Citation Nr: 1801349 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 12-28 844 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for sleep apnea, to include as secondary to a service-connected acquired psychiatric disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. Jones, Counsel INTRODUCTION The Veteran had active service from July 1972 to December 1974 and from January 2004 to March 2005. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. This matter was before the Board in June 2017 at which time it was remanded for additional evidentiary development. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND Pursuant to the Board's June 2017 remand instructions, a VA medical opinion was to be obtained to determine the etiology of the Veteran's sleep apnea. Specifically, the VA examiner was to provide an opinion as to whether the Veteran's sleep apnea was caused or aggravated by his service connected posttraumatic stress disorder (PTSD). The requested opinion was to be accompanied by a thorough reasons and bases. It was noted that such discussion may include factors such as what may have caused the Veteran's sleep apnea as well as any medical studies addressing the relationship between sleep apnea and PTSD. An addendum VA medical opinion was obtained in June 2017. The examiner concluded that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected PTSD. In support of this finding, the examiner noted that up to date medical references indicate that important risk factors for obstructive sleep apnea are advancing age (the Veteran in 63 years old); male gender; obesity (the Veteran is just below obese); and craniofacial abnormalities. She noted that additional risk factors in some studies include nasal congestion (the Veteran has chronic rhinitis), smoking, and family history. She noted that up to date medical references do not indicate that PTSD causes or aggravates obstructive sleep apnea. The Board finds that the June 2017 remand instructions have not been followed. Stegall v. West, 11 Vet. App. 268 (1998). In this regard, while the examiner determined that the Veteran's sleep apnea was not caused or aggravated by his service-connected PTSD, she did not provide a rationale to support her finding beyond citing to risk factors for sleep apnea. In that regard, the Board observes that in the December 2017 appellate brief presentation, the Veteran's representative noted that in the June 2017 VA medical opinion, the VA examiner listed weight gain as one of the important risk factors for obstructive sleep apnea. The Veteran's representative asserted that at least one of the medications prescribed to treat the Veteran's psychiatric disorder causes weight gain. The evidence available to the Board does not indicate that the VA examiner considered the possible effects of the medications used to treat the Veteran's service-connected PTSD on his sleep apnea. In light of the foregoing, an additional VA medical opinion must be obtained on remand. Accordingly, the case is REMANDED for the following action: 1. Obtain an opinion from a suitably qualified VA examiner regarding the nature and etiology of the Veteran's sleep apnea. Access to records in the Veteran's electronic claims files should be made available to the examiner for review in connection with his or her opinion. A VA examination may be provided if deemed appropriate. The examiner is to provide opinions to the following: (a) Is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's sleep apnea was incurred in service or is otherwise causally related to his active service or any incident therein? (b) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's sleep apnea was caused by his service-connected PTSD, to include medication used to treat the psychiatric disability? (c) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's sleep apnea has been aggravated (chronically worsened) by his service-connected PTSD, to include medication used to treat the psychiatric disability? If aggravation is found, please identify the baseline level of disability prior to aggravation, to the extent possible, based on the medical evidence and also any lay statements as to the severity of the condition over time. A clear explanation for all VA medical opinions is required, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner cannot respond without resorting to speculation, it should be explained why a response would be speculative. In rendering the requested opinions, the VA examiner must consider and discuss the articles provided by the Veteran regarding the relationship between sleep apnea and PTSD. The examiner must also discuss the article referenced by the Veteran's representative regarding side effects of medications used to treat the Veteran's service-connected psychiatric disability. 2. After undertaking any development deemed necessary, readjudicate the issue on appeal, considering all the evidence of record. If the benefit sought on appeal remains denied, provide the Veteran and his representative with a Supplemental Statement of the Case and the opportunity to respond. The case should then be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter or matters 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. §§ 5109B, 7112 (2012). _________________________________________________ K. Conner Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (2012), 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).