Citation Nr: 18150330 Decision Date: 11/15/18 Archive Date: 11/14/18 DOCKET NO. 17-04 696 DATE: November 15, 2018 REMANDED Entitlement to service connection for a sleep disorder, to include obstructive sleep apnea (OSA) with insomnia, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1986 to August 1990. The Veteran appeals a May 2014 rating decision denying service connection for OSA with insomnia (claimed as sleep disturbances). The Veteran has OSA and insomnia. See December 2013 E.A. medical statement. He does not contend that his sleep condition relates directly to his time on active duty. Rather, he argues that his service-connected tinnitus causes or aggravates his sleep disorder. See October 2016 VA Form 9. Consistent with VA’s duty to assist, VA must provide a medical examination when there is evidence of (1) a current disability; (2) an in-service injury; (3) some indication that the claimed disability may be associated with the established injury; and (4) insufficient competent evidence of record for VA to make a decision. See McClendon v. Nicholson, 20 Vet. App. 79, 84 (2006). The third prong, which requires evidence that the claimed disability or symptoms “may be” associated with the established event, has a low evidentiary threshold. See 20 Vet. App. at 83. In support of his position, the Veteran submitted a document from clinician E.A. stating that she is “not sure if the tinnitus caused [the Veteran’s] insomnia however both symptoms improved with use of CPAP.” See December 2013 E.A. medical statement. Further, the Veteran submitted articles suggesting a connection between tinnitus and insomnia. See, e.g., R.L. Folmer & S.E. Griest, Tinnitus and Insomnia, 21 (5) AM. J. OTOLARYNGOL 287-93 (2000). Therefore, the Veteran has presented some evidence connecting tinnitus with sleep disturbances. However, the articles and E.A.’s statement are not clear as to whether the Veteran’s tinnitus aggravates his sleeping disorder, his sleeping disorder aggravates his tinnitus, or both. As such, the low evidentiary standard under McClendon is met, and a VA examination is necessary to determine if the Veteran’s sleep disorder is caused or aggravated by his service-connected tinnitus. Further, in a September 2015 statement, the Veteran says he was seen at the Charlotte VA Outpatient Clinic, where he discussed his sleep issue and was referred to the audiology department. See September 2015 Veteran statement. He also says he was scheduled for an appointment with the audiology department on September 30, 2015, and he planned to attend. Id. VA treatment records have not been associated with the claims file. As such, the Board notes that there are identified, outstanding treatment records that should be obtained. See Sullivan v. McDonald, 815 F.3d 786, 793 (2016). On remand, the AOJ should obtain the missing records and associate them with the claims file. The matter is REMANDED for the following action: 1. Obtain any outstanding VA treatment records relevant to treatment the Veteran received for his sleep disorder that are not already of record. All obtained records should be associated with the evidentiary record. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified and the record clearly documented. 2. Schedule the Veteran for an examination to determine the nature and etiology of his sleep disorder. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the clinician. The examination must include a notation that this record review took place. After the record review and examination of the Veteran, the clinician should identify all sleep disabilities. For each identified disability, the clinician is asked to respond to the following inquiry: Is it at least as likely as not that the Veteran’s sleep disorder, to include OSA with insomnia, was (a.) caused or (b.) aggravated by his service-connected tinnitus? In rendering this opinion, the clinician is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the clinician rejects the Veteran’s reports, he or she must provide an explanation for such rejection. The clinician is not to improperly discount the Veteran’s lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The clinician is to discuss the relationship between the Veteran’s tinnitus and sleep disorder, and if the severity of the Veteran’s tinnitus aggravates the Veteran’s sleep disorder symptoms. The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the clinician must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Salazar, Associate Counsel