Citation Nr: 18151223 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 13-35 367 DATE: November 16, 2018 REMANDED Entitlement to service connection for sleep apnea is remanded. REASONS FOR REMAND The Veteran had active duty service from January 1983 to January 1986. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. In September 2017, the Board remanded the case for further development. The case has since been returned to the Board for appellate review. The Veteran was afforded VA examinations in December 2017 and August 2018 in connection with his claims. The December 2017 VA examiner opined that it is less likely as not that the Veteran’s current sleep apnea was incurred in or caused by his military service and instead found that it was likely related to post-service factors, including weight gain. The August 2018 VA examiner also stated that the Veteran’s sleep apnea was not due to service. Although the examiners did provide thorough rationales for their opinions, they did not specifically address whether the Veteran’s sleep apnea could be related to any environmental exposures in service. In this regard, the Veteran has claimed that he had environmental exposures while deployed to Grenada in 1983 during Operation Urgent Fury, including white dust, smoke from burning piles, and fumes from C-130s and other military aircraft. See October 2017 correspondence; August 2018 VA examination report. In addition, he has alleged that he took cover from small-arms fire and hit his head on a rock, losing consciousness for several minutes. According to the Veteran, following this incident, he suffered from fatigue and disturbed sleep. See August 2015 VA treatment records; October 2017 correspondence; October 2018 statement. The VA examiners did not address these specific allegations. In addition, the Veteran has alleged that his service-connected post-traumatic stress disorder (PTSD) caused his sleep apnea. See October 2018 statement in support of claim. This secondary theory of entitlement to service connection for sleep apnea has not yet been addressed. Therefore, the Board finds that a remand is needed to obtain an additional medical opinion. The matter is REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for sleep apnea that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA treatment records. 2. Thereafter, the AOJ should refer the Veteran’s claims file to a suitably qualified VA examiner for a medical opinion as to the etiology of any current sleep apnea. An additional examination should only be performed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should state whether it is at least as likely as not that the Veteran’s sleep apnea manifested in service or is otherwise causally or etiologically related to his military service, to include any symptomatology, injuries, and environmental hazards therein. The Veteran has claimed that he had environmental exposures while deployed to Grenada in 1983 during Operation Urgent Fury, including white dust, smoke from burning piles, and fumes from C-130s and other military aircraft. See October 2017 correspondence; August 2018 VA examination report. He also asserted that he took cover from small-arms fire and hit his head on a rock, losing consciousness for several minutes. He has indicated that, following that incident, he suffered from fatigue and disturbed sleep. See August 2015 VA treatment records; October 2017 correspondence; October 2018 statement. The examiner should also opine as to whether it is at least as likely as not that the Veteran’s sleep apnea was either caused by or permanently aggravated by his service-connected PTSD. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it.) A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The AOJ should review the examination report to ensure compliance with this remand. If the report is deficient in any manner, the AOJ should implement corrective procedures. 4. The AOJ should complete any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D.S. Chilcote, Associate Counsel