Citation Nr: 18142912 Decision Date: 10/17/18 Archive Date: 10/17/18 DOCKET NO. 14-22 787 DATE: October 17, 2018 REMANDED Issue of service connection for sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty for training from June 1978 to October 1987, and active duty from April 1988 to November 1997. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision issued by the Department of Veterans Affairs (VA). The Veteran perfected his appeal. See November 2013 Notice of Disagreement; May 2014 Statement of the Case; June 2014 VA Form 9. In February 2016, the Board remanded this matter for further development of the Veteran’s claim of service connection for sleep apnea. Specifically, the Board directed the Agency of Original Jurisdiction (AOJ) to obtain VA treatment records from April 2014 to present, attempt to obtain treatment records from Dr. A. Sheikh at Carthage Area Hospital and notify the Veteran and his representative if the records sought are not obtained, and schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s sleep apnea. The requested development is associated with the claims file. See May 2014 to October 2016 VA treatment records; April 2016 Form VA 21-0820; November 2016 Supplemental Statement of the Case; April 2016 VA examination. The Board determines that there has been substantial compliance with the Board’s directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Issue of service connection for sleep apnea is remanded. The Board cannot make a fully-informed decision on the issue of service connection for sleep apnea because clarification is need on whether there is a medical link between the current diagnosis of sleep apnea and service. In addition, no VA examiner has opined whether sleep apnea is secondary to his prescribed medication for the Veteran’s service connected posttraumatic stress disorder (PTSD) with major depressive disorder, including his medication causing weight gain that either caused or aggravated his sleep apnea. The April 2016 VA examination report indicates that the Veteran’s sleep apnea was less likely than not incurred in or caused by an in service injury, event, or illness. The VA examiner gave rationale that there is no documented evidence of a sleep apnea diagnosis, or credible evidence of respiratory symptoms to support a sleep apnea diagnosis, in the service treatment records. However, it is unclear if the VA examiner considered the November 2013 lay statement from the Veteran’s spouse, in which she relates to observing respiratory symptoms related to sleep apnea. In addition, clarification is needed on the VA examiner’s opinion that sertraline and divalproex may have varying effects on sleep apnea, and whether this suggests an aggravation of his current sleep apnea disorder. The Veteran’s spouse relates that she observed the Veteran snore loudly, stop breathing, and wake up tired in the morning prior to his separation in 1997. The Veteran and his spouse have been married since August 1992, so she had the opportunity to personally observed the Veteran’s symptoms during his service and is competent to testify to symptoms observable to a lay person. See Charles v. Principi, 16 Vet. App 370, 374 (2002). Her November 2013 lay statement is also consistent with the Veteran’s attempts to obtain a sleep study as earlier as October 2004 and his reported history to treatment providers that his wife has told him he snored loudly for many years and has observed apneas. See October 2004 private treatment record; March 2018 VA treatment record. It is unclear if the November 2013 lay statement was considered when the VA examiner found no credible evidence of a sleep apnea or other respiratory disorder to support a sleep apnea diagnosis during the Veteran’s service. In addition, the 2016 VA examination report indicates that sertraline and divalproex may aggravate and/or exacerbate the obstructive sleep apnea to varying degrees. A May 2016 VA treatment record shows sertraline and divalproex as an active outpatient medication during the period on appeal. The Board finds that an addendum opinion is needed to clarify if the Veteran’s sertraline and divalproex are medications used to treat his service connected PTSD with major depressive disorder and, if so, what permanent effect, if any, the medication has on his sleep apnea. The Veteran, through his representative’s October 2014 brief, also asserts that Depakote was used to treat his service connected PTSD and caused his weight gain, which then caused his sleep apnea on a secondary basis or by aggravation. The assertion that Depakote caused the Veteran to gain weight is consistent with a September 2016 VA psychiatric treatment record, in which the Veteran indicated he was hesitant to restart Depakote as it caused significant weight gain for him in the past. The Board finds that an addendum opinion on whether there is service connection due to obesity as secondary to PTSD with major depressive disorder is needed. The matter is REMANDED for the following action: 1. If possible, obtain an addendum opinion from the same April 2016 VA examiner. If it is not possible, obtain an addendum opinion from an appropriate medical professional to determine the nature and cause of the Veteran’s sleep apnea. If the examiner determines that it is necessary, schedule the Veteran for a VA examination regarding the etiology of his sleep apnea. The examiner should respond to the following: (a) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s sleep apnea began in (or is otherwise related to) the Veteran’s military service? The examiner should specifically consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms. The examiner should specifically consider the Veteran’s complaints of sleep problems since 2004 and the November 2013 statement from his spouse. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (b) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s obesity is proximately due to or the result of his service connected PTSD, including as a side effect of his medication? If so, the examiner should then consider if the Veteran’s sleep apnea is proximately due to or the result of his obesity. If the examiner finds sleep apnea is not proximately due to or the result of obesity, the examiner(s) should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s current sleep apnea is aggravated (permanently made worse) by obesity. (c) The examiner is also asked to consider if it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s current sleep apnea is aggravated (permanently made worse) by his PTSD medications, separated from any obesity-related effects. The examiner(s) should consider and discuss the Veteran’s lay testimony and assertions regarding any pertinent complaints and symptoms, including his assertion that is PTSD medication resulted in weight gain, which then caused his sleep apnea. A detailed explanation (rationale) is requested, including citing to supporting clinical data (and/or medical literature), as appropriate. (d) If the Veteran’s sleep apnea or obesity is deemed to be unrelated to service, the examiner should, if possible, identify the cause considered more likely and explained why that is so. 2. After the above development has been completed, review the record and ensure that all development sought in this remand has been completed. Arrange for any further development indicated by the results of the development requested above, and re-adjudicate the claims. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Lin, Associate Counsel