify the baseline level of severity of the aggravated disorder before the onset of aggravation. The examiner's attention is invited to the August 2009 articles and the July 2009 letter from physician assistant W.M. indicating sleep apnea may have contributed to the development of hypertension. The phrase "at least as likely as not" does not mean "within the realm of possibility," but rather that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against. Any opinions offered should be accompanied by the underlying reasons for the conclusions. If the examiner is unable to offer the requested opinions, it is essential that the he or she offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382, 392-93 (2011). 3. Ensure completion of the foregoing and any other development deemed necessary, then readjudicate the Veteran's claim. If the requested benefit remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).